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Bay County Medical Care Facility

564 West Hampton Road, Essexville, MI 48732 · Government - County · 161 certified beds · (989) 892-3591 Medicare & Medicaid certified

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Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$165,536 in federal fines2 Medicare payment denials
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $165,536 in federal fines (most recent 2025-03-11)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1458 W Center Rd · (989) 895-4830 · Call to confirm hours
Pharmacy
1454 W Center Rd Ste 2 · (989) 316-4280 · Call to confirm hours
Grocery
578 W Center Rd · (989) 893-8281 · Call to confirm hours
Park
873 W Ridge Rd · 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 3 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.9%10.8%15.4%better
Long-stay residents who lose too much weight6.3%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.8%0.9%better
Long-stay residents with a urinary tract infection0.3%1.5%2.0%better
Long-stay residents with depressive symptoms1.9%4.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.3%3.0%3.3%better
Long-stay residents whose ability to walk worsened5.1%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.9%19.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers3.0%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control23.4%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.9%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine96.4%79.5%79.4%better
Short-stay residents rehospitalized after admission29.3%24.0%22.6%worse
Short-stay residents with an outpatient ER visit10.6%11.7%12.0%better
Long-stay hospitalizations per 1,000 resident days2.481.841.67worse
Long-stay outpatient ER visits per 1,000 resident days2.161.641.80worse

§ 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.

47.2% 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 123 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.2%U.S. median 51.5%
Got home and stayed home
13.8%U.S. median 10.7%
Went back to hospital
34.9%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 34.9% 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 66 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 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF47.2%CMS range 38.4–55.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.8%CMS range 10.1–18.110.7%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 discharge34.9%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 discharge24.2%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 discharge31.8%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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.4%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 hospitalization6.8%CMS range 3.4–10.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 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

1.32
RN hours/ resident / day
1.32
LPN hours/ resident / day
3.75
Aide hours/ resident / day
6.39
Total nurse hours/ resident / day
0.79
RN hoursweekends
53.9%
Total nursing turnover
80.8%
RN turnover

How full it usually is: this home is certified for 161 beds and averages 93.7 residents a day — about 58% occupied, or roughly 67 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.39 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.32 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.75 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 5.39 hrs/resident/day on weekends vs 6.79 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.53 to 0.79 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

8
deficiencies at the latest standard inspection (2026-04-29)
5
at the previous standard inspection (2025-04-17)

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.

26 citations, most serious first. The 13 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2025-12-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake 2660956.Based on interview and record review, the facility failed to protect the one (#701) resident's right to be free from sexual abuse by another resident of three residents reviewed resulting in a non-verbal, severely cognitively impaired resident (#701) having their genital area touched by Resident #702, and staff not immediately separating the residents. Findings include:Review of Facility Reported Incident (FRI) documentation revealed on 10/12/25 at approximately 11:37 AM, the Administrator was informed of allegation of sexual abuse involving Resident #701 and Resident #702. Per the FRI, Resident #702 is Resident #701's father and was witnessed by staff with their placed on (Resident #701's) groin region. An interview was conducted with the Director of Nursing (DON) on 1218/25 at 10:00 AM. During the interview the DON verbalized the facility switched Electronic Medical Record (EMR) system from Matrix to Point Click Care (PCC) on 10/1/25. Review of facility provided…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Actual harm · G2025-04-17 · 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 1) Prevent and implement preventive measures to avoid pressure ulcers for 2 residents (Resident #39 and Resident #62) of 3 residents reviewed for pressure ulcers and 2) Follow through with the intervention of an air mattress for 1 resident (Resident #39), resulting in Resident #62 having a facility-acquired, preventable, Stage IV pressure ulcer and, for both residents, an increased likelihood for infection, cross contamination, antibiotic usage with side effects, pain, and discomfort. Findings Include: Resident #39: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 7/24, and physician orders dated 4/13/25 through 4/17/25, and nurses' progress notes dated 4/13/25 through 4/17/25, revealed Resident #39 was [AGE] years old, admitted to the facility on [DATE], alert and able to make own healthcare decisions, had a trach (artificial breathing stoma) and dependent on staff for Activities of Daily Living/ADL. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-03-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to adequately supervise and prevent injuries/falls for three residents (Resident #7, Resident #18, Resident #279), resulting in multiple injuries of residents and prolonged illness and hospitalizations. Findings included: Record review of the facility 'Compliance with Reporting Allegations of Abuse/Neglect/Exploitation' policy dated 3/30/2023 revealed it is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the administrator of the facility and to other appropriate agencies. Injuries of unknown source: Includes circumstances when both the following conditions are met. (i.) The source of the injury was not observed by any person or could not be explained by the resident. (ii.) The injury is suspicious because of the extent of the injury, location of the injury, the number of injuries…

    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 before2026-04-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include: On 04/27/2026 at 9:27 AM, during the initial kitchen tour with Director of Dining Services L, observed the drain line to the ice machine sitting inside the drain. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 04/27/2026 at 9:54am observed the interior walls of the microwave visibly soiled in the one east kitchenette. During this observation, Director of Dining Services L was interviewed on how often the microwave is cleaned, and he stated it's cleaned after every use. On 04/27/2026 at 10:00am observed the interior wall of oven door visibly soiled with grease in the one west kitchenette.…

