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Westwood Nursing Center

16588 Schaefer, Detroit, MI 48235 · For profit - Corporation · 108 certified beds · (313) 345-5000 Medicare & Medicaid certified

Call the home — (313) 345-5000 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 May 2026
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
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
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (2/5)

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
13705 McNichols Rd W · (313) 638-9333 · Call to confirm hours
Pharmacy
16800 Schaefer Hwy · (800) 746-7287 · Call to confirm hours
Grocery
16215 Cruse St
Park
13999 Curtis St · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 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 improved from 1 to 3 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 rating3★
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 increased18.1%10.8%15.4%worse
Long-stay residents who lose too much weight4.0%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.4%0.8%0.9%better
Long-stay residents with a urinary tract infection0.3%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 restrained0.5%0.1%0.1%worse
Long-stay residents with falls causing major injury1.6%3.0%3.3%better
Long-stay residents whose ability to walk worsened12.9%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication34.1%19.4%18.9%worse
Long-stay residents given the seasonal flu vaccine66.9%95.0%95.3%worse
Long-stay residents with pressure ulcers6.6%5.1%4.7%worse
Long-stay residents with worsening bladder/bowel control18.7%20.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table46.3%14.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication10.6%1.1%1.4%worse
Short-stay residents given the seasonal flu vaccine20.0%79.5%79.4%worse
Short-stay residents rehospitalized after admission25.8%24.0%22.6%worse
Short-stay residents with an outpatient ER visit10.3%11.7%12.0%better
Long-stay hospitalizations per 1,000 resident days2.021.841.67worse
Long-stay outpatient ER visits per 1,000 resident days2.431.641.80worse

* 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.

34.9% 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.

34.9%U.S. median 51.5%
Got home and stayed home
12.2%U.S. median 10.7%
Went back to hospital
70.8%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 70.8% 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 89 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 SNF34.9%CMS range 21.6–51.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.2%CMS range 8.8–16.610.7%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 discharge70.8%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 discharge71.9%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 discharge58.4%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 identified98.7%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 setting94.0%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 discharge81.0%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 stay0.6%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 worsened0.6%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 hospitalization8.7%CMS range 5.5–14.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.011.02Oct 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

0.25
RN hours/ resident / day
1.10
LPN hours/ resident / day
2.10
Aide hours/ resident / day
3.44
Total nurse hours/ resident / day
0.20
RN hoursweekends
49.0%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 108 beds and averages 106.3 residents a day — about 98% occupied, or roughly 2 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 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 2.83 hrs/resident/day on weekends vs 3.69 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.27 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

4
deficiencies at the latest standard inspection (2025-12-18)
3
at the previous standard inspection (2024-10-11)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · D2026-05-26 · 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 is based on Intake#2993239. Based on interview and record review, the facility failed to thoroughly investigate and elopement for one Resident (R304) of three reviewed for accidents. Findings include: A review of the medical record revealed that R304 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type; Delusional Disorder; and Post-Traumatic Stress Disorder (PTSD). The resident's Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact.Further review revealed that an Elopement Risk Assessment completed upon admission on [DATE] identified R304 as being at risk for elopement, with a score of five. Despite the identified risk, the facility failed to develop a care plan or implement interventions to address the resident's elopement risk.A review of the facility's incident report revealed on 4/6/26 at approximately 12:00 a.m., R304 exited the facility through a second-story window and landed on the ground.…

    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 · D2026-05-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #2993239. Based on interview and record review, the facility failed to provide adequate supervision and implement appropriate safety interventions for one Resident (R304) of three residents reviewed for accidents, resulting in the resident to have jumped out of a two-story window, fracturing (breaking) their leg and required hospitalization. Findings include:Record review revealed the facility submitted an incident report to the State Agency (SA) which stated, in part, that at approximately midnight, Nurse C heard a noise and entered R304's room. Upon entering, Nurse C observed the resident climbing out of the window. Nurse C attempted to intervene; however, the resident jumped from the window and landed on his feet in the yard below. Nurse C instructed a Certified Nursing Assistant (CNA) to call for assistance while additional nursing staff responded to the scene. Emergency Medical Services (EMS) were contacted, and the resident was assessed. Pain and skin assessments were…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-12-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to clean and maintain food service equipment affecting 102 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.Findings include:On 12/15/2025 at 9:00 A.M., An initial tour of the food service was conducted with Nursing Home Administrator NHA and Dietary Manager D. The following items were noted: Domestic hot water supply temperatures were monitored for 2 of 2 hand washing sinks, utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following hot water supply temperatures were recorded: Hand Sink #1: 80.0 - 90.0 degrees Fahrenheit; Hand Sink #2: 85.0 - 95.0 degrees Fahrenheit. The wall mounted paper towel dispensers were also observed non-functional for 2 of 2 hand washing sinks. The Fridgidaire stainless steel refrigerator interior appliance light bulb was observed missing. NHA stated: I will have maintenance replace the bulb. The 2022 FDA…

