Iron County Medical Care Facility
1523 U.S. Highway 2, Crystal Falls, MI 49920 · Government - County · 200 certified beds · (906) 875-6671 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- it has an abuse, neglect, or exploitation citation (F0602), cited Apr 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 improved from 1 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.5% | 10.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.8% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.1% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.3% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 6.5% | 4.3% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.3% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 17.4% | 12.0% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 10.9% | 19.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.6% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 28.0% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.9% | 14.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 5.7% | 1.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 95.7% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.6% | 24.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 30.9% | 11.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.81 | 1.84 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.04 | 1.64 | 1.80 | worse |
§ 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.
41.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 41.7%CMS range 27.5–52.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 6.5–16.7 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.5–13.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 200 beds and averages 113.5 residents a day — about 57% occupied, or roughly 86 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 4.20 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.85 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 3.47 hrs/resident/day on weekends vs 4.49 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.83 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 1 administrator has left in the past year.
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 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.
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.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · E2026-06-24 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
All times are noted in Eastern Daylight Time unless otherwise noted. Based on observation and interview, the facility failed to maintain two exterior doors and one interior door, resulting in an increased potential for pest infestation and a possible decrease in satisfaction of living for residents. Findings Include:On 6/23/2026 at 1:25 PM daylight was observed coming in under the exit door #20 in the Skyway Basement, and the door sweep was missing from this door. During this observation, Maintenance Director (MD) D agreed that daylight was visible under this door and stated the door sweep needed to be replaced and that these entry doors received a lot of use, resulting in wear and tear. On 6/23/2026 at 1:34 PM the exterior door on the 200 wing vestibule was observed and had a door sweep that was damaged with a quarter inch space observed between the door and the door jamb, allowing daylight to be visible under the door. Also observed the door sweep missing from the interior door, with an approximate half inch space between the door and the threshold, allowing daylight to be visible…
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.
- Potential for harm · E2025-04-17 · tag F0756 — failed to review each resident's drug regimen — patternEnsure 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 All times are noted in Eastern Daylight Time unless otherwise noted Based on interview and record review, the facility failed to ensure that Medication Regimen Reviews (MRR) were reviewed, addressed by the Physician, and maintained in the clinical record for four Residents (#67, #36, #65, and #90) of five residents reviewed for MRR, resulting in the potential for the administration of unnecessary medications and adverse medication side effects. Findings include: Resident #67 (R67) Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R67 was admitted to the facility on [DATE] with active diagnoses that included: dementia, anxiety disorder, depression, psychotic disorder, and diabetes mellitus. R67 scored a 7 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. Review of R67's Electronic Medical Record (EMR) revealed no pharmacy reports were available for 10/21/24, 11/27/24, 12/26/24, 2/17/25, and 3/21/25. During an interview on 4/16/25 at…
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.
- Potential for harm · E2025-04-17 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 maintain a medication error rate less than 5% in four Residents (#95, #8, #70, & #23) of 12 residents reviewed for medication administration. This deficient practice resulted in a medication administration error rate of 13.33%, based on 4 medication errors in 30 opportunities for error. Findings include: Resident #95 (R95) R95 was admitted to the facility on [DATE] with diagnoses of dementia, Down Syndrome, hypokalemia (low potassium level), and others. R95 had a physician's order dated 4/15/25 to administer three 10 mEq (milliequivalent) Potassium Chloride ER (extended release) capsules. The order contained the instruction: Do not crush. On 4/16/25 at 12:50 PM, Registered Nurse (RN) K was observed preparing and administering medications on the 800-unit, Lilac Lane. When preparing medications for R95, RN K opened the capsules of potassium and crushed the content of the capsules before placing the crushed content in pudding. RN K was asked…
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.
