Dimondale Nursing Care Center

Location & what’s nearby

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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

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.

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.

51.2% 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 114 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 67.1% 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 85 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 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 24% 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.

Staffing

How full it usually is: this home is certified for 150 beds and averages 141.6 residents a day — about 94% occupied, or roughly 8 beds typically open. It runs fairly full. 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 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.28 hrs/resident/day on weekends vs 3.81 on weekdays — 14% thinner on weekends. RN hours go from 0.72 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% 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

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.

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.

30 citations, most serious first. The 14 most serious are shown; the remaining 16 are one tap away and print in full.

• Actual harm · G2025-07-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to correctly identify, treat, resulting in worsening and non-healing of pressure ulcers for three residents (R29, R32, R81) out of five residents reviewed for pressure ulcers. Findings Include: Resident #29 (R29) Wounds were reviewed for R29. Review of the medical record reflected R29 was admitted to the facility on [DATE], with diagnoses that included chronic pain, delirium, and reduced mobility. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R29 scored 9 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Terminal Kennedy ulcers (KTU) and pressure ulcers are both types of skin breakdown, but they are different in their cause, appearance, and meaning. A pressure ulcer happens when there is prolonged pressure on one area of the skin, usually over bony parts of the body. This pressure reduces blood flow to the tissue, eventually leading to skin…

  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
• Actual harm · Gcited before2025-02-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess, monitor, document, and provide appropriate and timely treatment per professional standards of practice for one (#9) of one Residents reviewed for management of known Congestive Heart Failure (CHF-inability of the heart to pump blood efficiently, causing shortness of breath, fatigue, leg and foot swelling, and weakness), resulting in a 44 pound weight gain, shortness of breath, acute respiratory failure with hypoxia, acute pulmonary edema and acute re-hospitalization for acute exacerbation of CHF. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R9 was a [AGE] year old female admitted to the facility on [DATE] with re-admission post hospital stay 1/24/25 related to exacerbation of Congestive Heart Failure(CHF), with diagnoses that included hypertension (HTN, high blood pressure), chronic CHF, chronic kidney disease, diabetes mellitus and depression. The MDS reflected R9 had a Brief…

  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
• Actual harm · Gcited before2024-06-28 · 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 refers to intake MI00145124. Based on observation, interview and record review, the facility failed to competently assess and monitor for changes in condition and notify the physician of pertinent findings in a timely manner for 2 residents (Resident #103 and Resident #104) resulting in the potential for and actual harm from unrecognized, clinically significant changes in condition and uncontrolled pain. Findings: Resident #103(R103) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R103 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included aftercare arthroplasty right hip removal prosthesis and insertion of antibiotic spacer post hip infection, muscle weakness, need for assistance with person care, cardiomyopathy, hypertension (high blood pressure), anemia, atrial fibrillation, and congestive heart disease. The MDS reflected R103 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively…

  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
• Actual harm · Gcited before2024-06-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #121(R121) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R121 was a [AGE] year old male admitted to the facility on [DATE], with recent re-admission post new onset diabetes mellitus on 4/4/24 with prior diagnoses that included traumatic brain injury with left craniotomy, pelvic fracture, hypertension (high blood pressure), diabetes insipidus, seizure disorder, hypopituitarism, hypothyroidism, speech and language deficits following brain injury, weakness, difficulties walking and depression. The MDS reflected R121 a BIM (assessment tool) score of 7 which indicated his ability to make daily decisions was severely impaired. The MDS reflected R121 had no behaviors including rejection of care. During a telephone interview on 6/11/24 at 11:59 a.m., R121's father and Durable Power of Attorney (DPOA) Z verified was R121 responsible party. R12's DPOA Z reported concerns that facility did not notify him of changes in R121 care at times. R121's DPOA Z reported on 3/29/24, when R121…

