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The Villa at Great Lakes Crossing

22811 W Seven Mile Rd, Detroit, MI 48219 · For profit - Individual · 96 certified beds · (313) 534-1440 Medicare & Medicaid certified

Call the home — (313) 534-1440 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Dec 20241 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • 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
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)

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 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Urgent care / clinic
7800 W Outer Dr · (313) 543-6200 · Call to confirm hours
Pharmacy
Walgreens0.6 mi
20001 7 Mile Rd W · (313) 537-3284 · Call to confirm hours
Grocery
18201 7 Mile Rd W · (313) 534-2233 · Call to confirm hours
Park
Park 8250.4 mi
19613 W 7 Mile Rd · (586) 443-9631 · Typically dawn to dusk
Place of worship
19125 Greenview Ave · (313) 537-2590

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 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 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 increased9.5%10.8%15.4%better
Long-stay residents who lose too much weight4.5%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms6.0%4.3%6.5%typical
Long-stay residents who were physically restrained0.4%0.1%0.1%worse
Long-stay residents with falls causing major injury0.4%3.0%3.3%better
Long-stay residents whose ability to walk worsened15.0%12.0%16.1%typical
Long-stay residents on antianxiety or hypnotic medication7.9%19.4%18.9%better
Long-stay residents given the seasonal flu vaccine96.2%95.0%95.3%typical
Long-stay residents with pressure ulcers5.2%5.1%4.7%worse
Long-stay residents with worsening bladder/bowel control20.9%20.0%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table8.2%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine76.2%79.5%79.4%typical
Short-stay residents rehospitalized after admission29.6%24.0%22.6%worse
Short-stay residents with an outpatient ER visit10.2%11.7%12.0%better

§ 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.

54.8% 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 78 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.8%U.S. median 51.5%
Got home and stayed home
12.0%U.S. median 10.7%
Went back to hospital
42.5%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 42.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 47 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 45% 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 SNF54.8%CMS range 43.1–67.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.0%CMS range 9.2–15.410.7%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 discharge42.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge46.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge48.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified78.3%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge92.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 hospitalization7.2%CMS range 3.8–13.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 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

0.22
RN hours/ resident / day
1.24
LPN hours/ resident / day
1.98
Aide hours/ resident / day
3.44
Total nurse hours/ resident / day
0.12
RN hoursweekends
50.0%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 96 beds and averages 92.5 residents a day — about 96% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.92 hrs/resident/day on weekends vs 3.64 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.26 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% 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

8
deficiencies at the latest standard inspection (2026-02-20)
5
at the previous standard inspection (2025-01-14)

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.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · Gcited before2024-12-11 · 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

    This citation pertains to intake #MI00148730 Based on observation, interview, and record review, the facility failed to ensure the use of an appropriate wheelchair for one resident (R902) of three residents reviewed for accidents, resulting in a fractured tibia and fibula (the two long bones in the lower leg that connect the knee to the ankle). Findings include: An anonymous complaint received by the State Agency alleged R902 was not placed in an appropriate wheelchair for transport and sustained a broken tibia and fibula. On 12/11/24 at 9:34 AM, a power wheelchair was observed in the hallway outside R902's room. It was observed the power chair had very long and wide foot rests to prevent feet from slipping off the foot rests. On 12/11/24 at 9:38 AM, R902 was observed in their bed. At that time, an interview was conducted with R902 regarding an accident that occurred resulting in their broken leg bones. R902 said on the morning of 11/11/24 two Certified Nurse Aides (CNA's), CNA 'A' and CNA 'B' transferred them into a manual wheelchair so they could attend an eye appointment. R902…

    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 before2026-06-10 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff adhered to Enhanced Barrier Precautions (EBP) by wearing the required personal protective equipment (PPE) during wound care for three residents (R401, R402 and R403) of three residents reviewed under EBP due to colonization or risk factors associated with multidrug-resistant organisms (MDROs). The failure to utilize required isolation gowns during high-contact resident care increased the risk of transmission of MDROs and other infectious pathogens among residents.Findings include:On 6/10/26 at 10:40 AM, observed the Wound Care Nurse (WCN) perform wound care to R403's sacral/coccyx wound. After gathering supplies, the WCN cleansed and changed the dressing. Throughout the wound care procedure, the WCN did not wear an isolation gown as required under EBP.On 6/10/26 at 10:50 AM, observed the WCN perform wound care to R401's sacral/coccyx wound. The WCN cleansed the wound and changed the dressing without wearing an isolation…

