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Westlake Health Campus

10735 Bogie Lake Road, Commerce, MI 48382 · For profit - Limited Liability company · 61 certified beds · (248) 363-9400 Medicare & Medicaid certified

Call the home — (248) 363-9400 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0740)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
Worth asking about
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1 William Carls Dr · (248) 387-2733 · Call to confirm hours
Pharmacy
1325 E Commerce Rd · (248) 360-5461 · Call to confirm hours
Grocery
535 W Commerce Rd · (248) 363-0535 · Call to confirm hours
Park
360 S Commerce Rd · (248) 926-0063 · Typically dawn to dusk
Place of worship
5236 Carroll Lake Rd · (248) 363-7620

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

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.4%10.8%15.4%better
Long-stay residents who lose too much weight6.7%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.8%1.5%2.0%better
Long-stay residents with depressive symptoms10.5%4.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.1%3.0%3.3%typical
Long-stay residents whose ability to walk worsened0.0%12.0%16.1%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication26.2%19.4%18.9%worse
Long-stay residents given the seasonal flu vaccine97.1%95.0%95.3%typical
Long-stay residents with pressure ulcers1.7%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control18.9%20.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.8%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine98.2%79.5%79.4%better
Short-stay residents rehospitalized after admission29.5%24.0%22.6%worse
Short-stay residents with an outpatient ER visit14.9%11.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.061.841.67worse
Long-stay outpatient ER visits per 1,000 resident days1.891.641.80typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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.

68.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 372 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

68.0%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
80.6%U.S. median 56.6%
Met the expected recovery
0.58U.S. median 0.31
Therapy hours / resident / day
0.27hours / resident / day
Physical therapy
0.25hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 80.6% 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 180 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 0.58 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 34% 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.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF68.0%CMS range 62.7–72.151.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 8.6–13.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge80.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge80.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge73.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting84.5%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge93.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.3%CMS range 4.3–9.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.821.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.31
RN hours/ resident / day
0.91
LPN hours/ resident / day
1.98
Aide hours/ resident / day
4.19
Total nurse hours/ resident / day
0.93
RN hoursweekends
34.3%
Total nursing turnover
26.7%
RN turnover

How full it usually is: this home is certified for 61 beds and averages 58.2 residents a day — about 95% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. 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 4.19 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.31 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 3.63 hrs/resident/day on weekends vs 4.42 on weekdays — 18% thinner on weekends. RN hours go from 1.46 to 0.93 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below the national median of 45%.

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

4
deficiencies at the latest standard inspection (2026-01-07)
5
at the previous standard inspection (2024-10-09)

Deficiencies are fewer than at the previous inspection — improving. 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.

ABCDEFGHIJKL

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.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · G2025-10-07 · 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 #2623642Based on interview and record review, the facility failed to conduct accurate assessments, complete wound treatments per Physician orders, implement interventions in a timely manner and have new wounds regularly assessed by medical providers for one resident (R901) of two residents reviewed for pressure ulcers, resulting in R901 developing two unstageable pressure ulcers on the left and right buttock that worsened into an infection which required an acute care transfer. Findings include:On 10/7/25 a concern submitted to the State Agency was reviewed that alleged R901 developed multiple pressure ulcers that became infected while at the facility. On 10/7/25 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] with diagnoses including Displaced intertrochanteric fracture of left femur, Osteomyelitis (bone infection) unspecified and was discharged to the hospital on 7/14/25. A review of R901's MDS (minimum…