  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 · F2025-07-08 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record reviews, the facility failed to effectively create and maintain the Water Management Plan effecting 144 residents, resulting in the increased likelihood for development of Legionellosis and other opportunistic waterborne pathogens.Findings include:On 07/01/25 at 09:30 A.M., Record review of the facility Water Management Plan was reviewed with Director of Maintenance (DM) K. The following items were noted:The facility Water Management Plan was observed missing the following content:1. A clear definition of the current Water Management Team Members.2. A written narrative of the potable water supply system from headwork's to sanitary discharge.3. A clear identification of increased and/or high-risk areas within the potable water supply for legionella bacterium development.4. Failure to utilize and follow an accepted industry standard reference resource (American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) 188, Centers for Disease Control and Prevention (CDC), etc.).On 07/01/25 at 10:55 A.M., An interview was…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-07-08 · 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

  Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 144 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality.Findings include:On 07/01/25 at 11:47 A.M., A common area environmental tour was conducted with Director of Housekeeping and Laundry Services (DHLS) J. The following items were noted:1 East (149-170)Soiled Utility Room: The room was observed heavily malodorous from limited return-air exhaust ventilation. (DHLS) J indicated he would contact maintenance for necessary repairs.Shower Room: The return-air-ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. (DHLS) J indicated he would have staff thoroughly clean and sanitize the return-air ventilation grill as soon as possible.1 South (300-324)Nursing Station: 1 of 5 chairs were observed (etched, scored, particulate). The damaged area measured approximately 3-inches-long by 1-inch-wide twice.Pantry/Clean Utility Room: The plaster…

  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 · E2025-07-08 · tag F0609 — failed to report abuse allegations — pattern
  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 Based on observation, interview, and record review the facility failed to ensure 9 out of 10 resident's (Residents #'s 11, 37, 42, 65, 94, 108, 124, 134, & 242) allegations of abuse were reported to the state agency.Findings Included:Per the facility face sheet R11 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 was cognitively intact. Record review of a concern form dated 5/17/2025, revealed R11 had documented on the concern form that she had run out of oxygen, and Certified Nurse Aid (CNA) JJ told her that she had to wait, and proceeded the leave to attend to another resident leaving R11 with no oxygen. R11 documented on the concern form that CNA JJ made her sit in urine soak brief for over six hours, until a nurse made CNA JJ change her. R11 documented that CNA JJ was being rude, R11 told CNA JJ she needed her labia washed due to the soap had not been washed out of…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-07-08 · tag F0610 — failed to investigate and act on abuse reports — pattern
  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 Based on interview, and record review the facility failed to ensure 9 out of 10 residents (Residents #'s 11, 37, 42, 65, 94, 108, 124, 134, & 242) allegations of abuse were thoroughly investigated, assure prevention of further potential abuse, and report the finding within five working days to the state agency. Findings Included:Per the facility face sheet R11 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 was cognitively intact. Record review of a concern form dated 5/17/2025, revealed R11 had documented on the concern form that she had run out of oxygen, and Certified Nurse Aid (CNA) JJ told her that she had to wait, and proceeded the leave to attend to another resident leaving R11 with no oxygen. R11 documented on the concern form that CNA JJ made her sit in urine soak brief for over six hours, until a nurse made CNA JJ change her. R11 documented that CNA JJ was…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-08 · tag F0585 — failed to handle grievances — isolated
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure grievances were promptly documented, investigated, tracked and resolved for one resident of one resident reviewed for grievances (Resident #8). Findings include:Review of the clinical record reflected R8 was admitted to the facility for long term care with diagnoses that included diabetes and hemiplegia. Review of the Minimum Data Set (MDS) dated [DATE], R8 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 07/01/25 11:25 AM, during an interview with R8, he reported multiple missing clothing items that have not been replaced despite multiple complaints. R8 reported this had been an ongoing issue and since his most recent hospitalization from 5/03/25 to 5/08/25 additional items were missing. R8 reported due history of former facility administration rummaging through his personal property and discarding items at will, R8 did not trust facility staff and reached out to the local Ombudsman to get involved in…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure for two out of two residents (Resident #11 and #242) the right to be free from abuse, and involuntary seclusion. Findings Include: Resident #11 (R11) Per the facility face sheet R11 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed R11 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 was cognitively intact.Record review of a concern form dated 5/17/2025, revealed R11 had documented on the concern form that she had run out of oxygen, and Certified Nurse Aid (CNA) JJ told her that she had to wait, and proceeded the leave to attend to another resident leaving R11 with no oxygen. R11 documented on the concern form that CNA JJ made her sit in urine soak brief for over six hours, until a nurse made CNA JJ change her. R11 documented that CNA JJ was being rude, R11 told CNA JJ she needed her labia washed due to the soap had not been washed out of that area yet, 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 · Dcited before2025-07-08 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to label and store medication in accordance with accepted professional principles, for one resident (#111) of seven residents during observation of medication administration, one of eight medication carts (to include medication for resident #342), and one medication refrigerator (one east refrigerator) of six refrigerators reviewed. Findings Included:Resident #111 (R111)Review of the medical record revealed R111 was admitted to the facility 02/16/2024 with diagnoses that included type 2 diabetes, congestive heart failure (CHF), atherosclerotic heart disease (build up of substances in artery walls), hypertension, sleep apnea, insomnia, bilateral cataracts, depression, and gastro-esophageal reflux. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/09/2025, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (intact cognition) out of 15. During observation of medication administration on 7/03/2025 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-07 · 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 Based on interview and record review, the facility failed to notify the physician and PACE((Program of All-Inclusive Care for the Elderly) of a change in condition for 1 resident (R104) of three residents reviewed for change of condition, resulting in R104 being hospitalized . Findings included: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 [AGE] year-old female admitted to the facility on [DATE] from the hospital for respite care, with diagnoses that encephalopathy, seizure disorder, chronic obstructive pulmonary disease, respiratory failure, diabetes, kidney failure, anxiety, and depression. The MDS reflected R104 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for bed mobility, transfers, dressing, bathing and toileting. Review of the complaint received by the State Agency alleged the facility failed to prevent a significant medication error for R104. During a telephone…

