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The Orchards at Samaritan

5555 Conner Avenue, Suite 4000, Detroit, MI 48213 · For profit - Individual · 120 certified beds · (313) 344-4100 Medicare & Medicaid certified

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Flagged for abuse1 actual-harm citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • 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 (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
10809 Mack Ave · (313) 824-1000 · Call to confirm hours
Pharmacy
9934 Harper Ave · (313) 921-3537 · Call to confirm hours
Grocery
10148 Gratiot Ave · (800) 332-2394 · Call to confirm hours
Park
Conner Playfield, 11220 Harper Ave · Typically dawn to dusk
Place of worship
5632 Montclair St · (313) 922-3591

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 2 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 held steady at 2 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 rating2★
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 increased12.8%10.8%15.4%better
Long-stay residents who lose too much weight5.7%5.4%5.4%typical
Long-stay residents with a catheter left in their bladder0.3%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms0.0%4.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.0%3.0%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened10.7%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication8.9%19.4%18.9%better
Long-stay residents given the seasonal flu vaccine97.2%95.0%95.3%typical
Long-stay residents with pressure ulcers3.4%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control22.2%20.0%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table20.2%14.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine53.1%79.5%79.4%worse
Short-stay residents rehospitalized after admission24.1%24.0%22.6%typical
Short-stay residents with an outpatient ER visit8.7%11.7%12.0%better
Long-stay hospitalizations per 1,000 resident days1.761.841.67typical
Long-stay outpatient ER visits per 1,000 resident days0.691.641.80better

* 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.

40.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 44 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

40.5%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
0.20U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% 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 SNF40.5%CMS range 27.2–52.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 7.3–16.810.7%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 dischargenot 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 dischargenot 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 dischargenot 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 identified82.6%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 settingnot 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 dischargenot 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 stay0.0%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 worsened0.0%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 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

0.33
RN hours/ resident / day
1.12
LPN hours/ resident / day
2.09
Aide hours/ resident / day
3.55
Total nurse hours/ resident / day
0.27
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 120 beds and averages 100.0 residents a day — about 83% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 3.09 hrs/resident/day on weekends vs 3.73 on weekdays — 17% thinner on weekends. RN hours go from 0.36 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

9
deficiencies at the latest standard inspection (2025-03-26)
5
at the previous standard inspection (2024-02-29)

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

Inspection deficiencies

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

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.