    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 · F2026-02-20 · tag F0809 — failed to serve meals on a reasonable schedule — widespread
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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 meals were delivered in a timely manner and in accordance with the scheduled mealtimes for the residents. Findings:On 2/18/26 at 11:30 AM, during observation of kitchen lunch service with AM Cook/Manager-in-Training (MiT) D, Dietary Manager (DM) F, and Regional Dietary Director (RDD) K, the steam table was set with pans of food ready to be served to facility residents. The following was noted while obtaining the temperatures of food on the steam table:- The mechanical soft beef stew contained large pieces of stew meat and potatoes approximately the size of golf balls.- The vegetables designated for the residents on a pureed diet contained pieces of pea-sized vegetables.- No pans of pureed meat were present.- The first meal ticket on the tray service line was for a resident on a mechanical soft diet. On 2/18/26 at 11:50 AM, DM F was queried about the consistency of the food prepared for the residents on mechanical soft and pureed diets. DM F said that AM Cook/MiT D indicated that the situation had been…

    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 · F2026-02-20 · 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: 1. Ensure wall surfaces were in good repair and cleanable; 2. Ensure light fixtures, vents, and a resident refrigerator were maintained in a clean and sanitary manner; 3. Ensure cleaned ladles were properly stored; and 4. Properly date-label food in the resident refrigerators. Findings include: On 2/18/26 at 8:47 AM, a tour of the kitchen was conducted with AM [NAME] and Manager in Training (MIT) D and then with Dietary Manager (DM) F. The following items were noted: The wall behind the clean pot/pan shelving unit showed surface damage and paint loss from repeated impact. Two wall panels beside the three-compartment sink drainboard were detached, exposing the raw block wall behind them. A light fixture cover positioned above the cooking range exhibited visible grease accumulation in the form of suspended droplets. DM F said the hood and light fixture covers were cleaned once a month. DM F added, If something looks like it's going to drop in the food, we move stuff (the cooking food) over and clean the light…

    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 · F2026-02-20 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the reach-in cooler, located in the dietary office, was maintained in good working order. Findings include: On 2/18/26 at 9:09 AM, during a tour of the kitchen with Dietary Manager (DM) F, the following was noted: - The temperature log for the reach-in cooler located in the dietary office documented the following AM temperatures:2/15/26: 49 F (Fahrenheit).2/16/26: 48 F2/17/26: 44 F2/18/26: 45 F- The thermometer inside of the reach-in cooler registered 47 F.- The gasket for the left positioned cooler door was not installed which kept the cooler door ajar, causing the internal temperature to rise above safe levels. The door gasket was observed lying on top of a metal shelving unit.DM F said they have been having a little problem with this unit, and that maintenance had been fixing on it. DM F said this refrigerator should be maintained between 30-40 degrees. Staff were to contact maintenance if the temperature was above 40 degrees. On 2/18/26 at 9:11 AM, AM [NAME] D indicated maintenance did not come 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-20 · tag F0636 — pattern
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to complete and/or ensure the timely completion of comprehensive resident assessments (a complete interdisciplinary evaluation of a resident's physical , mental, psychosocial and functional status) in accordance with regulatory requirements for 13 residents (R4, R6, R33, R53, R72, R93, R94, R95, R101, R114, R124, R125, and R139) out of 13 residents reviewed for Minimum Data Set (MDS) assessment accuracy and timeliness.Findings include:During record review the following was identified: R4 Record review of R4's electronic medical record revealed admission into facility on 2/19/25 with a pertinent diagnosis of schizophrenia (mental disorder). Record review of R4's MDS Quarterly Assessment with a due date of 1/29/26 was not completed as required. R6 Record review of R6's electronic medical record revealed admission into facility on 3/4/20 with a pertinent diagnosis of hemiplegia (paralysis). Record review of R6's MDS Quarterly Assessment with a due date of 1/14/26 was completed on 2/19/26. R33 Record review of R33's electronic…

