Maple Woods Manor

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.

52.5% 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 127 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 31.9% 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 72 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 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 151 beds and averages 103.2 residents a day — about 68% occupied, or roughly 48 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.88 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 2.56 is at or above 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 3.53 hrs/resident/day on weekends vs 4.02 on weekdays — 12% thinner on weekends. RN hours go from 0.54 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% 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.

33 citations, most serious first. The 15 most serious are shown; the remaining 18 are one tap away and print in full.

• Actual harm · G2026-04-08 · 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 Intake Numbers 2685912 and 2701537.Based on interview and record review the facility failed to protect one resident's (Resident #302) right to be free from neglect, resulting in 1. Significant delay in the administration of enteral nutrition and hydration; 2. Discharge medication orders (insulin and tube feed formula) were not followed without a rationale; 3. Untimely intervention for persistently elevated blood glucose levels and lack of communication to the practitioner; and 4. An ongoing respiratory assessment and monitoring of an acute infection with antibiotic administration, which led to an unnoticed change in condition requiring hospitalization. Findings Include:On [DATE] at approximately 2:30 PM, a review was conducted of Resident #302's medical records and it revealed he was admitted to the facility on [DATE] at approximately 6:30 PM with diagnoses that included, Cerebral Infarction, Pneumonia, Dysphagia, Type 2 Diabetes. Further review of the record yielded 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 · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-06-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  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 Numbers MI00153484 and MI00153865. Based on interview and record review the facility failed to promptly assess a change in condition for one resident (Resident #501) of two residents reviewed for pain, resulting in a delay in pain treatment and discovery of bilateral femur fractures. Findings include: Resident #501: On 6/20/2025 at 9:45 AM, Resident #501 was observed sleeping in bed and did not appear to be in any distress. Two CNA (Certified Nursing Assistants) in the room shared the resident is a two person assist and fully dependent on care. On 6/20/2025 at 10:42 AM, Maintenance Director O shared the Shower Aide informed her as they were lowering Resident #501 in the bed (via mechanical lift) it tilted forward. She explained the pivot point was too tight which caused the Hoyer to tilt, but they were able to safely lower the resident to the bed. On 6/20/2025 at 11:05 AM, CNA P stated she last showered Resident #501 on 5/27/2025 and was assisted by CNA H. As they were placing…

  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 before2025-01-21 · 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 This citation pertains to Intake Number MI00149458. Based on observation, interview and record review, the facility failed to operationalize policies and procedures for skin/wound assessments and prevent the development of pressure ulcers for three residents (Resident #1, Resident #2, and Resident #3) of three residents reviewed for wound and skin care, resulting in Resident #1's development of facility- acquired Stage III pressure ulcer to the coccyx area, five suspected deep tissue injuries on the right and left feet and pain; Resident #2's development of facility-acquired right buttock pressure wound stage II and right ischium pressure wound stage IV, and the potential for wounds to go undetected and untreated, pain and wound infection. Findings include: A review of the facility document titled Wound Measurement, revealed, .Suspected Deep Tissue Injury-Purple or maroon localized area of discolored intact skin or bold-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area…

  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 · G2024-02-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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 ensure an ongoing and comprehensive nutritional assessment and timely implementation and evaluation of person-centered interventions to prevent weight loss for one resident (Resident #94) of two residents reviewed, resulting in Resident #94 experiencing a severe weight loss and the likelihood for a decline in overall health status. Findings include: An observation of Resident #94 occurred on 2/12/24 at 11:53 AM in their room. The room was dark, with the light with the overhead lights off and the window shades closed. The Resident was in bed, with one leg half off the bed and their eyes open. The Resident had a gaunt appearance. When spoke to, Resident #94 made eye contact and smiled but did not provide a verbal response. The Resident's lips were noted to be dry with peeling skin. There were no beverages on the dresser next to the bed and/or the overbed table. Record review revealed Resident #94 was admitted to the facility on [DATE] with…

  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 · G2022-11-03 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  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 1.) assess and monitor for urinary/catheter changes for Resident #33 and prevent facility acquired urinary tract infections for three (3) Residents (#9, #76, #95) resulting in the likelihood for bladder injury, cross contamination and facility acquired urinary tract infections requiring antibiotic therapies. Findings Include: Record review of facility 'Urinary Tract Infection; Catheter Associated UTI's (CAUTI's) Prevention & Surveillance Guidelines' policy dated 10/2011 revealed it is the policy of the facility to apply evidenced-based guidelines to alterable risk factors in the development of nosocomial Urinary Tract Infections (UTI's) . Resident #9: In an interview and observation on 10/31/22 at 10:27 AM with Resident #9 during the entrance tour of the survey revealed a catheter with large amount of urine, estimated over 1000cc hanging at the bedside with a leaf privacy flap. In an interview with Resident #9 about his catheter revealed…