32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · Gcited before2025-12-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes 2687870 and 2692032.Based on observation, interview, and record review, the facility failed to protect the resident's (R701) right to be free from physical abuse by Certified Nursing Assistant (CNA) B resulting in hospitalization for a dislocated shoulder.Findings include: On 12/16/25 at 10:55 a.m. R701 was observed self-propelling in a wheelchair, with a sling applied to the right arm. R701 was asked what happened to the arm. R701 began to laugh and made an unclear statement. R701 was asked if the arm was in pain. R701 looked at the arm, smiled, and rolled away. On 12/15/25 at 11:35 a.m. the Nursing Home Administrator (NHA) provided the facility reported incident regarding an allegation of staff to resident abuse that occurred on 12/1/25 between 9:30 p.m. and 10:00 p.m. (reported on 12/2/25) involving R701. R701 sustained a dislocated right shoulder and was sent to the hospital for treatment. Review of the Incident Summary documented in part: On 12/2/25 at approximate 4:30 AM,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Actual harm · G2024-11-08 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such 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 This citation pertains to intakes MI00145596 and MI00145720. Based on interview and record review the facility failed to ensure scheduled and as needed pain medications were administered per the physician's orders for one (R103) of three residents reviewed for pain management resulting in uncontrolled pain, frustration, anger, and feelings of helplessness. Findings include: On 11/6/24 at 11:57 a.m. the complainant (R103) was contacted and spoken to about the allegations submitted to the state agency complaint hotline on 7/11/24. The complainant said the complaint was made because of multiple daily calls from R103 not getting pain medication ((R103) would literally be in tears begging me to come get him because he was in so much pain. (R103) called me the first night he was there crying because he couldn't get his pain pill. Nobody would answer the call bell.) The complainant also said R103 left the facility due to not receiving decent medical care. Nurse progress note dated 8/20/24 documented R103 left 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 · Dcited before2026-04-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This citation pertains to intake 2959471.Based on interview and record review, the facility failed to protect the resident's right to be free from misappropriation of property by an employee for one (R115) out of two residents reviewed for abuse resulting in an employee using R115's debit card.Findings include:On 3/16/2026 the State Agency (SA) received a complaint with an allegation of misappropriation of property.On 4/24/2026 at 9:00 AM, the facility incident report dated 2/3/2026 and the facility investigation report and addendum dated 2/13/26 were reviewed with the Nursing Home Administrator (NHA). The NHA said R115 reported on 2/3/2026 that her debit card was missing $981 dollars. Review of the facility investigation revealed that an employee, Certified Nursing Assistant (CNA) J was identified as using R115's debit card based off financial records provided by the debit card company reviewed by the NHA with family friend K.On 4/24/2026 at 9:30 AM, CNA J' was contacted via phone with no response.On 4/24/2026 at 9:35 AM, an attempt was made to contact R115 via phone. The phone…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    This citation pertains to intake 2959471.Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of an injury of unknown origin to the State Agency (SA) for one (R115) of two residents reviewed for abuse.Findings include:On 3/16/2026 the State Agency (SA) received a complaint with an allegation of a resident fall with injury.Review of R115's progress note dated 2/1/2026 revealed, New order for resident per Dr. to complete neuro checks for 3 days every 6 hours for bruise on left side of forehead on eyebrow. New order for Tylenol 650mg q6h prn and apply ice to bruise.Review of R115's Unwitnessed incident report dated 2/2/2026 revealed, Resident observed laying in bed experiencing involuntary rapid movements. Resident observed hitting her right eye and attempting to hold her right arm with her left hand. These movements are uncontrollable by resident at times. Right eye discoloration observed with swelling. Resident has involuntary movement with her head. Swings head abruptly especially when speaking. Resident unable to…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer medications according to physician orders for one (R703) of four reviewed for medications. Findings include:A review of the Electronic Medical Record (EMR) revealed R703 was originally admitted on [DATE] and readmitted [DATE] with diagnoses included Chronic systolic (Congestive) Heart Failure, Acute Kidney Failure and Traumatic Subarachnoid Hemorrhage. Further review revealed a Brief Interview for Mental Status score of 15/15 which indicated intact cognition. Further review of the medical record revealed a progress note dated 2/18/2026 at 20:03 which stated Received resident sitting in chair with pants off with some sob writer administered breathing treatment and explained to resident that dr started them on new med prednisone to help reduce sob (shortness of breath) and to help their lungs fight back writer able to calm resident tolerated meds well can make needs known, continent of bowel & bladder, call light within reach will continue to…