    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 before2025-12-18 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    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 Based on observations, interviews, and record reviews, the facility failed to clean and maintain the physical plant affecting 103 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and reduced air quality. Findings include:On 12/15/2025 at 09:50 A.M., Three 6-inch by 6-inch [NAME] tiles were observed (cracked, broken, missing), within the facility entrance foyer. Nursing Home Administrator NHA stated: We can just fill the holes in with concrete. On 12/15/2025 at 11:03 A.M., An environmental tour of the facility Laundry Service was conducted with Nursing Home Administrator NHA. The following items were noted: Three of three commercial dryer enclosed fire box exteriors, safety shields, and flooring surfaces were observed soiled with accumulated and encrusted dust and lint deposits. NHA indicated he would have staff thoroughly clean behind the commercial dryers as soon as possible. The flooring surface, located directly behind the two commercial washers, was observed…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-18 · 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 observations, interviews, and record reviews, the facility failed to: (1) provide sufficient domestic hot water supply, and (2) provide appropriate ambient room temperatures affecting 103 residents, resulting in the increased likelihood for resident discomfort.Findings include:On 12/15/2025 at 9:00 A.M., An initial tour of the food service was conducted with Nursing Home Administrator NHA and Dietary Manager D. The following items were noted: Domestic hot water supply temperatures were monitored for 2 of 2 hand washing sinks, utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following hot water supply temperatures were recorded: Hand Sink #1: 80.0 - 90.0 degrees Fahrenheit; Hand Sink #2: 85.0 - 95.0 degrees Fahrenheit. On 12/15/2025 at 12:18 P.M., The 2-North Dining Room was observed unoccupied with a cool/cold ambient air temperature. Note: Residents were also observed seated at bedside tables awaiting their lunch meal, within the adjacent hallway corridor outside 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-18 · 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 and implement a discharge plan of care for one (R66) of six residents reviewed for discharge planning. Findings include: On 12/15/2025 at 9:18 AM, R66 was observed in her room and interviewed. R66 said she was supposed to be discharged from the facility, but no one had come to talk to her about the process. R66 stated, I was only supposed to be at the facility for short term rehabilitation. During the conversation R66 became tearful and anxious. Record review of R66's Electronic Health Record (EHR) revealed she was admitted on [DATE] with pertinent diagnoses of fracture of left fibula, hypertension, cognitive communication deficit, dementia, hypothyroidism, and anemia. The EHR revealed the residents' most recent admission date of 10/28/2025. The resident had a court-appointed guardian. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/2025 revealed a Brief Interview for Mental Status (BIMS) score of 11 -…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-20 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    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 MI00150156. Based on interview and record review, the facility failed to ensure appropriate information was communicated to the receiving hospital for one resident (R105) out of five residents reviewed for transfer. Findings include: It was reported to the State Agency that the facility failed to transfer a resident to the hospital with pertinent medical information. An anonymous complainant reported that the EMTs (Emergency Medical Technicians) that transported R105 to the hospital were only provided a piece of copy paper with the resident's name, date of birth , physician's name, and facility's medical record number for the resident written on it. A review of the clinical record for R105 documented an initial admission date of 8/15/24 and readmission on [DATE]. R105's diagnoses included dementia, unspecified psychosis, and delusional disorders. A Minimum Data Set assessment dated [DATE] documented the resident had severe cognitive impairment. A review of progress notes…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-10-11 · tag F0755 — failed to provide safe pharmacy services — widespread
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to establish a record of receipt, disposition, or reconciliation of controlled drugs (a drug that the government regulates for possession and use, i.e. narcotics) in the facility's back-up box (secured storage unit of controlled drugs), resulting in the facility being unable to account for the receipt of, disposition of, or discrepancies of controlled drugs in the facility's back-up box with the potential for drug diversion and controlled drugs being unavailable to administer to residents as prescribed. Findings include: On 10/08/24 at 3:36 PM the facility's back-up box designated for controlled drugs was observed to have a red plastic lock on it. There was no medication log or any documentation to record what medications were in the back-up box. There was no reconciliation log to determine receipt of, administration of, or disposition of any medication in the medication room. The interim Director of Nursing, Registered Nurse C was present during the observation of the back-up box. RN C said, We don't 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · 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 Review (ARR) form for Mental Illness (MI)/ Intellectual Disability (ID)/ Related Conditions Identification (DCH-3877) document was completed and sent to the local state agency for an evaluation for a Level II determination for one (R1) of six residents reviewed for PASSARs, resulting in R1 not being screened for mental disorder or intellectual disability care needs and the potential for R1's care needs being unmet. Findings include: According to R1's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with diagnoses that included bipolar disorder and schizophrenia. R1 admitted with the following psychoactive medications prescribed: - Duloxetine 60 mg (milligrams) QD (every day) for depression. - Sertraline 50 mg QD for obsessive compulsive disorder and depression. On 9/4/24 the Social Work (SW) progress notes documented the resident admitted with bipolar disorder,…