    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 · Past Non-Compliance
  • Potential for harm · Fcited before2026-01-07 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    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 maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: On 1/5/26 at approximately 9:40 a.m., during the initial tour of the kitchen, the following concerns were observed with cook F. Multiple single portioned condiments with an expired use by date (UBD) of 12/25/25 were observed in the reach in refrigerator. Two bags of refrigerated boiled eggs were observed without a UBD. A single serving portioned container of barbeque sauce was observed without any received or used by dates. an uncovered/cooked turkey breast was observed in a pan without any labeling on it indicating a used by date or a cooked date. An opened to air bag of frozen fried chick was observed in the freezer without a UBD or a received date. Two pans of pureed broccoli and green beans were observed without any labeling. A bag of frozen chicken breast was observed 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-07 · 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 has two deficient practices. Deficient practice #1 Based on observation, interview and record review the facility failed to ensure a Physician's order was obtained for a wound dressing for one resident (R75) of one resident reviewed for non-pressure wounds. Findings include:R75 On 1/05/2026 at approximately 10:36 a.m., R75 was observed in their room, laying in their bed. R75 was observed to have multiple foam dressings on their left forearm that were undated and had dried blood showing through. R75 was asked how they got the wound and they reported they had fragile skin and ripped their skin getting out of bed the day before. On 1/6/26 at approximately 11:42 a.m., R75 was observed in their room, up in their bed. R75 was observed to have to multiple foam bandages on their left forearm. The bandages were both dated 1/5/26. R75 was queried regarding the bandages and reported they had been changed by the Nurse the previous night (1/5/26). On 1/7/27 at approximately 8:50 a.m., R75 was observed in their…

    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 · D2026-01-07 · 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 observations, interviews and record reviews the facility failed to ensure nutritional supplements were provided as ordered, failed to ensure timely assistance was provided for meals and failed to modify the plan of care to the resident current needs for one (R8) of three residents reviewed for Nutrition. Findings include:On 1/5/26 at 9:30 AM, R8 was observed lying on their back in bed and did not wake with verbal stimuli. Observed against the wall was R8's breakfast tray with a bowl of dry rice cereal, a sliced banana, yogurt and coffee unopened. Utensils wrapped in a navy color cloth napkin was observed to be unopened. There was no staff present in the room.Review of the meal ticket on the breakfast tray noted the following in part, . Magic cup. Peach Oatmeal. Diced Peaches. Resident Notes: [NAME] Krispies, Diced Banana, Yogurt. decaf coffee. The magic cup was not observed on the resident's tray.On 1/7/26 at 9:04 AM, R8 was observed laying on their back in bed waving their arm with their eyes unopened.…

    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 · D2026-01-07 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Physician orders and a comprehensive plan of care was in place for one resident (R77) on oxygen therapy of one resident reviewed for respiratory care. Findings include: On 1/05/2026 at approximately 10:52 a.m., R77 was observed in their room, up in their wheelchair. R77 was observed to have oxygen infusing at 2 LPM (liters per minute). R77 was asked if they know how much oxygen they should be receiving and they reported they did now know. On 1/6/26 at approximately 2:05 p.m., R77 was observed in the common area, up in their wheelchair. R77 was observed to have a portable E-tank of oxygen infusing via nasal canula at 2.5 LPM. On 1/6/26 at approximately 2:30 p.m., R77 was observed in their room, laying in their bed. R77 was observed to have oxygen infusing at 2 LPM. On 1/6/26 the medical record for R77 was reviewed and revealed the following: R77 was initially admitted to the facility on [DATE] and had diagnosis including Chronic…

    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 · E2025-09-10 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    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: MI002570414. Based on observation, interview and record reviews the facility failed to consistently maintain an ongoing Infection Control Surveillance system and ensure to consistently follow the facility's policy for the Infection Prevention and Control Program. This deficient practice had the potential to affect multiple residents residing in the facility, (including R's 902 and 905) two of three residents reviewed for Infection Control Surveillance. Findings include:R902A review of a complaint submitted to the State Agency (SA) documented concerns of the facility's timeliness to treat R902's bilateral conjunctivitis. The complaint also noted multiple concerns with the facility's Infection Control Surveillance. On 9/9/25 at 11:22 AM, R902 was observed lying on their back in bed. An interview was conducted with the resident at that time. A review of the medical record revealed R902 was re-admitted to the facility on [DATE] with diagnoses that included: acute and chronic…

    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 · D2025-09-10 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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: 2570414. Based on observation, interview and record review the facility failed to follow their policy regarding the follow up of concerns for one (R902) of four residents reviewed for quality of care. Findings include: A review of a complaint submitted to the State Agency (SA) documented multiple concerns verbalized to the facility's staff with no resolution. On 9/9/25 at 11:22 AM, R902 was observed lying on their back in bed. An interview was conducted with the resident at that time. A review of the medical record revealed R902 was re-admitted to the facility on [DATE] with diagnoses that included: acute and chronic respiratory failure, hemiplegia and hemiparesis following cerebral infarction affect left non-dominant side, dysphagia (difficulty swallowing) and required staff assistance for all activities of daily living. R902 was documented to be their own responsible party. On 9/9/25 at 11:45 AM, the facility's Administration was asked to provide all concerns/grievances filed…