    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 · Past Non-Compliance
  • Potential for harm · Dcited before2025-12-16 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 This citation pertains to intakes 2687870 and 2692032. Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of physical abuse for one (R701) in accordance with section 1150B of the Act, resulting in acts of physical abuse going unreported in a timely manner and further placing residents in harm's way.Findings include: Review of the clinical record documented R701 was initially admitted into the facility on 5/7/20 and readmitted on [DATE] from the hospital for a right dislocated shoulder. R701's other diagnoses include unspecified psychosis, polyneuropathy, adjustment disorder, and dementia. According to the quarterly Minimum Data Set assessment dated [DATE], R701 had severe impaired cognition (BIMS-3) and required total assistance with two-person assistance with activities of daily living. On 12/15/25 at 11:35 a.m. the Nursing Home Administrator (NHA) provided the facility reported incident regarding an allegation of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI00152529 and MI00153381. Based on interview and record review the facility failed to prevent verbal abuse for two residents (R901 and R909) out of five residents reviewed for abuse. Findings include: Record review of Facility Reported Incident dated 5/21/25 revealed an allegation of a staff to resident verbal altercation. Record review of R901's electronic medical record revealed admission into the facility on 7/29/24 with a malignant neoplasm (cancer) of ovary. The Electronic Medical Record (EMR) further revealed R901 had scored 15 out of 15 (intact cognition) on a Brief Interview for Mental Status (BIMS) dated 5/5/25. Record review of R908's EMR revealed admission into the facility on 6/15/23 with a pertinent diagnosis of unspecified dementia. EMR further revealed resident had scored 3 out of 15 (severe impairment) on a Brief Interview for Mental Status (BIMS) dated 6/27/25. Review of a signed written statement from R901 dated 5/21/25, it was documented by R901 that…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-03-26 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    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 a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week; resulting in the potential for inadequate coordination of emergent or routine care that could cause negative outcomes. This deficient practice had the potential to affect all residents in the facility. Findings include: On 3/26/25 at 8:16 AM review of the nurses' schedule for the months of October, November and December 2024 with staffing coordinator H, revealed there was no Registered Nurse (RN) coverage on the following date: October 20th, 2024. Staffing coordinator H acknowledged the facility had difficulty in the past finding RN coverage for weekends and that sometimes the Director of Nursing (DON) would cover a shift. Staffing coordinator H was not aware that the DON coverage does not count towards RN coverage when the facility census is greater than 60 residents. On 3/26/25 at 12:30 PM the DON was interviewed and said there have been times when an RN was not available, and the expectation is that there is 8-hour 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-03-26 · tag F0802 — failed to prepare enough nourishing food — widespread
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    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 employee sufficient dietary staff and ensure operational consultation was provided to supervisory staff, resulting in inadequate sanitation in the kitchen. This deficient practice had the potential to affected 99 of the 104 residents that consumed meals from the kitchen. Findings include: On 3/24/25 at approximately 9:15 A.M. Food Service Supervisor (FFS) D was observed on the [NAME] unit assisting in collecting trays and transporting food carts to the elevator to go to the kitchen. while collecting trays and carts FSS D was checking unit refrigerators and taking resident's requests. At 10:00 A.M. during an observation of the kitchen FSS D was observed organizing the walk-In refrigerator and freezer to place delivered stock. During the observation FSS D was queried concerning current staffing in the department. FSS D reported one employee had called in the current morning and one dietary aide had resigned the previous month, and that position was vacant. During the observation of the sanitation in the kitchen…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-03-26 · 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 provide a safe and sanitary kitchen for food storage, preparation and service, resulting in the potential for food borne illnesses. This deficient practice affected 99 of the 104 residents within the facility. Findings include: On 3/24/25 at 10:00 A.M. and 3/25/25 at 11:40 A.M. the A.M. cook was observed wearing a beard restraint covering his beard but not his mustache. During a follow up observation on 3/25/25 at 11:50 A.M. in the presence of Area Manager (A.M.) F the employee was made aware of the improper use of the restraint and then adjusted it to cover the mustache and beard appropriately. On 3/25/25 at 12:15 P.M. during a lunch meal observation in the [NAME] Unit Dining room (400 hall) a tray with approximately eight containers of potato salad and assorted desserts were placed on top of the steam table cart. At 12:40 P.M., the temperature of the potato salad was recorded at 60 Degrees Fahrenheit (D.F.) There was no ice bath or cooling device in place to maintain proper holding temperature while the items…

    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 · Ecited before2025-03-26 · tag F0761 — failed to label and store drugs safely — pattern
    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 review, the facility failed to ensure proper cleaning and disposal of loose medications were conducted for one medication cart (400 Hall Cart) of four medication carts observed for medication storage and cleanliness. Findings include: On 03/26/25 at 09:35 AM, an observation and interview were conducted with Nurse G's 400 hall medication cart. Upon inspection of medication cart 400, a total of 19 loose pills were scattered on the bottom of the first and second drawers of the medication cart. The loose pills were varied in shapes, colors and sizes. In addition, the first and second drawers of medication cart 400 had dried tan stains, lint, and dust. On 03/26/25 at 09:45 AM, an interview was conducted with Nurse G regarding the loose medications and uncleanliness of medication cart 400. Nurse G said that the cart should be clean. When asked about their policy for loose medications, Nurse G said the pills should have been thrown away. On 03/26/25 at 10:35 AM, an interview was conducted with the Director of Nursing (DON) regarding the 19 loose…