    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 · E2026-02-20 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual 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 prepare meat and vegetables to the proper food consistency for the 23 residents receiving mechanical soft textured meals and 4 residents receiving pureed textured meals in the facility. Findings include: On 2/18/26 at 11:30 AM, during observations of the kitchen lunch service with AM Cook/Manager-in-Training (MiT) D, Dietary Manager (DM) F, and Regional Dietary Director (RDD) K, the steam table was set with pans of food ready to be served to facility residents. The following was noted while obtaining the temperatures of food on the steam table:- The mechanical soft beef stew contained large pieces of stew meat and potatoes approximately the size of golf balls.- The vegetables designated for the residents on a pureed diet contained pieces of pea-sized vegetables.When queried about the size of the stew meat, potatoes, and vegetables, AM Cook/MiT D stated, I was doing too much today. On 2/20/26 at 10:57 AM, DM F indicated that AM Cook/MiT D was informed that the size of the stew meat was too big for the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide scheduled showers for one resident (R37) and timely nail care for one resident (R18) out of three residents reviewed for activities of daily living (ADL). Findings include: R37 – On 2/18/26 at 10:57 AM, R37 was observed awake and lying in bed. R37 stated, I'm not getting showers on a regular basis. I've gone a week and half without one. R37 reported that staff attributed the missed showers to low staffing levels. A review of the clinical record for R37 documented an admission date of 1/2/26 with diagnoses of thoracic spinal cord injury, colostomy status, and neuromuscular dysfunction of bladder. A Minimum Data Set assessment dated [DATE] documented intact cognition and dependence on staff for shower/bathing. Review of R37's care plans documented in part the following: Focus: (R37) requires assistance with daily care needs related to paraplegia. Intervention: Assist resident with ADL's. Total dependence with bathing (on) Tuesday…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure medications were properly stored in accordance with accepted standards in one of three medications refrigerators reviewed. This deficient practice had the potential to affect the safety and integrity of medications stored for resident use.Findings include:An observation conducted on 2/19/2026 at 2:48 PM revealed the second- floor medication refrigerator had multiple medications stored at a temperature of 28 degrees Fahrenheit.Record review of the second-floor medication refrigerator temperature log revealed recorded temperatures ranging between 28 degrees Fahrenheit (F) and 30 degrees Fahrenheit from February 1 through February 19. 2026.Record review of Manufacturers Guidelines a list prepared for all the medications observed in second-floor medication refrigerator by the Director of nursing (DON) revealed that the medications should be stored at a temperature of 36 degrees Fahrenheit to 46 degrees Fahrenheit.During an interview, conducted on 2/20/26 at 11:17 AM with the DON, it was reported that 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-20 · tag F0947 — failed to train nurse aides adequately — isolated
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to ensure three out of five Certified Nurse Aides (CNA O, P, and Q) completed the required 12 hours of annual training to ensure adequate resident care.Findings include:On 2/20/2026 at 10:35 AM, the CNA in-service logs were reviewed with the Human Resources Manager (HRM) R. HRM R said that there were no records for trainings for CNA P and CNA Q and that CNA O did not have the required dementia training. HRM R said the trainings were important because the staff interacts with resident's who have dementia.On 2/20/2026 at 1:05 PM, the Director of Nursing (DON) was interviewed and said the expectation is for CNAs to receive 12-hour annual training including dementia and abuse since we have numerous residents with dementia.Review of the facility policy titled Training Requirements revised 2/2026 revealed in part.2. The following additional training requirements are outlined for all nurse aids: Must be no less than 12 hours per year. Address the care of the cognitively impaired.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-14 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 Preadmission Screening (PAS)/ Annual Resident (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification forms DCH-3877 and/or DCH-3878 documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for mental illness needs in a timely manner for three (R13, R15, and R56) of five residents reviewed for PASAAR, resulting in the potential for residents not to receive care and services appropriate to their mental health needs. Findings include: R13: On 1/12/25 at 1:15 p.m. review of the electronic medical record documented R13 was initially admitted into the facility on 9/6/19 with a readmission on [DATE] with diagnoses that included paranoid schizophrenia. According to the quarterly Minimum Data Set assessment dated [DATE], R13 had a BIMs of 12 (moderate impaired cognition), and required total assistance with activities of daily living. Review of the Preadmission Screening (Level I…