    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 · D2025-09-10 · 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 This citation pertains to intake: 2599423. Based on interviews and record reviews the facility failed to ensure a physician order was followed for one (R903) of two residents reviewed for catheter care. Findings include: A review of a complaint submitted to the State Agency (SA) noted that R903 was admitted to on 8/15/25 with a foley catheter due to urinary retention. On the morning of 8/21/25 the resident was . eating in the dining room, and he did not feel good. (R903) looked pale, dizzy, and he did not seem like himself. The complainant stated they requested the nurse to check for a UTI (urinary tract infection). The complainant stated the nurse talked to the doctor who stated . (R903) would have to get blood drawn first, and that it would take two days for the results to come back. The complainant then requested to speak to the doctor and was told the doctor was gone for the day. The complainant stated . felt that they had no choice but to take (R903 name) to the hospital at that point. The resident 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 · D2025-07-23 · tag F0550 — failed to protect resident dignity and rights — isolated
    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 Based on observation, interview, and record review, the facility failed to provide dignified care for one Resident (R500) of four residents reviewed for dignity. Findings include: On 7/23/25 at 12:38 p.m., R500 was observed in their hospital bed wearing a gown. On 7/23/25 at 12:39 p.m., R500 reported earlier in the day Nurse Aide, (NA) C, checked their incontinence brief when they told NA C they did not want to be checked or changed, as their brief was dry. R500 stated NA C checked their brief anyways and said they felt harassed by NA C, as this was intrusive. R500 explained it was their right not to be checked against their wishes, since their brief was dry. On 7/23/25 at 1:21 p.m., NA C was asked what occurred when they checked R500's incontinence brief earlier on 7/23/25. NA C reported they asked R500 if they could check their brief for incontinence, and R500 responded they did not want their brief checked. NA C stated they still checked R500's brief for incontinence, and the brief was dry. When asked why…

    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 · F2024-10-09 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to maintain the exterior dumpster area in a sanitary manner. This deficient practice had the potential to affect all residents in the facility. Findings include: On 10/7/24 at 9:05 AM, 8-10 trash bags were observed on the ground next to the dumpster. There was a brown liquid leaking out onto the ground from one of the bags. Dietary Manager (DM) D stated that the dumpster was probably full, so staff put the bags on the ground. DM D further stated that the dumpster was emptied this morning, but the bags had not yet been transferred into the dumpster.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-09 · tag F0740 — failed to provide behavioral / mental-health care — pattern
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    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 coordination of behavioral health services for five (R4, R17, R35, R32 and R145) of five residents reviewed for behavioral health care, resulting in delayed and/or unmet mental and psychosocial care needs and staff unaware of individualized approaches and targeted behaviors. Findings include: R145 On 10/07/24 at approximately 10:01 a.m., R145 was observed in the hallway/common area sleeping on the couch and was difficult to arouse. On 10/08/24 at approximately 9:25 a.m., R145 was observed in their room, laying in their bed with a nasal cannula that was infusing oxygen at two liters per minutes. R145 appeared to be confused when asking questions regarding the staffing levels in the facility was and providing nonsensical responses. On 10/7/24 the medical record for R145 was reviewed and revealed the following: R145 was initially admitted to the facility on [DATE] with diagnoses that included vascular dementia, unspecified severity,…

    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
Show the remaining 10 citations
  • Potential for harm · D2024-10-09 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 Based on interview and record review, the facility failed to notify, in writing, the reason for a discharge out of the facility to a representative of the State Long term Care Ombudsman for one (R40) of one residents reviewed for discharges. Findings include: On 10/8/24 the medical record for R40 was reviewed and revealed the following: R40 was initially admitted to the facility on [DATE] and was transferred to the hospital on 8/4/24 and did not return. A review of R40's MDS (minimum data set) with an ARD (assessment reference date) of 7/26/24 revealed R40 needed assistance from facility staff with their activities of daily living. A progress note dated 8/04/2024 at 11:19 a.m., revealed the following: Writer received resident resting in bed with eyes open. Resident is A&O x1(alert and oriented to themselves) with some confusion. Resident vital signs WNL (within normal limits), denies pain. CRCA (Certified Nursing Assistant) informed writer resident refused to let CRCA get her dressed and said she is not going…