    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 · D2024-10-11 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 apply hand splinting as ordered for two (R18 amd R81) of five residents reviewed for Range of Motion (ROM), resulting in a potential loss of ROM to dependent residents with known contractures and the potential for decline in overall health status. Findings include: R18 On 10/08/24 at 9:54 AM, R18 was observed in the hallway propelling their wheelchair with their left hand. R18's right hand fingers were curled into the palm. R18 was asked if they could open their right hand and they said, No. I had a stroke and my fingers are stuck this way. R18 was asked if they had a splint and the resident said, They (staff) don't always put it (splint) on. On 10/09/2024 AM at 08:46 AM, R18 was observed in their room sitting in a wheelchair. R18's right hand was wrapped with a white kerlix dressing while holding an Adaptive utensil. R18 was asked why their hand was wrapped. R18 said it wrapped so that they could hold their fork. A review of R18's electronic medical records noted readmission of 1/19/2024 with the diagnosis…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2024-03-29 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    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 MI00143461. Based on interview and record review, the facility failed to ensure resident's medical record accurately documented the administration of prescribed medications for one resident (R101) out of three residents reviewed for medical record documentation, resulting in the potential for staff and providers lacking accurate information to care for the resident. Findings include: A review of the admission Record for Resident #101 (R101) documented an initial admission into the facility on [DATE]. R101's clinical record documented multiple readmissions and discharges, including a readmission on [DATE] with a discharge on [DATE], a readmission on [DATE] with a discharge on [DATE], and finally a readmission on [DATE] with a discharge on [DATE]. R101's diagnoses included foreign body of alimentary tract, unspecified intestinal obstruction, specified eating disorder, non-suicidal self-harm, schizoaffective disorder, anxiety disorder, and bipolar disorder. A Minimum Data Set (MDS)…