    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
Show the remaining 16 citations
  • Potential for harm · Dcited before2025-01-14 · 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 develop, implement, and revise care plans for one resident (R83) of two residents reviewed with an indwelling catheter, resulting in the potential for a lack of monitoring, implementation of interventions and unmet care needs. Findings include: On 1/13/25 at 5:00 P.M. License Practical Nurse G (LPN) was asked to assist in observing R83's indwelling catheter. Prior to the observation Nurse G reported the resident only had several nephrectomy tubes (a thin flexible tube that drains urine from the kidney into a bag outside the body) and not an indwelling catheter. During the observation Nurse G indicated the indwelling catheter had been discontinued a while ago. However, during the observation an indwelling catheter was present. Review of the electronic medical record (EMR) revealed R83 was admitted to the facility on [DATE] with diagnoses of: Encephalopathy, epilepsy, acute kidney failure, dissection of abdominal aorta and protein calorie…

    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 · Dcited before2025-01-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure appropriate and safe storage of an oxygen tank at the bedside of one Resident 54 (R54) of three residents reviewed for respiratory care, resulting in the potential for environmental hazard and resident injury. Findings include: On 01/12/25 at 10:44 am, an observation of R54 room revealed an oxygen cylinder without a stand, propped between the resident's bed and bedside table. Near the top of the oxygen cylinder regulator, the gauge was at Full. This indicated the cylinder was full of oxygen. If an oxygen tank falls over, it can become a dangerous projectile due to the high-pressure valve releasing oxygen rapidly, creating a risk of explosion, fire, and personal injury. R54 was observed sitting in their wheelchair wearing a nasal canula oxygen tubing. R54 said that they need their oxygen to breathe. R54 stated, Sometimes I get really short of breath and have to turn my oxygen up higher. R54 was asked if he notified staff when they…

    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 · D2025-01-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure an indwelling foley catheter was secured for one resident R16 of four residents reviewed for catheter care with the potential to cause irritation and/or trauma. Findings include: On 1/13/2025 at 11:40 AM, R16 was observed without a leg strap to secure their indwelling foley catheter. R16 was initially admitted on [DATE], with a pertinent diagnosis of Pneumonia, Congestive Heart Failure, Dysphagia (impaired speech), Muscle Weakness, and Bipolar. Record review for R16 Electronic Medical Record (EMR) revealed R16 Annual Brief Interview for Mental Status, (BIMS) on 10/25/2024 was 15/15 for cognition (intact cognition.) On 1/13/2025 at 11:45 AM, an interview with Certified Nursing Assistant, (CNA) D, said there was no leg strap and they would go and get one. On 1/13/2025 at 11:45 AM, an interview with Wound Care Nurse, (WCN) E revealed there was no anchor device attached and they would apply one when they finished wound care. On…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-14 · 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 date respiratory equipment for two residents (F9 and F16) of three residents reviewed for respiratory care. Findings include: R16 On 1/14/2025 at 10:00 AM, R16 was observed with a nebulizer mask and connecting tubing that were not dated. R16 was initially admitted on [DATE], with a pertinent diagnosis of Pneumonia, Congestive Heart Failure, Dysphagia (impaired speech), Muscle Weakness, and Bipolar. Record review of the Electronic Medical Record (EMR) noted R16 Annual Brief Interview for Mental Status, (BIMS) on 10/25/2024 was 15/15, indicating intact cognition. On 1/14/2025 at 10:05 AM Licensed Practical Nurse, (LPN) A was interviewed and said the contracted Respiratory Company comes out on Friday and changes and dates the tubing. R9 On 1/14/2025 at 9:51 AM, R9 was observed with a nebulizer mask and connecting tubing that were not dated. Record Review for R9 EMR showed R9 Annual BIMS on 11/1/2024 was 0/15 for cognition (impaired…