    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 · D2024-10-09 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 provide a written copy of the bed hold notification to the resident/resident's representative, upon acute transfer to the hospital for one (R40) of one residents reviewed for transfers/discharges. Findings include: On 10/8/24 the medical record for R40 was reviewed and revealed the following: R40 was initially admitted to the facility on [DATE] and was transferred to the hospital on 8/4/24 and did not return. A review of R40's MDS (minimum data set) with an ARD (assessment reference date) of 7/26/24 revealed R40 needed assistance from facility staff with their activities of daily living. A progress note dated 8/04/2024 at 11:19 a.m., revealed the following: Writer received resident resting in bed with eyes open. Resident is A&O x1(alert and oriented to themselves) with some confusion. Resident vital signs WNL (within normal limits), denies pain. CRCA (Certified Nursing Assistant) informed writer resident refused to let CRCA get her dressed and said she…

    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 · D2024-10-09 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record reviews the facility failed to implement an effective antibiotic stewardship program for three (R302, 192, & 193) of five residents reviewed for infections. Findings include: Review of the Center for Disease Control's (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes, dated 2015: .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority.Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics when followed over a year .studies have shown that40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include…

    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 · Fcited before2023-09-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    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 ensure food in the kitchen was stored in a sanitary manner, food items were labeled and dated when opened or prepared, and prepared food and condiments were discarded by their use by dates. This had the potential to affect all residents who eat food from the kitchen. Findings include: On 9/12/23 at 8:50 AM, an observation of the kitchen was conducted with Director of Food Service (DFS) 'K'. The following was observed in the walk-in refrigerator: 1. Corn with a use by date of 9/11/23. 2. Tuna salad prepared by the facility with a use by date of 9/11/23. The following was observed in the reach-in refrigerator that contained beverages: 1. Watermelon juice with a use by date 9/11/23. DFS 'K' reported that all items should be removed and discarded by their use by date. The following was observed in the reach-in refrigerator that contained condiments: 1. 10 single portion cups of mustard with use by date of 9/7/23. 2. 27 single portion mustard with use by date of 9/10/23 3. 8 single portion cups of sour cream 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-14 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 observations, interviews, and record reviews the facility failed to consistently ensure the pharmacist findings documented whether an irregularity was identified or not and failed to ensure the physicians review, action and rationale of the identified medication irregularity was documented and maintained in the resident's medical record for five (R's 12, 8, 6, 35 & 27) of five residents reviewed for unnecessary medications. Findings include: R8 On 9/12/23 at 10:40 AM, R8 was observed sitting in their high back wheelchair in the community room in front of the television. R8 was observed picking at a blanket that covered the lower portion of their body. R8 was dressed appropriately and was observed to be well kept. Review of the medical record revealed R8 was admitted into the facility on [DATE] with a readmission date of 2/16/23 and diagnoses that included: dementia, type 2 diabetes mellitus, hypertension, and falls. A Minimum Data Set (MDS) assessment dated [DATE], documented 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-14 · tag F0578 — failed to honor advance directives / code status — isolated
    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

    Based on observations, interviews, and record reviews the facility failed to consistently educate and offer residents the option to formulate an advance directive and failed to implement an Advance Directive policy that required the facility staff to provide information to the resident and/or resident representative on their rights to formulate an advance directive resulting in the potential for missing information or incorrect wishes for resident's advance directives. Findings include: Review of the facility's policy titled Guidelines for Advance Directives (with a review date of 12/31/22) revealed no documentation to provide information to the resident or resident representative about their rights to formulate an advance directive. On 9/14/23 at 8:50 AM, the facility's Director of Social Work (DSW) C was interviewed and asked about the facility's process in providing new admissions with information and offering them the opportunity to formulate an advance directive and if they choose to formulate an advance directive, what is the facility's protocol. DSW C stated they do confirm…

