Church of Christ Care Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

52.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 123 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 46.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 52 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 129 beds and averages 112.7 residents a day — about 87% occupied, or roughly 16 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.39 hrs/resident/day on weekends vs 3.66 on weekdays — 7% thinner on weekends. RN hours go from 0.50 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.

• Actual harm · Gcited before2025-08-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 1238200.Based on interview and record review the facility failed to utilize the required two staff to complete incontinence care for one sampled resident (R4) of four residents reviewed for accidents, resulting in a fall from the bed and a fracture of the right arm. Findings include:During a closed record review of R4's medical record it was noted that R4 was transferred to the hospital after a fall during care. A review of R4's medical record progress notes revealed, 8/17/25 -Writer called to room by nurse assistance. Res (resident) observed on floor, lying on right side. Lying next to bed closest to the window. Nightstand and bed side table next to [R4], close to [R4's] head. Res is alert and verbal. Verbal complaints of pain to right side. Physician in house. Assessed at bedside while on floor. Order received to send to ER (Emergency Room) via 911. Res kept in same position. No active bleeding noted at this time. Awaiting EMT's (Emergency Medical Technicians).Further review…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess, identify, provide treatment and prevent pressure ulcers for two residents (R78 and R21) of seven reviewed for pressure ulcers, resulting in the development and worsening of pressure ulcers. Findings include: R78 On 07/31/24 at 11:12 AM, Registered Nurse (RN) H was observed assessing R78's wound in their room. A strong foul odor was noted coming from the wound when RN H pulled R78's covers back. A review of R78's record revealed they were initially admitted to the facility on [DATE], and readmitted on [DATE] with the following diagnoses: Muscle weakness generalized, wounds and unspecified encephalopathy. The Brief Interview for Mental Status (BIMS) revealed a score of 6/15 indicating a cognitive impairment. On admission R78 was identified as high risk for developing pressure ulcers. A review of the readmission physician note dated 5/24/24 documented, Wound care physician progress note: .L (left) foot callus/hallux- Stage 2 (Partial…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake M100144181. Based on observation, interview and record review, the facility failed to implement measures to prevent multiple falls for one (R701) of eight residents reviewed for falls, resulting in a right femur fracture that required a surgical repair, additional assistance with transfers and pain management. Findings include: Review of the facility record for R701 revealed an admission date of 05/19/23 with diagnoses that included Alzheimer's Disease, Diabetes Mellitus, and Difficulty in Walking. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Mental Status (BIMS) score of 03/15 indicating Severe Cognitive Impairment. Review of R701's admission Fall Risk Evaluation dated 05/19/23 revealed a score of 10 (evaluation instructions state If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan.) On 05/01/24 at 11:45 PM, R701 was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-11 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  This citation pertains to Intake: 3030980 Based on interview and record review, the facility failed to prevent misappropriation of property for one resident (R901) of three residents reviewed for misappropriation. Findings include:A review of a complaint submitted to the State Agency (SA) revealed (R901's) money ($60.00) was reported missing (0n 5/14/26) from their possession after receiving from trust fund on 5/11/26. Upon investigation identified Housekeeper A had entered into R901's room on three separate occasions outside of their job duties. On 6/11/26 at 9:57 AM, an interview was completed with R901 who reported they obtain $60.00 monthly from the resident trust fund and allocates the money to family members to run errands on their behalf. The resident confirmed they obtained their $60.00 for the month of May, placed it inside a pouch, and placed it on their overbed table. Upon waking up one morning they discovered the money was missing. R901 explained they do not know who took the money but explained they did not leave their room after receiving the money and getting up in…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Incident 2984504.Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff, affecting one resident (R701) of three reviewed for abuse.Findings include: An allegation of staff to resident abuse was submitted to the state agency on 3/27/26 documenting; On the afternoon of 3/27/26, a hospice representative told the Administrator that [R701] had concerns regarding the midnight shift and was afraid of the two ladies that cared for her. Licensed Practical Nurse (LPN) B and Certified Nurse Assistant (CNA) C were assigned to [R701] from 11 p.m. on 3/26/26 until 7 a.m. on 3/27/2026. An investigation revealed that around 11:30 p.m. on 3/26/26, [R701] began calling out for help. LPN B and CNA C entered the room. LPN B told [R701] to stop yelling and they are not the only patient on this floor. [R701] began calling out for help again that they could not reach they're call cord. When LPN B and CNA C entered the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · F2025-08-20 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to have available and don/doff (put on and take off) personal protective equipment (PPE-gowns, gloves, masks, etc.) for one resident on Enhanced Barrier Precautions (EBP) (R117) out of six reviewed for infection control. Findings include:R117On 8/19/2025 at 2:00PM, R117's door was observed with a sign stating the room was on Enhanced Barrier Precautions (EBP). No PPE was observed on the door, or in the room.On 8/19/2025 at 2:08 PM, Certified Nursing Assistant (CNA) J was observed going into R117's room and provided care to R117 and their roommate, both were on EBP. CNA J was noted to have on gloves and a mask. CNA J was asked if they put on a gown while providing care. CNA J reported they did not put on a gown and that there was not one available.On 8/20/2025 at 11:00 AM, an infection control meeting was held with the Director of Nursing (DON). The DON reported they completed EBP training earlier in the year and they have been facing some challenges since changes in staffing. A review of a facility policy…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-08-20 · tag F0908 — failed to keep essential equipment working — widespread