- Potential for harm · Ecited before2025-04-17 · tag F0880 — failed to prevent and control infections — patternProvide 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 ensure hand hygiene was performed during fresh water pass and catheter care, for 7 Residents (R11, R32, R33, R38, R50, R52 and R55), out of 22 sample residents reviewed for hand hygiene. This deficient practice resulted in the potential for cross-contamination of infectious organisms between residents in the facility. All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. Findings include: During an observation of fresh water pass on 4/15/25 at 2:08 p.m. , Certified Nurse Aide (CNA) A was observed delivering fresh water mugs and removing the previously used water mugs from resident rooms. CNA A delivered fresh water and removed previously used water mugs from R11's, R32's, R33's, R52's, R50's, and R38's rooms, without the performance of hand hygiene between rooms. During an interview on 4/15/25 at approximately 2:30 p.m., when asked if they had performed hand hygiene between rooms while passing fresh water and removing used water mugs from resident rooms, CNA A stated, No, I did not…
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.
- Potential for harm · D2025-04-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. Based on observation, interview and record review, the facility failed to 1. Ensure oxygen was administered per physician order and; 2. Ensure maintenance of oxygen and nebulizer equipment in a sanitary manner, for one Resident (#65) of one resident reviewed for oxygen administration. Findings include: Resident #65 (R65) Review of the Minimum Data Set (MDS) assessment, dated 2/2/2025, revealed R65 was admitted to the facility on [DATE] and had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), anxiety and dementia. Further review of the MDS revealed R65 scored 10 out of 15 on the Brief Interview for mental Status (BIMS), indicating the Resident had moderate cognitive impairment. On 4/15/2025 at 2:38 p.m., R65 was observed sleeping in bed and was receiving supplemental oxygen via nasal cannula from a portable oxygen concentrator with a flow rate of three liters per minute (3 L/min). A tag attached to the oxygen tubing 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.
- Potential for harm · D2025-04-17 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to prevent duplicate drug therapy of Vitamin D for one Resident (#90) of five residents reviewed for unnecessary medications. This deficient practiced resulted in an excessive dose of D3 and the potential for Vitamin D toxicity. All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. Findings include: Resident #90 (R90) Review of R90's admission Record revealed admission to the facility on 2/9/24, with current active diagnoses that included: fracture of the left femur, mild cognitive impairment, urinary tract infection and vitamin D deficiency. Review of available Medication Regimen Review (MRR) reports for R90 revealed the following, in part: 1. Consultation Report Date 5/30/24, Comment: [R90] receives ergocalciferol (vitamin D2) 50,000 units weekly on Thursdays. vitamin D3 is more efficiently absorbed and utilized by the body and may be better at increasing and maintaining vitamin D in the body. Recommendation: Please consider changing from ergocalciferol (vitamin D2) to vitamin D3 50,000 units…
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.
- Potential for harm · F2024-04-24 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. This deficient practice placed all 115 residents in the facility at risk for quality care concerns. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted.) During an interview on 4/24/24 at 1:34 PM, the Risk Manager, Registered Nurse (RN) G reviewed the QAPI policy, the attendance documentation for the QAPI meetings and identified the people and positions who were in attendance. The QAPI meeting sign in sheets revealed: 6/28/23: The Director of Nursing (DON), Nursing Home Administrator (NHA), Medical Director, Infection Preventionist (IP), and more than two others were present. 9/27/23: The DON, NHA, IP and more than two others were present. The Medical Director or designee was not present. 11/29/23: The DON, IP and more than two others were present. The Medical Director and NHA were not present. 1/16/24: The DON, NHA, IP and more than two others were…
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.
- Potential for harm · D2024-04-24 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI00140019 and MI00140881. Based on interview and record review, the facility failed to prevent misappropriation of narcotic medication for one Resident (R266) of two residents reviewed for misappropriation. Findings include: All time recorded in Eastern Daylight Time (EDT) unless otherwise noted. R266 was admitted to the facility on [DATE] with diagnoses including unspecified fracture of T7-T8 vertebra (spinal fracture) and ankylosing spondylitis of the thoracic region (inflammatory arthritis affecting the spine). Review of R266's Minimum Data Set (MDS) assessment, dated 10/2/2023, revealed R266 was cognitively intact. Review of R266's Controlled Substance Proof of Use Record, revealed the following: Hydrocodone-Acet [acetaminophen] 5MG [milligram] - 325MG give 1 Tablet By Mouth Every 4-6 Hours As Needed. Amount Received: 30. Date Received: 9/26/23. Further review of the Record revealed the following doses of the medication were signed out by Registered Nurse (RN) H as…
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.