    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 · D2023-09-14 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 observations, interviews, and record reviews the facility failed to ensure professional standards of practice was consistently implemented by the facility nursing staff (medication administration for R35, R41, R45). Findings include: Medication Administration Observation On 9/13/23 at approximately 8:55 AM, Registered Nurse (RN) L was observed preparing the morning medications for R41. RN L was observed to have administered R41's medications and exited the room. RN L discarded a few needles in the sharps and then stated they were going to obtain the blood pressure of another resident. Review of R41's September 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed RN L did not sign R41's morning medications as administered. On 9/13/23 at 10:59 AM, RN L was interviewed and shown R41's September 2023 MAR and TAR and asked why they failed to document the morning medications as administered. RN L stated they didn't know what happened but would follow up immediately.…

    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 · D2023-09-14 · 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 Based on observation, interview, and record review, the facility failed to prevent recurrent skin tears during mechanical lift transfers for one (R40) of two residents reviewed for accidents. Findings include: On 9/12/23 at 9:45 AM, R40 was observed lying in bed. A fall mattress was observed on both sides of the bed. At that time, R40 did not wish to answer questions. Review of R40's clinical record revealed R40 was admitted into the facility on 9/21/20 with diagnoses that included: hydrocephalus, Type 2 diabetes mellitus, and dementia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R40 had severely impaired cognition, no behaviors, required extensive physical assistance from at least two staff members for bed mobility, and was totally dependent on at least two staff members for transfers. On 2/19/23 at 11:27 AM, the following was documented in a Nursing progress note: During the morning patients care, while resident was transferring by 2 staff members from the bed to the wheelchair by 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-14 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 ensure the proper disposal of a controlled medication was completed (for R35) by one (Licensed Practical Nurse - LPN) M of four nurses observed for the medication administration observation. Findings include: On 9/13/23 at 9:18 AM, LPN M was observed preparing the morning medications for R35. LPN M was followed into the unit 100 hallway to obtain a medication from the units' medication storage room. LPN M obtained the needed medication from the storage room and was observed to have dropped four pills from R35's medication cup. The four pills identified were tolterodine 4 mg (milligram) extended-release capsule, potassium chloride 10 mEq ER (extended release) tab, gabapentin 100 mg capsule and docusate sodium 100 mg capsule. LPN M was observed to discard all four medications into the medication cart sharp container and proceeded to obtain another tolerodine capsule, potassium chloride tab, gabapentin capsule and docusate sodium capsule from the medication cart and controlled medication storage. LPN M 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-14 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record reviews the facility failed to consistently ensure medications were properly secured for two medication carts of four medication carts reviewed. Findings include: On 9/13/23 at 8:40 AM, an observation was made of the 300-hallway medication cart to have been unlocked and unattended. The medication cart drawers were opened to verify that the cart was unlocked. Observed in the medication cart was the medications for all of the residents that resided on the 300-hallway. At 8:51 AM, Registered Nurse (RN) L returned to the cart and was asked the facility's protocol on locking the medication carts and RN L explained that the cart should be locked when they walk away from it, however they stepped away from the cart briefly to help the aide with resident and forgot to lock the cart. On 9/13/23 at 9:30 AM, an observation was conducted of Licensed Practical Nurse (LPN) M preparing the morning medications to administer to R35. LPN M obtained the prepared cups of medications and left the medication cart unlocked. LPN M was followed into R35's room, LPN…

    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.

    Pharmacy Service 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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to TRILOGY HEALTH SERVICES — 123 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 →