    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 · D2025-03-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to repair the floor of one resident (R95) of three reviewed for a homelike environment resulting in frustration and a potential hazard. Findings include: On 3/24/25 at 11:10 AM, R95 was interviewed about living conditions at the facility and stated, There is a hole in my floor. I asked them to fix it, it's been a year. There was an approximate six by -four-inch patch of missing floor covering observed near R95's foot of bed. R95 verbalized frustration that the hole had not been fixed. On 3/26/25 at 7:43 AM, R95's room was observed with Maintenance Supervisor (MS) C. MS C acknowledged the missing floor tile near the foot of R95's bed. When queried about a work order for the missing tile MS C replied, I'm aware of the tile issue but haven't had the opportunity to fix it yet. MS C said there wasn't a work order for the flooring and the facility staff were not utilizing a formal work order system. MS C acknowledged the repair was not completed…

    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
Show the remaining 20 citations
  • Potential for harm · Dcited before2025-03-26 · 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

    Based on observation, interview, and record review the facility failed to properly store an oxygen tank for one (R33) out of two residents reviewed for oxygen therapy, resulting in the potential for injury. Findings include: On 03/24/25 at 02:09 PM, R33 was observed in bed, on their left side, wearing oxygen via nasal canula. The oxygen was set at 2 liters via concentrator. R33 said that they were oxygen because they are short of breath. The oxygen tubing did not have a date label. On the right side of R33's bed was a green cylinder oxygen tank, the pressure gauge on the regulator needle position was at full. The oxygen tank was observed without a medical rack/stand (oxygen tanks should be stored upright and secured in a stand or cart to prevent them from tipping over, which can cause damage and potential leaks). A review of R33's electronic medical record revealed an admission to the facility on 8/15/2021 with the diagnosis of Stroke, Seizures, Atrial Fibrillation, Asthma, Chronic Obstructive Pulmonary Disease, Diabetes Type II, Heart Disease, Smoker, and Chronic Pain. R33 had a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to date/label oxygen tubing for two residents (R9 and R33) and failed to ensure a physician order regarding oxygen use for one resident (R33) of three residents reviewed for respiratory care. Findings include: R9 On 03/24/25 at 12:39 PM, R9 was observed sitting on the side of the bed, wearing sweatpants and a tee-shirt. R9 was not wearing oxygen at the time. R9 said that they wear oxygen at night or when they are short of breath. R9's oxygen tubing laid across their bed. The oxygen tubing was not labeled with a date. When queried how frequently their oxygen tubing was changed, R9 indicated they were unsure. R9's oxygen concentrator (a medical device that separates nitrogen from the air to be able to breathe up to 95% pure oxygen) was next to their bed with a thick white substance smeared across the top and dust debris in the crevices of the medical device. A review of R9's electronic medical record revealed an admission to the facility on 1/31/2024 with the diagnoses of Morbid Obesity, Seizure Disorder, 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 · D2025-03-26 · tag F0756 — failed to review each resident's drug regimen — isolated
    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 interview and record review the facility failed to address Medication Regimen Review (MRR) recommendations timely for one resident (R4) of five residents reviewed for medication regimen review, resulting in the continuance of unnecessary medications and a lack of communication of recommended medication changes between pharmacist and physician. Findings include: R4 Record review of R4's Electronic Health Record (EHR) revealed R4 was admitted into the facility on 7/21/22 with most recent readmission on [DATE] with diagnoses that included cerebral infarction (stroke), major depressive disorder, and anxiety disorder. According to the quarterly Minimum Data Set (MDS) dated [DATE], R4 had intact cognition. On 3/25/25 at 3:51 PM, R4's monthly Medication Regimen Review irregularity reports dated 1/11/25 were reviewed with the Director of Nursing (DON) and revealed: Please respond to the following: Duplicate orders: It appears the resident has the following duplicate orders that are being administered: 1.…