  Keep all essential equipment working safely.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure the ice machine near the main kitchen was backflow protected. This deficient practice had the potential to affect all residents in the facility. Findings include: On 08/18/2025 at 11:45 AM, the ice machine drain line was observed to extend down inside the floor drain. There was no air gap between the bottom of the drain line pipe and the flood rim of the floor drain. Dietary Manager O confirmed the lack of an air gap and stated she would let Maintenance know. According to the Food & Drug Administration (FDA) 2022 Model Food Code, Section 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-20 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop/implement comprehensive care plans for three residents (R13, R88, and R99) out of four reviewed for Care Plans. Findings Include:R13 On 8/18/25 at 9:00 AM, R13 was observed sitting on the side of the bed. R13 appeared anxious with nervous speech and finger movements. A review of the medical record for R13 occurred and revealed the following: R13 was initially admitted to the facility on [DATE] and after a brief hospitalization was readmitted [DATE] with following diagnoses including: Dementia, Schizophrenia, Depression and Chronic Obstruction Pulmonary Disease. A review of R13's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental status (BIMS) assessment score of 14/15 indicating intact cognition. Further review of R13's medical record revealed a care plan for antipsychotic medications and an intervention noted was for staff to monitor behaviors. Care plan interventions documented Monitor behavior…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-20 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to complete an accurate resident assessment for one sampled resident (R36) of 23 reviewed for assessments. Findings include:On 8/18/25 at 9:17 AM, R36 was observed in their bed and asked if they had a pressure ulcer. R36 replied, Yes.On 8/19/2025 at 10:13 AM, an observation of R36's skin was completed with a nurse and a Physician. R36's skin was observed with a rash that started from the middle of their back to the back of R36's legs. R36's skin was observed to no longer have a pressure ulcer.A review of R36's medical record noted R36 was admitted to the facility on [DATE] with a diagnosis of Chronic Respiratory failure. A review of R36's Minimum Data Set (MDS) annual assessment dated [DATE], noted R36 with a moderately impaired cognition and R36 required assistance by staff to complete activities of daily living. Further review of R36's MDS noted, that R36 had one unhealed stage two pressure ulcer (characterized by a partial thickness loss…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-20 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
  Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to provide built up utensils for one resident (R99) out of one reviewed for Adaptive Equipment. Findings include:On 8/18/2025 at 9:25 AM, R99 was observed eating breakfast. R99's meal ticket was noted to have a note stating built up utensils highlighted in blue. R99 was observed eating with regular utensils. R99 stated they rarely get the right utensils, and that the built-up utensils really help them with their meals and the pain they have in their hands.A review of the medical record revealed that R99 admitted into the facility on 8/16/2024 with the following medical diagnoses, Muscle Weakness and Bi-Polar Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R99 also required assistance with bed mobility and transfers. On 8/18/2025 at 9:30 AM, Occupational Therapist (OT) E was shown R99's meal ticket and the regular utensils. OT E reported R99 should have built up utensils and they will have to check with the kitchen…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 1238202.Based on observation, interview, and record review, the facility failed to provide 1:1 feeding assistance for one resident (R16) and grooming assistance for one resident (R20) out of three reviewed for Activities of Daily Living (ADL). Findings include:R16 On 8/18/2025 at 10:44 AM, R16 was observed in bed. R16 was noted to be sitting with the head of bed (HOB) elevated and a clothing protector on. The bedside table was pulled over them and their breakfast tray was sitting in front of them. R16 was noted to have a hash brown and eggs on their clothing protector and eggs on their face. R16 was observed attempting to pick up their eggs with their fingers. The meal ticket was noted to have 1:1 assistance and highlighted in yellow. A review of the medical record revealed that R16 was admitted into the facility on 1/6/2022 with the following diagnoses, Cerebrovascular Disease and Alzheimer's Disease. A review of the Minimum Data Set assessment revealed a Brief Interview for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to reposition one resident (R113) in a timely manner out of two reviewed for interventions for pressure ulcers. Findings include:On 08/18/2025 at 9:56 AM, 12:25 PM, and 4:05 PM, R113 was observed lying on their back in bed with arms down on sides. The head of the bed was elevated to 40 degrees. R113 was on an air mattress, wearing a hospital gown with heel boots on. On 08/19/2025 at 10:01 AM, observed R113's family in room providing mouth care, and grooming for R113. The family member stated they were at the facility for a care conference and expressed concerns that since R113 returned from the hospital, the resident has not been talking, and staff are not assisting R113 to get out of bed. On 08/19/2025 at 12:12 PM, 1:59 PM, and 3:43 PM, observed R113 lying on their in bed with wedge cushion slightly under left hand. The head of the bed was elevated to 40 degrees. R113 was on an air mattress, wearing a hospital gown with heel boots on. A…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to apply oxygen per physician order for one resident (17) out of 2 reviewed for respiratory care. Findings include.On 08/18/2025 at 9:01 AM, and 12:05 PM, R17 was observed sitting on the side of the bed without oxygen in use. The oxygen concentrator was on, and the tubing was lying on the floor by the bedside. On 08/19/2025 at 7:15 AM, R17 was observed sitting at the side of the bed without oxygen in use. The oxygen concentrator was on, and the tubing wrapped around concentrator. On 08/19/2025 at 9:56 AM, R17 was observed leaving the facility with a family member and no oxygen in use.On 08/19/2025 at 10:15 AM, during an interview with Registered Nurse (RN) M regarding oxygen for R17, RN M replied, I think [R17] oxygen is ordered as needed, I do believe. A review of the medical record for R17 revealed R17 was admitted into the facility 03/15/2024 with diagnoses included Respiratory Failure, Chronic Kidney Disease, and Congestive Heart Failure. R17 was admitted to the facility with an order dated 03/15/2024 for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$40,940 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $17,345 — penalty dated 2025-08-20
• $23,595 — penalty dated 2024-08-01
• Medicare payment denial — starting 2025-09-17 for 12 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

CMS files one row per role, so the 16 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MI