  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 before2025-05-07 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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 prevent a significant medication error as evidenced by administration of Metoprolol (beta-blocker blood pressure medications) without monitoring blood pressure prior to administration for resident (R104), resulting in hospitalization. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 [AGE] year-old female admitted to the facility on [DATE] from the hospital for respite care, with diagnoses that encephalopathy, seizure disorder, chronic obstructive pulmonary disease, respiratory failure, diabetes, kidney failure, anxiety, and depression. The MDS reflected R104 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for bed mobility, transfers, dressing, bathing and toileting. Review of the complaint received by the State Agency alleged the facility failed to prevent a significant medication error for R104. During 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 · Past Non-Compliance
• Potential for harm · E2024-06-14 · tag F0561 — failed to honor residents' choices — pattern
  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
  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 their rights to self determination were honored for three residents (resident #15, #63 and #97) of six residents reviewed and facility census of 135 for self determination. Findings Include: On 6/11/24 at approximately 8:30 am, upon entering the facility entrance door, 2 separate typed signs were observed in clear plastic protector and posted on the main entrance door, the first sign read !!ATTENTION!! RESIDENTS & FAMILY DOORS LOCK AT 8 PM ALL RESIDENTS MUST BE INSIDE BY 8 PM The second sign, also in a plastic protector and taped to the door read Resident Visiting Hours Monday-Sunday 8:00 AM - 8:00 PM Resident #15 (R15) Review of the clinical record including the Minimum data Set (MDS) dated [DATE] reflected Resident # 15 (R15) was a admitted to the facility 09/09/23 with diagnosis that included lung cancer, depression and anxiety, further review of the clinical record reflected R15 was receiving hospice care. R15 scored 15 out 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

“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.

Fines & penalties

$35,282 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $35,282 — penalty dated 2025-07-08
• Medicare payment denial — starting 2024-07-17 for 9 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to NEXCARE HEALTH SYSTEMS — 20 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 →

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

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.4M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MI