    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 · D2025-03-26 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two residents (R4 and R5) of five sampled residents reviewed for medications, did not receive unnecessary medications in the form of the prolonged use of a cough syrup and an antacid, resulting in the potential for increased risk of adverse drug effects. Findings include: R5 Review of the electronic medical record documented R5 was initially admitted into the facility on 5/7/20 with a most recent readmission of 1/8/25 with diagnoses that included chronic obstructive disorder (COPD), angina, and dementia. According to the quarterly Minimum Data Set, dated [DATE], R5 had severe cognitive impairment (BIMS=3) and required extensive assistance with activities of daily living. On 3/25/25 at 11:17 a.m. review of the medication regimen review, report dated 7/6/24, documented a request for a stop date for the following order: Guaifenesin 100 mg/5ml two times a day, written on 5/17/24. Review of the physician's order dated 5/17/24 documented Guaifenesin…

    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 · D2025-03-26 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practices. Deficient Practice Statement #1. Based on observation, interview and record review the facility failed to maintain the physical environment in the kitchen in a safe and sanitary manner, repair and replace broken equipment, properly clean steam tables in three dining rooms and replace stained, soiled ceiling tiles. This deficient practice created an environment that lacked cleanliness and increased the potential for food contamination for 99 of 104 residents within the facility. Findings include: On 3/24/25 at 10:30 A.M. and again on 3/25/25 at 12:00 P.M. approximately (12) of the ceiling vents and covers in the kitchen, storeroom, emergency supply storage, and paper supply room were observed to be heavily soiled with blackened soot, ash and grease. In addition, the walls and storage area used for food carts were marked with black rubber scarring and had broken, chipped areas with exposed cement blocks. These areas were in disrepair. In the dish room the ceiling tiles…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-08 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 This citation pertains to intakes MI145596 and MI145720. Based on interview and record review the facility failed to report an allegation of employee to resident abuse to the State Agency for one resident (R103) of three residents reviewed for abuse, resulting in the potential for feelings of not being protected or safe within the facility, and for abuse to continue without being reported. Findings include: On 7/11/24 and 7/16/24, two complaints were reported to the state complaint hotline alleging employee to resident abuse on behalf of R103. The complainants alleged R103 was attacked by a female staff member (slapped residents arm several times). There was no facility reported incident (FRI) submitted by the facility for the allegation. On 11/6/24 at 10:37 a.m. an investigation submitted by the facility was reviewed and documented on 7/14/24 the Nursing Home Administrator (NHA) was notified of an allegation of abuse by staff R103 reported hit by an aide. The NHA concluded the incident did not occur. On 11/6/24…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00147722 and MI00146334. Based on observation, interview and record review, the facility failed to address changes in laboratory findings in a timely manner for R101 of two residents reviewed for a change in condition, resulting in significant critical laboratory values, delay in treatment, and hospitalization. Findings include: On 11/6/24 at 10:56 AM, R101 was observed in their room, wearing a gown, and sitting in a wheelchair. The resident had mild edema (swelling caused by too much fluid trapped in the body's tissues) in both lower legs. R101 was asked about when they became ill and sent to the ER in October. R101 said that they were feeling weak, dizzy, and short of breathe for a few days and was sent to the hospital to receive a blood transfusion. R101 stated that they were still feeling weak and did not feel like dressing. R101 stated, They said I need some iron. A review of R101's electronic medical record noted an initial admission on [DATE] with a diagnosis of Atrial…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the proper storage of a narcotic for one (R103) of three residents reviewed for medication administration potentially resulting in a missed dose, medication waste, and misappropriation. Findings include: Review of the clinical record documented R103 was admitted into the facility on 7/3/24 and discharged on 8/20/24 with diagnoses that included malignant neoplasm of mouth, dysarthria and anarthria, dysphonia, macular degeneration, generalized anxiety disorder, depression, chronic kidney disease, stage 3, and glaucoma. According to the admission Minimum Data Set (MDS) assessment dated [DATE] R103 was cognitively intact (BIMS=15) and required limited one person assistance with activities of daily living. The MDS also documented R103 received scheduled and PRN (as needed) pain regimen and experienced pain or hurting. Review of the physician's orders documented the following pain medication regimen to be administered: Oxycodone HCl Oral Tablet 5 MG…