- Potential for harm · D2024-04-24 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 report injuries of unknown source to the state agency for two Residents (R87 and R34) of two residents reviewed for abuse. Findings include: All times are recorded in Eastern Daylight Time unless otherwise noted. Resident #87 (R87) was admitted to the facility with a primary diagnosis of Alzheimer's Disease. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of two of fifteen, indicating R87 was severely cognitively impaired. The MDS documented R87 as having impaired range-of-motion in both upper extremities and both lower extremities. The MDS assessed R87 as being dependent on staff for all Activities of Daily Living (ADL) including mobility and transfers. The MDS indicated R87 was unable to stand or walk. R87 required a mechanical lift to transfer with the assistance of 2 staff. R87's care plan documented the use of a specialized wheelchair for mobility. The care plan indicated R87 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.
- Potential for harm · D2024-04-24 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Interview and record review the facility failed to conduct a thorough and complete investigation for an incident for one Resident (#34) of four residents reviewed for incidents. This deficient practice could result in adverse outcomes and unmet care needs. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted.) Resident #34 (R34) Review of R34's Minimum Data Set (MDS) comprehensive assessment, dated 7/17/23, revealed admission to the facility on 3/10/21, with active diagnoses that included: Alzheimer's disease, anxiety disorder, major depressive disorder, type 2 diabetes, chronic pain, congestive heart failure, and primary hypertension. R34 scored 3 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment. The MDS reveals that R34 requires substantial to maximum assistance to transfer. Review of facility incident report titled In-depth Case Review dated 1/29/23 revealed R34 had a incident on 11/29/23 at 1:30. R34 was found on the floor next to her wheelchair complaining of left pelvic pain. Incident…
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.
Show the remaining 6 citations
- Potential for harm · D2024-04-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and monitor pressure injuries to promote the healing of a facility-acquired pressure injury for One Resident (R109) of six residents reviewed for pressure injuries. Findings include: All times are recorded in Eastern Daylight Time unless otherwise noted. Resident #109 (R109) was admitted to the facility on [DATE]. A Minimum Data Set (MDS) Assessment completed on 12/20/24 documented R109 had no pressure injuries at the time of the assessment. During an interview on 4/23/24 at 9:23 a.m., R109 stated, They told me I have a sore on my bottom from laying on my back. R109 said he did not know how long the wound had been there. When asked if nurses had been assessing and treating the area, R109 said the nurses did not look at it, but instructed him to refrain from lying on his back. A form 'Acute & Chronic Wound Assessment V2' was reviewed. The form documented R109 had a facility-acquired left gluteal pressure injury identified on 3/7/24.…
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.
- Potential for harm · E2023-04-20 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 review, the facility failed to label multi-dose, insulin medications and ophthalmic (eye) medications according to pharmacy recommendations and professional standards of practice and ensure proper storage of medications in three of three medication carts reviewed for medication storage. This deficient practice resulted in the potential for administration of expired medications and decreased therapeutic effects of administered medications. Findings include: All times are recorded in Eastern Standard Time. On 4/19/23 and 3:20 PM, the Lilac Lane of 700 hall medication cart was observed with Licensed Practical Nurse (LPN) C, the following discrepancies were noted: a. Two multi-dose bottles of ophthalmic latanoprost medication eye drops, were opened and undated. b. Three multi-dose insulin glargine pens, two were dated as opened on 4/5/23 and had an expiration dated for 7/5/23, a third was dated as opened on 4/12/23 and had an expiration dated for 7/12/23. c. One loose white, round pill identified as carbamazepine 100 mg tablet was found in 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.