  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 · Ecited before2026-06-03 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  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 Number 3026069. Based on observation, interview and record review, the facility failed to ensure access to and answer call lights timely for three residents (#31, #49, #106) and a Confidential Group of Residents, resulting in the lack of timely care, residents' verbalizations of dissatisfaction with care and unmet care needs. Findings include: Resident #31: On 6/1/26 at 12:05 PM, Resident #31 was observed sitting in a recliner in their room. An untouched food tray was in place on the overbed table in front of them. An interview was completed at this time. When queried why they were not eating their food, Resident #31 adamantly responded they did not like what they received and that it was inedible. When asked if they were able to request something different to eat, Resident #31 responded they could but indicated it would be quite a while before someone answered their call light. Resident #31 pressed their call light at 12:08 PM. At 12:10 PM, two staff members were observed…

  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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-06-03 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  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 ensure palatable and appealing food for three residents (R6, R41 and R106) of five residents reviewed for food and a confidential group of residents. Findings include: Resident #106 (R106): R106 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease (COPD), chronic respiratory failure and cerebral infarction without residual deficits. On 06/01/2026 at 3:52PM, R106 was asked about the food the facility serves. R106 stated, the food is cold and she gets tired of getting cold food in her room. R106 says she has to have kitchen staff warm up items for her constantly. R106 stated that this occurs at all meals. On 06/02/2026 at 1:18PM, an interview was conducted with Dietary Manager (DM) L. DM L was asked if they have ever received complaints of cold food. DM L stated, I have and especially when I first started at the building. DM L stated the complaint is that by the time 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-13 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  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 intakes 2575094 and 2581072.Based on observation, interview and record review the facility failed to maintain a safe, functional, sanitary and comfortable environment, resulting in ambient temperatures of 84 degrees in resident care areas, no documentation of room or hall temperatures during an air conditioning outage, staff complaints of warm temperatures, residents discharging from the facility due to high temperatures, lack of available linen to provide peri-care and the increased likelihood of unmet care needs. Findings include:Environment:On 8/12/25 at 11:54am, an interview was conducted with Maintenance Assistant A. Maintenance Assistant A was asked when the air conditioning (AC) unit went out on the west short hall. Maintenance Assistant A stated that they believe the unit went out during the week of 07/21/25. Maintenance Assistant A was asked what caused the outage. Maintenance Assistant A stated that the contactor on unit 5 was wired incorrectly, we called an electrician 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-04-11 · 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 monitor and respond to abnormally low hot water temperatures per standards of practice for the prevention and management of Legionella for a census of 111 residents, resulting in the potential for growth of infectious organisms in the facility water supply. Findings Include: FACILITY Infection Control: On 4/09/2025 at 2:11 PM, the Infection Prevention and Control/IPC Nurses J and K were interviewed. Infection surveillance was reviewed and the IPC J said she and the Maintenance Director reviewed the facilities water management program and monitoring of water for Legionella at the monthly Infection Control Committee meeting that was a part of the Quality Assurance Process Improvement meetings. IPC J said if there was a problem with the water, the Maintenance Director would tell her about it. The IPC J was asked if there had been any mention of problems, and she said not that she knew. A review of the Water management program book identified a Legionella assessment form dated 3/17/25. It said the emergency water…

  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 · E2025-04-11 · tag F0578 — failed to honor advance directives / code status — pattern
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  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 interview and record review, the facility failed to ensure Code Status was documented and accessible in the medical record for 6 residents (#12, #21, #53, #79, #92 and #158) of 11 residents reviewed for Advance Directives, resulting in the potential for miscommunication of code status. Findings Include: Resident #12 Advance Directives A record review of the Face Sheet and Minimum Data Set/MDS assessment indicated Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Parkinson's disease, COPD, diabetes, kidney disease, heart failure and depression. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 14/15 and needed some assistance with care. A review of the advance directives and code status for Resident #12 in the electronic medical record/EMR, revealed the chart was not marked for the resident's specific code status. The Face Sheet had a heading for Code Status and next to it…