    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 · Dcited before2024-07-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00145863. Based on interview and record review the facility failed to provide adequate supervision for one (R102) of three residents reviewed for elopement, resulting in R102 exiting the facility without staff knowledge. Findings include: Review of an admission Record revealed, R102 admitted to the facility on [DATE] with pertinent diagnoses which included Dementia and Alcohol Dependence with Alcohol-Induced Persisting Dementia. Review of a Brief interview for Mental Status (BIMS) assessment dated [DATE] revealed R102 had severe cognitive impairment with a score of 4 out of 15. Review of an incident report dated 7/25/24 at 4:10 a.m., revealed, Resident was observed on the blue unit at 7:00pm, he then went to the brown unit where bingo was taking place. Resident was last observed at 8:45pm. Upon doing rounds while passing meds, writer and cena noticed that resident was not in his room. Staff proceeded to search all the units in effort to redirect resident back to his room,…

    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 · E2024-02-29 · tag F0658 — failed to meet professional standards of care — pattern
    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 observation, interview, and record review, the facility failed to ensure medication was administered properly and per physician's orders for four residents (R45, R61, R71, and R84) of eight residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not taken or administered properly. Findings include: In an observation on 2/28/24 at 8:09 a.m., Licensed Practical Nurse (LPN) B was observed at a medication cart preparing medication. Two trays sat on the medication cart. One tray had R45's name and a medication cup and the other had R61's name and a medication cup. LPN B then picked up both trays and entered R45 and R61's room. In an observation on 8:11 a.m., LPN B administered R61's medication and then walked to R45's bed and administered medication. Resident #71 In an observation on 2/28/24 at 8:19 a.m., LPN B prepared medication for R71. LPN B placed six medications in a cup. The medications 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-29 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure 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 administer medications accurately for two residents (R71 and R84) out of six residents during medication pass, resulting in a medication error rate of 17.86 %. Findings include: R71 In an observation on 2/28/24 at 8:19 a.m., LPN B prepared medication for R71. LPN B placed six medications in a cup. The medications did not include Senokot (laxative) or GlycoLax (used for relief of occasional constipation). In an observation and interview on 2/28/24 at 8:23 a.m., LPN B poured liquid protein in a souffle cup (small paper medication cup). LPN B was asked how much liquid protein should R71 receive, LPN B answered 30cc's (cubic centimeters). LPN B reported the liquid protein is poured in the paper medication cup and then into the drinking cup. There were no measurements observed on the small paper medication cup or drinking cup. In an observation on 2/28/24 at 8:27 a.m., LPN B entered R71's room and administered mediation including the liquid…

    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 · D2024-02-29 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 resident (R102) was assessed for self-administration of a medication. Findings include: On 2/27/24 at 11:31 AM, R102 was observed with an inhaler laying on the bed. R102 stated, I like to handle my inhalers myself. Record review of electronic medical records revealed R102 was admitted into the facility on 1/29/24 with a pertinent diagnosis of chronic obstructive pulmonary disease (COPD). According to the Minimum Data Set (MDS) dated [DATE], R102 had intact cognition. Further review of EMR revealed no physician orders to self-administer medications or a self-administration assessment was conducted. During an interview on 2/28/24 at 10:52 AM with Licensed Practical Nurse (LPN) G, it was reported that R102 self-administered inhaler medications. During an interview on 2/28/24 at 12:30 PM, the Director of Nursing (DON), reported that R102 did not have a Physician order or an assessment to self-administer medications and keep at bedside.…