    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 · D2024-12-11 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 #MI00148730. Based on observation, interview, and record review, the facility failed to thoroughly investigate an injury of unknown origin for one resident (R903) of three residents reviewed for abuse. Findings include: An anonymous complaint received by the State Agency alleged the facility improperly transferred a resident causing a broken toe. On 12/11/24 at 11:45 AM, R903 was observed seated in their wheelchair in the dining room on the second floor. It was observed their tongue protruded from their mouth. An interview was attempted with R903, however; they did not verbally respond to attempts at conversation. A review of R903's progress notes was conducted and revealed the following: A note entered into the record by Nurse 'D' dated 11/22/24 that read, .Activity Aide reported resident had pain in left foot upon assessment resident would not let underwriters <sic> touch foot with facial grimaces and moaning. Underwriter called Dr. and ordered x-ray of left foot . A Health…

    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 · D2024-12-11 · 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 intake #MI00147795 Based on observation, interview, and record review, the facility failed to appropriately assess and treat pain for one resident (R903) of three residents reviewed for pain. Findings include: On 12/11/24 at 11:45 AM, R903 was observed in their wheelchair in the activity room on the second floor, it was observed their tongue was protruding from their mouth. Conversation was attempted with R903, however; they did not engage in any type of verbal communication. A review of R903's clinical record was conducted and revealed they admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses that included: cerebral palsy, nutritional deficiency, protein calorie malnutrition, aphasia, and heart failure. R903's most recently completed Minimum Data Set assessment dated [DATE] revealed R903 had severely impaired cognition per staff assessment. Continued review of the record revealed a note entered into the record by Nurse 'D' dated 11/22/24 at 8:22 PM…

    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 · D2024-08-14 · tag F0777 — isolated
    Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
    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 MI00146222. Based on interview and record review the facility failed to inform the Physician of an abnormal x-ray result in a timely manner for one resident (R901) out three residents reviewed for notification of change, resulting in a delay in further treatment. Findings include: During an interview on 8/13/24 at 9:30 AM, R901 reported that after a fall on 7/25/24, pain was controlled with medications, but was not sent to hospital until 7/30/24. Record review of R901's electronic medical record revealed admission into the facility on 6/12/23 with a pertinent diagnosis of muscle wasting. According to the Minimum Data Set (MDS) dated [DATE], R901 had moderately impaired cognitive function and required substantial/maximal assistance with Activities of Daily Living (ADLS). Record review of Progress Notes dated 7/25/24, R901 had an unwitnessed fall. The Physician ordered an x ray of right foot. Record review of Radiology Results Report dated 7/26/24 documented, an x-ray was 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-18 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 MI00144894. Based on observation, interview, and record review the facility failed to administer tube feeding per physician order for one (R604) of three resident's reviewed for tube feeding, resulting in the potential for nutrition needs not being met and un-intended weight loss. Findings include: In an observation on 6/18/24 at 9:09 a.m., R604 did not have a tube feeding running (connected and actively providing nutrition). The tube feeding pump in R604's room did not have formula or water hanging. In an observation and interview on 6/18/24 at 1:44 p.m., Licensed Practical Nurse A turned on R604's tube feeding pump. R604's pump revealed R604 received 815 ml fed and 276 ml flush when the pump was last used. LPN A reported R604's feeding comes down depending on what time it was started. Review of an admission Record revealed, R604 admitted to the facility on [DATE] with pertinent diagnosis which included dysphagia and nutritional deficiency. Review of a Minimum Data Set (MDS) assessment…