    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 · D2024-03-07 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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 an unattached closet door for one resident (R905) of three residents reviewed for environment, resulting in resident dissatisfaction with the living environment and concern over protection of personal belongings. Findings Include: On 3/7/24 at 10:10 AM, R905 was observed pointing at the closet door reserved for R905's belongings. The door was off the hinges and in front of the open closet. The closet items were visible. R905 expressed unhappiness with the condition of the closet door and the exposure of personal belongings. The resident said having the door unattached was upsetting because anyone could come inside the room and see and take personal belongings. The resident stated My Coca Cola was taken. R905 also said the door had been in this condition since his admission, date of, 1/15/24 (over two months). Review of the clinical record of R905 admitted [DATE] according to the MDS (Minimum Data Set) dated 1/22/24 documents 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-07 · 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 This citation pertains to intakes MI142286 and MI141954. Based on observation, interview, and record review, the facility failed to maintain a clean bathroom and comfortable water temperatures for one resident (R902) and failed to maintain a clean bathtub (in a tub room commonly used by residents for toileting) to include R905, resulting in dissatisfaction with facility cleanliness and resident comfort. Findings Include: On 3/7/24 at 10:10 AM R905, was interviewed and expressed dissatisfaction with the cleanliness of the facility, specifically mentioning the tub room, I won't go in there now. Review of the clinical record of R905 admitted [DATE] according to the MDS (MDS (Minimum Data Set) dated 1/22/24 documented that resident has intact cognition. Resident is able to make all needs known independently. On 3/27/24 at 10:25 AM, an observation of the tub room revealed a dry dark green, thick substance covering the area just above the drain for an area approximately the size of a dollar bill and extending side 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-15 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    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 MI00140622. Based on interview and record review the facility failed to inform the resident representative for R901 of a change in condition out of three residents reviewed for hospitalization, resulting in R901's representative being unaware of a change in condition and transfer to the hospital. Findings Include: During an interview on 11/15/23 at 12:45 PM with Concerned Family Member A, it was reported that R901 was sent to the hospital on [DATE] and the facility did not make the family aware. Record review of Nursing Progress Notes dated 10/22/23 noted the following: Writer spoke with Dr (name redacted), regarding resident having diarrhea, and decreased appetite, patient is malaise (with discomfort). Resident stated he feels very ill. Resident requested to go to hospital. Dr (name redacted) gave order to send resident out, ADON (Assistant Director of Nursing) notified. Further record review revealed no documentation that a resident representative was made aware of 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-08-31 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00133617. Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) effectively maintain the food production kitchen physical plant effecting 80 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 08/28/23 at 06:57 A.M., An initial tour of the food service was conducted with Registered Dietetic Technician (DTR) C and Dietary [NAME] F. The following items were noted: The #1 hand wash sink hot and cold-water supplies were observed switched. The hot water supply was observed on the right-hand side and the cold-water supply was observed on the left-hand side. The cold-water supply should be on the right-hand side and the hot water supply should be on the left-hand side of the faucet assembly respectively. The #2 hand wash sink was observed with two actuation knobs, one for cold water and one for hot…

    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 before2023-08-31 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    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 pertains to Intake MI00133617 and MI00134554. Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 80 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased illumination, and cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 8/28/23 at 6:08 AM during the initial tour of the Memory Care unit the following was observed. Two unidentified residents were observed awake and sitting in the Memory Care dining room. Gnats were observed in the dining room. The left side panel of the window air conditioning (AC) unit was not fully closed, creating about a six-inch opened area. A screenless upper window panel in the dining room was opened about six inches. The opened AC side panel and screenless upper window made it possible for flying insects to enter the dining room. On 08/29/23 at 09:00 A.M., An environmental…

    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 before2023-08-31 · 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 This ciations pertains to Intake numbers MI00137230 and MI00137425. Based on observation, interview, and record review the facility failed to maintain a clean and homelike environment by providing storage space to put personal belongings in and remove trash and food off the floor for two residents (#33, #67) reviewed for safe, clean, comfortable homelike environment resulting unsanitary living conditions and the opportunity for missing personal items. Findings include: Resident #33 On 8/28/23 at 9:02 a.m. during the initial pool process, upon entering R33's room there were flies in the room landing on the resident's bed and privacy curtain. Upon further entrance, a pile dried food (noodles and vegetables), a dried red liquid, and plastic cup lids were observed on the floor from the night before. R33 was observed in the bed and asked what happened to the floor. The resident stated, It was an accident. I knocked my tray on the floor. They won't clean it up because I knocked it on the floor by mistake. It happened…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-31 · 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 #MI00137110 and MI00137114. Based on interview, and record review, the facility failed to timely investigate and submit to State Agency reports of abuse for 4 residents (R385, R536, R537, R2) out of 23 sampled residents for abuse resulting in the potential for further allegations of abuse to not be investigated timely. Findings include: R385 Review of the medical record revealed R385 was a [AGE] year old male resident admitted to the facility on [DATE] with diagnoses including postlaminectomy syndrome, abnormalities of gait, and low back pain. Review of the facilities incident report dated 4/20/23 revealed Resident reported to the administrator that he was jumped on by staff on midnight shift. When asked if he could explain what they did to him he expressed that they did like they did to him for 32.5 years that he was locked up. On the night he spoke off the staff at the facility had called the police because of (name of R385's) aggressive behavior; cursing at staff and…