    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 · D2024-02-29 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement a hospice care plan for one resident (R12) out of two residents reviewed for hospice care, resulting in not having goals and interventions to meet R12's hospice care needs. Findings include: On 2/27/24 at 12:30 PM, R12 was observed in room. During an the interview, R12 reported that hospice services did visit often. Record review of R12's electronic medical record (EMR) revealed admission into the facility on 8/3/18 with a pertinent diagnosis of adult failure to thrive. According to the Minimum Data Set (MDS) dated [DATE], R12 had impaired cognition and required assistance with Activities of Daily Living (ADLS). Further record review revealed resident had a significant change of condition on 1/8/24, and hospice services were started. Review of R12's EMR revealed no hospice care plan was implemented for nursing. During an interview on 2/28/24 at 10:46 AM with the Director of Nursing (DON), it was reported that R12 did not have a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed properly store nebulizer (used for breathing treatment) tubing between resident use, for one resident (R258) out of two residents reviewed for respiratory care, resulting in the potential for contamination of respiratory devices and the spread of infection. Findings include: During an observation on 2/27/24 at 9:52 AM, R258's nebulizer tubing and mask was lying on top of nightstand and was not stored in a plastic bag. Record review of R258's electronic medical record (EMR) revealed admission into the facility on 2/14/24 with a pertinent diagnosis of chronic obstructive pulmonary disease (COPD). According to admission progress notes dated 2/14/24, R258 had intact cognition and required limited to maximum assistance with Activities of Daily Living (ADLS). During an observation on 2/28/24 at 8:53 AM, R258's nebulizer tubing and mask was lying on top of nightstand and was not stored in a plastic bag. During an interview on 2/28/24 at 8:53 AM with R258, it was reported that the tubing and mask just laid on 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake number MI00114339. Based on observation, interview and record review, the facility failed to provide timely incontinence care for one resident (R53) of ten residents reviewed for Activities of Daily Living (ADL), resulting in the potential for skin breakdown and infection. Findings include: In an observation on 2/27/24 at 11:52 a.m., R53 laid in bed and the room had a strong urine smell. In an observation on 2/27/24 at 1:56 p.m., Certified Nursing Assistant (CNA) D performed incontinence care for R53. A strong urine smell was noted in R53's room. R53's brief was heavily saturated with urine as evidencd by the dark blue lines down the center of the brief and the bed pad was soiled as evidenced by yellow staining. In an interview on 2/27/24 at 2:02 p.m., CNA D reported R53 was checked and changed at 7am and 12pm. CNA D reported R53's bed pad was changed because it was wet. Review of an admission Record revealed, R53 admitted to the facility on [DATE] with pertinent diagnoses which…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-08 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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

    This citation pertains to MI00129654. Based on observation, interview, and record review, the facility failed to properly date-label food stored in Unit 300's resident refrigerator and store an ice scoop in a clean and sanitary manner. These deficient practices resulted in the potential for food-borne illness for the residents that resided on Unit 300. Findings include: During an observation and interview on 12/7/2022 at 1:35 PM of the Nourishment Room on Unit 300 with nursing Unit Manager (UM) D the following was noted: 1. The ice scoop for the ice chest was stored in a torn disposable cup. The cup was not covered, nor did it have holes for drainage. UM D stated, We normally store it in a plastic bag. 2. The contents of the resident refrigerator revealed the following items were undated and not labeled with a resident's name: a bag with a carryout container of a burger and fries; a bag containing a small container of unidentifiable prepared food, popcorn, and a carbonated beverage; and a bag of a variety of fruit cups. The refrigerator freezer contained an 14-ounce container of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-08 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident's (#59) personal belongings were inventoried and accounted for, of five residents reviewed for personal property, resulting in missing/unaccounted items and resident dissatisfaction. Findings include: During the initial tour of the facility on 12/6/2022 at 1:26 PM, Resident #59 (R59) was observed awake, dressed, and sitting in her room. R59 said that three to four months ago she received an outfit for her birthday. The outfit was a pants and top set both adorned with a lady's face with red lips. R59 stated, I only wore it once. It was a birthday present. It was reported (missing). R59 said she never got the outfit back. A review of the Facesheet for R59 documented an initial admission date of 6/3/2022 and readmission date of 8/9/2022. September is R59's birth month. R59's diagnoses included Diabetes Mellitus-Type 2 and Peripheral Vascular Disease. A Minimum Data Set, dated [DATE], documented intact cognition. On 12/7/2022 at 2:45…