    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 · E2024-03-28 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to submit Minimum Data Set (MDS) assessments in a timely manner, for nine (R3, R6, R8, R18, R19, R39, R43, R47, and R73) of 11 residents reviewed for resident assessments, resulting in the delay of time-sensitive information, potentially affecting the level of care and quality of life for the identified residents. Findings include: R18 On 3/27/24 at 11:50 A.M. record review for R18 indicated the resident was admitted to the facility on [DATE]. Review of MDS record revealed R18's MDS assessment was overdue by 120 days. Further record review revealed the assessment completion date was more than 14 days after the assessment reference date (late). R43 On 3/27/24 at 2:30 PM, record review of resident's MDS data revealed R43 was admitted to the facility on [DATE]. R43's quarterly MDS was scheduled to be submitted to the Center for Medicaid Services (CMS) in October of 2023. Record review revealed that the MDS was not submitted until January 2, 2024. R8 On…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-28 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to notify one resident (R88) of three residents reviewed for Beneficiary Protection Notice about the discontinuation of their Medicare part A skilled benefits in a timely manner. Findings include: A review of R88's EMR (Electronic Medical Record) revealed, R88 was admitted to the facility 11/17/23 and discharged from the facility 12/24/23. R88 had the following medical diagnoses: Cellulitis (bacterial infection of the skin typically causing redness and swelling), difficulty walking, and generalized muscle weakness. A review of R88's Quarterly MDS (Minimum Data Set) dated 11/21/23 revealed, R88 had a BIMS (Brief Interview of Mental Status) score of 15/15 (cognitively intact). According to the MDS, R88 was completely dependent with bed mobility, transfers, and toileting. As documented in the MDS, R88 was receiving physical therapy three times a week (therapy start date 11/18/23). A review of R88's SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage) form revealed, R88 was to receive Medicare Part 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-28 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 complete a change in condition PASARR (Pre-admission Screening and Annual Resident Review) Level One Form for one resident (R61) of four residents reviewed for PASSARs, resulting in the PASARR Level Two screening not being completed and potential lack of mental health care services. Findings Include: A review of R61's EMR (Electronic Medical Record) revealed, R61 was admitted to the facility on [DATE]. R61 had a medical diagnosis of Major Depressive Disorder. A review of R61's Quarterly MDS (Minimum Data Set) dated 1/2/24 revealed R61 had a BIMS (Brief Interview of Mental Status) score of 15/15 (cognitively intact). A review of R61's PASARR Level 1 screening, dated 6/19/23 and completed by the local hospital, revealed section two of the document indicated the screening criteria for a PASARR Level 2 referral was documented as No to all questions. Screening criteria questions were related to if the resident had dementia or mental illness, if the resident…

    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 · Dcited before2024-03-28 · 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

    Based on interview and record review, the facility failed to create a comprehensive skin condition care plan for one resident (R27) of one resident reviewed for skin conditions. Findings include: On 3/26/24 at 10:55 AM R27 was observed sitting in a wheelchair in the dining room. R27 had a bump on the left side of her forehead. On 3/27/24 at 1:30 PM Nurse B was queried regarding the bump seen on R27's forehead. Nurse B said R27 had the bump when she was first admitted to the facility. Nurse B said it was not as it was now. Nurse B stated, I have only been here for two months and that is what I was told when I asked. On 3/27/24 at 2:52 PM the DON (Director of Nursing) was interviewed regarding R27's bump on her forehead. The DON said R27 came into the facility with the bump. The DON could not remember what the bump was called. The DON looked into R27's EMR and said she could not find it in R27's diagnoses. The DON called the MDS Nurse C. The DON was heard saying to the MDS Nurse C that the bump should be in the medical diagnoses and that it should be care planned. On 3/27/24 at 3:00…

    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 · Dcited before2024-03-28 · 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 date oxygen tubing for one resident (R61) of three residents reviewed for oxygen use. Findings include: On 3/27/24 at approximately 12:00 P.M., during an observation with the Director of Nursing (DON) of the 100 unit, R61's oxygen tubing was observed undated. The DON inspected the entire oxygen tubing and stated, The company was just here yesterday evening 3/26/24 and they should have placed a date on the tubing, I am not sure why they are not doing that. Review of the Physician orders dated 2/12/24, documented R61 was prescribed: Oxygen (02) 2 Liters via nasal cannula continuous every shift monitor 02 level. On 3/27/24 at 3:30 P.M., review of the admission Record revealed R61 was admitted to the facility 6/19/23, with pertinent diagnoses of: Chronic obstructive lung disease, bipolar disorder, hypertension, and anemia. The Minimum Data Set (MDS) dated [DATE] indicated R61 had a Brief Interview of Mental Status (BIMS) score of 15/15…