RatingThis homeChain avg
Overall 4 of 54.2-0.2 vs chain
Health inspection 3 of 53.5-0.5 vs chain
Staffing 5 of 53.3+1.7 vs chain
Quality measures 4 of 54.8-0.8 vs chain
The other 122 homes this chain runs (chain average 4.2★, per CMS)
1 of 5Heritage TheFindlay, OH 1 of 5The Oaks Rehabilitation and Healthcare CenterZanesville, OH 2 of 5Homewood Health CampusLebanon, IN 2 of 5Violet Springs Health CampusPickerington, OH 2 of 5Woodmont Health CampusBoonville, IN 3 of 5Cobblestone Crossings Health CampusTerre Haute, IN 3 of 5Creasy Springs Health CampusLafayette, IN 3 of 5Cumberland Pointe Health CampusWest Lafayette, IN 3 of 5Forest Park Health CampusRichmond, IN 3 of 5Franciscan Health Care CenterLouisville, KY 3 of 5Greenleaf Health CampusElkhart, IN 3 of 5River Terrace Health CampusMadison, IN 3 of 5Scenic Hills At The MonasteryFerdinand, IN 3 of 5Smiths Mill Health CampusNew Albany, OH 3 of 5Springhurst Health CampusGreenfield, IN 3 of 5Springs Of Richmond, TheRichmond, IN 3 of 5St Mary Healthcare CenterLafayette, IN 3 of 5Stonegate Health CampusLapeer, MI 3 of 5Sun Prairie Senior LivingSun Prairie, WI 3 of 5Taylor Springs Health CampusGahanna, OH 3 of 5The Willows at Fritz FarmLexington, KY 3 of 5The Willows at HamburgLexington, KY 3 of 5The Willows at HarrodsburgHarrodsburg, KY 3 of 5The Willows at SpringhurstLouisville, KY 3 of 5Villages At Oak Ridge, TheWashington, IN 3 of 5Waunakee Valley Senior LivingWaunakee, WI 3 of 5Wellbrooke Of CarmelCarmel, IN 4 of 5Arlington Place Health CampusIndianapolis, IN 4 of 5Ashford Place Health CampusShelbyville, IN 4 of 5Aspen Place Health CampusGreensburg, IN 4 of 5Avalon Springs Health CampusValparaiso, IN 4 of 5Bethany Pointe Health CampusAnderson, IN 4 of 5Blair Ridge Health CampusPeru, IN 4 of 5Bridgepointe Health CampusVincennes, IN 4 of 5Cedar Creek Health CampusLowell, IN 4 of 5Clearvista Lake Health CampusIndianapolis, IN 4 of 5Forest Springs Health CampusLouisville, KY 4 of 5Glen Oaks Health CampusNew Castle, IN 4 of 5Glen Ridge Health CampusLouisville, KY 4 of 5Meadows Of Delphos TheDelphos, OH

Showing 40 of 122; lowest-rated first.

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

Owner / managerTypeRoleShareSince
CONTINENTAL MERGER SUB LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
NORTHSTAR HEALTHCARE INCOME INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
NORTHSTAR HEALTHCARE INCOME OPERATING PARTNERSHIP LPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
TRILOGY HOLDINGS NT-HCI, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
LANCASTER POLLARD MORTGAGE COMPANY LLCOrganization5% OR GREATER MORTGAGE INTERESTsince 04/27/2017
CORBIN, KATHYIndividualW-2 MANAGING EMPLOYEEsince 08/16/2011
FIGHTMASTER, LISAIndividualW-2 MANAGING EMPLOYEEsince 12/01/2015
BARNEY, LEIGHIndividualCORPORATE OFFICERsince 11/01/2019
BRYANT, WILLIAMIndividualCORPORATE OFFICERsince 01/05/2016
BUFFORD, RANDALLIndividualCORPORATE OFFICERsince 11/01/2019
CONNER, GREGORYIndividualCORPORATE OFFICERsince 06/03/2021
DAVIS, DAVIDIndividualCORPORATE OFFICERsince 08/21/2017
MEHAFFEY, TODDIndividualCORPORATE OFFICERsince 01/31/2022
PIETROWSKI, CRISTINAIndividualCORPORATE OFFICERsince 01/31/2022
PROSKY, DANNYIndividualCORPORATE OFFICERsince 12/01/2015
STREIFF, MATHIEUIndividualCORPORATE OFFICERsince 12/01/2015
TRILOGY MANAGEMENT SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2021
HAYES, BRENTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2021

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.

$15.7M
Net patient revenuemost recent cost report
+9.3%
Operating marginrevenue minus expenses
$2.0M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 23%Medicare 11%Other / private 66%

This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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

$381per resident / day
operating cost
$11,596per month
≈ monthly operating cost
$420per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.

Typical monthly cost in Michigan
$11,254/mo
Nursing home (semi-private)
$11,969/mo
Nursing home (private)
$5,818/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235642. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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