    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 · Dcited before2022-12-08 · 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 obtain physician orders related to the assessment, monitoring, and replacement type and size of a tracheostomy (trache) tube (device inserted in neck to provide an effective airway), affecting one resident (R87) out of one resident reviewed for tracheostomy care, resulting in the potential for infection at the tracheostomy site and the possibility of the wrong tracheostomy tube being used when replacement was needed. Findings include: On 12/6/22 at 11:22 AM, Resident #87 was observed in bed with a tracheostomy tube in place. R87 confirmed that care for the tracheostomy tube was performed independently. Record review of R87's Facesheet revealed admission into the facility on 8/24/21 and readmission on [DATE] with pertinent diagnoses of tracheostomy status and malignant neoplasm (cancer) of larynx (airway to lungs). According to the Minimum Data Set (MDS) dated [DATE], R87 had intact cognition and was provided supervision with most…

    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 · D2022-12-08 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such 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 interviews and record reviews, the facility failed to consistently operationalize procedures related to the completion of dialysis communication forms for one resident (#10) out of two residents receiving dialysis services, resulting in missed opportunities to document and communicate resident's clinical conditions, dietary provisions, and the potential for unmet care needs. Findings include: In an interview on 12/6/22 at12:15 PM, Resident #10 (R10) stated, They do not give me anything to eat before going to dialysis, and the nurses do not come into the room to check on me after dialysis. The nurses are not collecting my dialysis communication forms. A review of R10's medical record revealed an initial admission date of 5/29/22 and readmission date of 9/7/22. R10's medical diagnoses included end stage renal disease (kidney disease) and dependence on renal dialysis (treatment for kidney disease). A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of R10's dialysis care plan…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately store and label medication in two out of four medication carts and one out of four medication storage rooms reviewed for storage and labeling of medications, resulting in the potential for inaccurate medication administration and cross-contamination. Findings included: On [DATE] at 10:28 AM, an observation of the Unit 400 medication cart was made with Licensed Practical Nurse (LPN) J. A NovoLog insulin pen and a Lantus insulin pen were observed with no resident identifier label. On [DATE] at 1:12 PM, an observation of the Unit 200 medication cart was made with LPN K. An Insulin Aspart pen had no resident identifier label. On [DATE] at 1:15 PM, a review of the medication storage room on Unit 200 revealed an over-the-counter vitamin D3 with an expiration date of 4/2020. During an interview on [DATE] at 12:15 PM, the Directore of Nursing (DON) stated, The unit managers are supposed to audit the medication in the storage area every…

    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 THE ORCHARDS MICHIGAN — 15 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 2 of 51.9+0.1 vs chain
Health inspection 2 of 52.0≈ chain avg
Staffing 2 of 51.7+0.3 vs chain
Quality measures 4 of 53.4+0.6 vs chain
The other 14 homes this chain runs (chain average 1.9★, per CMS)

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 / managerTypeRoleSince
THOMAS, JOLANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/06/2025

CMS files one row per role, so the 2 rows in the source record cover these 1 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

$12.6M
Net patient revenuemost recent cost report
+7.0%
Operating marginrevenue minus expenses
$1.3M
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 56%Medicare 7%Other / private 38%

This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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

$298per resident / day
operating cost
$9,057per month
≈ monthly operating cost
$320per 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 235632. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-26, 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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