    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 before2024-03-28 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform proper hand hygiene and glove usage during catheter care for one resident (R39) of one resident reviewed for urinary catheters resulting in the potential for the spread of infection. Findings include: On 3/27/24 at 10:16 AM an observation was made of R39's catheter care. CNA (Certified Nursing Assistant) F sanitized and donned gloves. CNA F touched R39's chair to see if there were any towels in the chair. CNA F pulled the privacy curtain closed. CNA F placed clean towels on resident bed side table. CNA F positioned R39 flat in bed in preparation for a bed bath. CNA F grabbed a basin from R39's closet. CNA F went into R39's bathroom and filled the basin with water. CNA F took off R39's brief and cleansed R39's perineum (the space between the anus and genitals). CNA F degloved and washed hands. CNA F donned gloves and went into R39's drawer in search for an item. CNA F dried R39's Perineum and placed a gown on R39. CNA F degloved…

    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 · D2023-12-14 · 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 intake MI00141391. Based on interview and record review the facility failed to report an injury of unknown origin to the State Agency (prior to investigation) for one resident (R902) out of three residents reviewed for accidents, resulting in the facility not reporting an injury of unknown origin to the State Agency and the potential for continued unreporting of incidents of unknown injury. Findings include: During an interview on 12/13/23 at 12:30 PM, Concerned Family Member G reported that R902 had sustained a head injury on 11/29/23. Review of R902's face sheet revealed admission into the facility on [DATE] with a Paralytic Syndrome (hard or impossible to move one or more parts of the body). According to the Minimum Data Set (MDS) dated [DATE], R902 had impaired cognition and required staff assistance with all Activities of Daily Living (ADLS). Record review of the facility Incident Audit Report dated 11/29/23, documented the following: . Nursing Description: During rounding writer…

    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 before2023-12-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00141391. Based on interview and record review the facility failed to reposition a total dependent resident (R902) out of three residents reviewed for accidents, resulting in a head injury. Findings include: During an interview on 12/13/23 at 12:30 PM, Concerned Family Member G reported that R902 had sustained a head injury on 11/29/23. Review of R902's face sheet revealed admission into the facility on [DATE] with a pertinent diagnosis of Paralytic Syndrome (hard or impossible to move one or more parts of the body). According to the Minimum Data Set (MDS) dated [DATE], R902 had impaired cognition and required assist with all Activities of Daily Living (ADLS). Record review of Incident Audit Report dated 11/29/23 documented the following: . Nursing Description: During rounding writer observed resident with swollen area to left side of forehead. Resident does not speak and could not explain the reason for the swollen area. Resident was observed lying in bed . (dated 11/29/23 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.

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

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

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 VILLA HEALTHCARE — 18 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 52.8-0.8 vs chain
Health inspection 3 of 52.3+0.7 vs chain
Staffing 1 of 52.7-1.7 vs chain
Quality measures 4 of 54.5-0.5 vs chain
The other 17 homes this chain runs (chain average 2.8★, 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 / managerTypeRoleShareSince
OMNIA OPCO HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2023
AARON, JONATHANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2023
BAUMOL, YEHOSHUAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2023
GRAF, MARCELLAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2023
KNIGHT, NATALIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/06/2023
SINGERMAN, JOSEPHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2023
BERGER, MENACHEMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/16/2025
ISRAEL, BENJAMINIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/16/2025
KROLL, GABRIELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/16/2025
NAGEL, STEVENIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/16/2025
STERN, TODDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/16/2025

CMS files one row per role, so the 14 rows in the source record cover these 11 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.

$11.2M
Net patient revenuemost recent cost report
-6.7%
Operating marginrevenue minus expenses
$1.8M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 66%Medicare 5%Other / private 30%

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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. 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

$365per resident / day
operating cost
$11,111per month
≈ monthly operating cost
$343per 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 235402. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-20, 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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