- Potential for harm · E2023-04-20 · tag F0800 — patternProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
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 follow the menu and did not serve planned meal items according to 13 resident tray cards out of 20 meals observed on the Trillium Wing. This deficient practice resulted in the potential for inadequate intake and unmet nutritional needs. Findings include: During breakfast service in the Trillium Dining Room and on the Trillium hallway on 4/20/23 beginning at 8:28 AM, 10 breakfast trays were observed to have 4 oz (ounce) juices served, while the portion size of 8 oz was specified on the tray card. The Dietary [NAME] (Staff O) was serving the food and assembling the trays for the residents. Staff O stated the staff member responsible for pouring the juice knows the residents and there was a list used to pour the beverages prior to the meal service. Staff O did not have 8 oz juices poured so he said he was using the juices that were available. Other observations on 4/20/23 at the breakfast meal included three trays did not receive assorted cold cereal as indicated on the tray cards. Two tray cards revealed coffee…
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.
- Potential for harm · D2023-04-20 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
All times are Eastern Daylight-Saving Time (EDT) unless otherwise noted. Based on observation, interview, and record review, the facility failed to provide adaptive equipment during meal service for two residents (R53 and R65) of five residents reviewed for adaptive equipment use. This deficient practice resulted in increased difficulty with nutritional consumption and had the potential for decreased fluid intake and dehydration. Findings include: During a meal observation in the Trillium Dining Room on 4/20/23 at approximately 8:45 AM, R53 was observed to receive a breakfast meal. The tray card indicated R53 needed a cup with lid and straw. R53 received 4 oz (ounces) of apple juice, and 8 oz of 2% milk. Both beverages were served to R53 with the lids removed and no straw inserted. The Certified Nurse Aide (CNA) L who was serving, stated a straw and lidded cup did not work for R53 who did not suck through a straw but lifted the cups and tilted her head back to drink. During the meal observation, R53 was not observed to lift the beverages on her own. The medical record for R53…
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.
- Potential for harm · Dcited before2023-04-20 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 has two parts: A and B. A. Based on interview and record review, the facility failed to ensure an infection control program with a system of surveillance to identify and investigate a urinary tract infection (UTI) for one Resident (R23), out of three residents reviewed for inclusion on the infection control surveillance line listing and mapping. This deficient practice resulted in the potential for unidentified facility infections, inaccurate infection control surveillance, and the risk of urosepsis for R23. Findings include: All times noted are Eastern Standard Time (EST) unless otherwise noted. Review of R23's Minimum Data Set (MDS), dated [DATE], revealed R23 was admitted to the facility on [DATE] with active diagnoses that included: non-traumatic brain dysfunction, dementia, and psychotic disorder. R23 scored 15 of 15 on the Brief Interview for Mental Status (BIMS), reflective of intact cognition, and was able to make her needs known. During an interview on 4/20/23 at 11:20 a.m., when asked…
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.
- No harm found · C2024-04-24 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all 115 residents. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted.) Review of the CMS PBJ Staffing Data Report FY (fiscal year) Quarter 1 2024 (October 1- December 31) revealed the metric No RN hours and Failed to have Licensed Nursing Coverage 24 hours/day Triggered with Infraction dates being: No RN hours on- 10/8, 10/14, 10/15, 10/21, 10/22, 10/28, 10/29, 11/4, 11/5, 11/11, 11/12, 11/18, 11/19, 11/25, 11/26, 12/2, 12/3, 12/9, 12/10, 12/16, 12/17, 12/23, 12/24, 12/30, and 12/31. Failed to have licensed nursing coverage 24 hours/day-10/14, 10/15, 10/21, 10/22, 10/28, 10/29, 11/4, 11/5, 11/11, 11/12, 11/18, 11/19, 11/25, 11/26, 12/2, 12/3, 12/9, 12/10, 12/16, 12/17, 12/23, 12/24, 12/30, and 12/31. An interview was conducted on 4/24/24 at approximately 11:55a.m., with Registered Nurse (RN)…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| COUNTY OF IRON | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/03/2017 |
| KAUPPI, RYAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2025 |
| OMAN, LYNN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/21/2012 |
| POSSANZA, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/12/2023 |
CMS files one row per role, so the 7 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
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.
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 235257. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, 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.