  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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-11 · tag F0700 — pattern
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  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 quarterly assessments to determine the continued need for enabler bars, along with initial and monthly maintenance inspections of enabler bars, for four residents (#2, #71, #75, #76) of four residents reviewed for assist bars. Findings Include: Resident #2: On 4/9/2025 at 11:20 AM, Resident #2 was observed visiting with her son while enjoying lunch. Observed affixed to her bed were bilateral enabler bars. On 4/10/2025 at approximately 9:00 AM, a review was conducted of Resident #2's medical records and it indicated she was admitted to the facility on [DATE] with diagnoses that included, Atrial Fibrillation, Hypothyroidism, Dysphagia, Hypertension and psychotic disorder. Resident #2 required the assistance of one staff for daily cares. Further review was completed and it yielded the following results: Care Plan: Resident #2 does not have a care plan related to their enabler bars. Assist Bar Maintenance Log: Enabler bars installed on…

  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 · D2025-04-11 · tag F0553 — failed to let residents help plan their care — isolated
  Allow resident to participate in the development and implementation of his or her person-centered plan of care.
  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 interview and record review, the facility failed to include and document residents and resident representatives in care conferences for one resident (Resident #158) of one resident reviewed for Care planning participation Findings Include: Resident #158: Care Planning On 4/08/2025 at 11:32 AM, during an interview of the Representative/wife for Resident #158, she said the resident had been at the facility for almost 3 weeks and she had not been asked to participate in a Care conference or Care planning meeting with the resident and facility. She said she was not sure how he was doing or what the plans were for him. Resident #158 confirmed he had not been included in a Care planning meeting. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #158 was admitted to the facility on [DATE] with diagnoses: Dementia, heart failure, kidney failure, an intestinal disorder, sepsis, history of falls, rib fractures and gait and mobility abnormalities. The MDS assessment dated…

  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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-11 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  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 interview and record review the facility failed to timely revise/update care plans for two residents (R33, R63) of five residents reviewed for care plan revision, resulting in care plans not being revised as the status and needs of the residents changed related to weight loss and pressure ulcers. Findings include: Resident #33: Pressure Ulcers R33 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include dementia, major depressive disorder, chronic systolic heart failure, anxiety and hypertension. On 04/09/25 at 10:27AM, record review revealed that R33 has a suspected deep tissue injury (SDTI) on her right heel and ankle. On 04/10/25 at 09:56AM, record review of the admission minimum data set (MDS) does not reference R33 having a SDTI on the right heel and ankle. Record review of a skin assessment dated [DATE] revealed no skin conditions. Record review of a skin assessment dated [DATE] revealed R33 has multiple skin concerns, including an open area on the coccyx and an…

  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 · D2025-04-11 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure documentation, assessment and monitoring of a hand brace/splint for one resident (Resident #53) of one resident reviewed for rehab and restorative services. Findings Include: Resident #53: Rehab and Restorative On 4/09/25 at 9:05 AM, Resident #53 was observed lying in bed in her room; she was awake and talkative. She was observed to have a splint/brace on her right hand. She said her daughter had brought it in for her and the staff assisted her in putting it on and off. The resident was asked if she performed any exercises for her right hand or arm and she said she did not. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] ith diagnoses: paraplegia, heart failure, COPD, diabetes, history of seizures, kidney disease, anxiety and depression. The MDS assessment dated [DATE] revealed the resident had mild cognitive loss and needed…

  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 before2025-04-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  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 interview and record review the facility failed to act timely on a change in mental status for one resident (Resident #11) of one resident reviewed for a change in condition. Findings Include: Resident #11: On 4/9/2025 at approximately 11:40 AM, Resident #11 was observed resting in bed, she appeared to be in good spirits. When asked how her stay has been at the facility, she stated the, staff thinks I'm nuts, the resident was asked to expound upon this, and she explained she sees cats atop her tall dresser, wrapped in her peace sign blanket. The staff tell her that she is nuts due to her observation of cats. She continued the cats resemble wolves and the staff won't grab them down for her. Resident #11 continued she does not see them on a daily basis nor do they cause her any distress. On 4/9/2025 at 1:00 PM, Social Worker B was informed of the discussion with Resident #11 who stated other than depression she does not have a mental health history. Typically, nursing staff will alert her to things of…

  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

$58,583 in federal fines across 2 penalties.

• $42,990 — penalty dated 2025-01-21
• $15,593 — penalty dated 2024-02-15

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.

Part of a chain

This home belongs to THE PEPLINSKI GROUP — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 40 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

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.

This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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