    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 · D2023-08-31 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to develop a dialysis and activity daily living (ADLS) baseline care plan for one (R9) of one residents reviewed for baseline care plans, resulting in the potential for unmet needs of ADLS and dialysis care. Findings include: On 8/28/2023 at 10:28 a.m., R9 dialysis shunt dressing was observed with no date. Facility Staff confirmed later R9 gets dialysis at the facility and the shunt dressing get changed on dialysis days. According to the electronic medical record (EMR), R9 was admitted into the facility on 6/12/2023 with diagnoses of end stage renal disease, fluid overload, proteinuria (Protein in the urine), anemia, secondary hyperparathyroidism of renal origin, hypertension, hyperkalemia (high potassium level), diabetes mellitus type two, chronic diastolic heart failure, peripheral vascular disease, and major depressive disorder. R9's admission Minimum Data Set (MDS) assessment with a reference date of 6/18/2023 indicated R9 was cognitively intact with a BIMS (brief interview for mental status) score of 15/15, required…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-31 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This citation pertains to intake MI00137425. Based on observation, interview, and record review, the facility failed to ensure medication was administered timely and accurately per physician's orders for three residents (#30, #40, #284) of six residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not administered properly. Findings include: Resident #30 In an observation on 8/28/23 at 7:28 a.m. Licensed Practical Nurse (LPN) G prepared medication for Resident #30 (R30). LPN G placed a Ibuprofen (pain reliever) in the medication cup. LPN G then entered R30's room and administered the medication. In an observation and interview on 8/28/23 at 7:28 a.m. LPN G documented the medication administration in the MAR (Medication Administration Record). LPN G reported the MAR screen was red because R30's medications were late. Review of an admission record revealed, R30 admitted to the facility 12/10/14 with pertinent diagnosis which included Pain and Benign Prostatic Hyperplasia (BPH)…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-31 · 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 proper storage of insulin and disposal of expired insulin in one of two medication carts reviewed during inspection of medication carts, resulting in the potential for residents to receive expired medications with altered potency and efficacy. Findings include: In an observation on 8/28/23 at 7:48 a.m., a medication cart on the 1 South unit had undated and expired insulin which included: 1 Humalog Pen 3 Levemir Pens 5 Novolog Pens 3 Novolog vials, 1 vial dispensed on 6/18/23 and 1 vial with a open date of 7/25/23 1 Levemir vial 1 Humalog vial In an interview on 7:52 a.m., Licensed Practical Nurse (LPN) I reported insulin should have an open date when put it in the medication cart. LPN I then reported insulin expires in 28 days. In an interview on 8/28/23 at 11:46 a.m., the Director of Nursing (DON) reported insulin should be dated when opened and put in the cart. DON reported insulin expires 28 days after being in the cart. Review of an Medication Storage policy with a revised date of July 2023 revealed,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-08-31 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to report staffing data to the Payroll-Based Journal (PBJ) with the potential to affect all 80 residents residing in the building. This deficient practice resulted in the potential for staffing concerns leading to quality of care concerns. Findings include: Per a review of the PBJ report for Fiscal Year Quarter 2 2023 (January 1 - March 30), the facility failed to submit data for the quarter. The facility also triggered for a One Star Staffing Rating (indicating a lack of reported staffing or inadequate staffing). On 8/31/23 at 1:5 p.m., the Nursing Home Administrator (NHA) was interviewed about the PBJ report and submission. The NHA said Human Resources (HR) submits to CMS (Center for Medicaid/ Medicare Services). At that time the facility did not have a consistent HR personnel. A new HR was just hired in July.

    Administration 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.

Who owns this facility

Owner / managerTypeRoleShareSince
PATEL, AMEEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL100%since 10/01/2014

CMS files one row per role, so the 5 rows in the source record cover these 1 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$7.5M
Net patient revenuemost recent cost report
-31.3%
Operating marginrevenue minus expenses
$420K
Related-party expense4% of expenses

This home reported $420K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$341per resident / day
operating cost
$10,360per month
≈ monthly operating cost
$260per 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 235444. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-18, 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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