    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 before2026-04-29 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP) and, follow enhanced barrier precautions (EBP) for residents identified with qualifying wounds, for one resident #65 (R65) of three residents reviewed for infection prevention. This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility.Findings include: On 04/27/2026 at 9:27am observed ice machine filter dated 4/30/2020. On 04/27/2026 at 1:28pm observed an unused ozone treatment for the washers located in the laundry chemical room. The ozone tanks are partially capped from the plumbing system leading to the washers, but it remains connected to the water lines leading out towards the hallways. During this observation, Environmental Services Director O 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 · F2026-04-29 · 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 observation, interview, and record review, the facility failed to ensure appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for contamination to the water supply, affecting all residents. Findings include:On 04/27/2026 at 9:50am observed chemical feeder downstream of an atmospheric vacuum breaker (AVB) at the mop sink in the janitor's closet adjacent to the kitchen. On 04/27/2026 at 10:15am observed hose with attached spray nozzle downstream of a hose bib vacuum breaker (HBVB) in the trash compact area. On 04/27/2026 at 10:16am observed chemical feeder downstream of an AVB in the trash compact area. On 04/27/2026 at 1:54pm observed outside spigot with an attached hose without backflow prevention. During this observation, Assistant Director of Plant Operations N stated the backflow preventer is on work order, but they haven't gotten to installing them yet. On 04/27/2026 at 2:08pm observed an inside spigot with an attached hose without backflow prevention in the old garage. During this observation, Assistant Director of Plant…

    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 before2026-04-29 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 that timely care was provided in a dignified manor to 3 of 3 residents reviewed for dignity (Residents R4, R10 and R45).Findings include: A review of R4's medical record revealed an admission into the facility on 2/20/24 and re-admission on [DATE] with diagnoses that included paraplegia, muscle weakness and open wound of scrotum and testes. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 10/15 that indicated moderately impaired cognition and the Resident was dependent on helper for personal hygiene and toileting hygiene and needed substantial/maximal assistance to roll left and right. On 4/29/26 at 9:20 AM, an observation was made of the Resident lying in bed. CNA R had the Resident positioned flat on his back with covers off, gown pulled up, and incontinence brief opened. The CNA was assisting with perineal care. The Resident's bed was elevated to about window height. There was a…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-29 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 advance directives were in place and completed appropriately for one resident (Resident #99) of one resident reviewed for advanced directives.Findings include:Review of the medical record revealed Resident #99's (R99) most recently admitted to the facility on [DATE] with diagnoses that included cerebral infarction, heart disease, heart failure, atrial fibrillation and dysphagia.Further review of the medical record revealed R99 was able to make his own informed medical decisions. Review of the Minimum Data Set assessment dated [DATE] revealed R99 was cognitively intact and was able to make his own medical decisions.Review of R99's Resident Code Status and Specific Treatments form dated 4/16/26 revealed that Do not resuscitate (DNR) was selected, however R99 did not sign the form, rather R99's wife had signed the form.Further review of R99's medical record failed to reveal any type of Durable Power of Attorney (DPOA) for Health Care (HC)…

    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 · D2026-04-29 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 provide clinical rationale for administration of duplicate/triplicate antidepressant therapy of two (#6 & #55) residents of six reviewed for unnecessary medications.Findings Include:Resident #6On 4/28/2026 at approximately 1:00 PM, a review was completed of Resident #6's medical records and it revealed she admitted to the facility on [DATE] with diagnoses that included, Alzheimer's Disease, Major Depressive Disorder, Insomnia and Generalized Anxiety Disorder. Further review of Resident #6's chart yielded the following:Physician Orders:Escitalopram (Lexapro) Oxalate Oral Tablet 20 MG (milligrams) for Major Depressive Disorder.Trazadone HCI (hydrochloride) Oral Tablet 50 MG for Major Depressive DisorderLexapro and Trazadone are both antidepressants.Care Plan: .admitted with diagnoses of Deprssion, Anxiety, Panic Disorder and insomnia in addition to Dementia. administer medications as prescribed.psychotropic medication management provided by (psychiatric…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-29 · 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 ensure peripherally inserted central catheter (PICC) dressing changes were completed timely for one resident (R23) of one reviewed for PICC lines. Findings include:R23 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include infection of a superficial incisional surgical site, acute respiratory failure and atherosclerotic heart disease. On 04/27/2026 at 11:08AM, a peripherally inserted central catheter (PICC) line was observed in the right upper arm of R23. The dressing was dated 4/15/26. On 04/27/2026 at 11:11AM, record review revealed a physician's order dated 03/26/2026 that reads: PICC line dressing change one time a day every Wednesday related to infection following a procedure, superficial incisional surgical site subsequent encounter. On 04/27/2026 at 11:13AM, record review of the April 2026 treatment administration record (TAR) revealed that on 04/22/2026 the dressing change was signed out as not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure oxygen tubing was changed out weekly and nebulizers were stored properly for two residents (R2 and R75) of five residents reviewed for respiratory care. Findings include: Review of the medical record revealed that Resident #2 (R2) was [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease (COPD), chronic respiratory failure, heart failure and tachycardia. During an observation on 04/27/2026 at 12:39PM, R2's oxygen tubing was dated 4/20/26 and there was a nebulizer in a bag, hanging on the wall next to the bed. The nebulizer equipment was stored together, and moisture was noted in the medication reservoir. During an observation on 04/28/2026 at 1:10PM, R2's nebulizer was found hanging on the wall in a bag, was dated 4/20/26 and the oxygen tubing was dated 4/20/26. During an interview on 04/28/2026 at 1:18PM, Assistant Director of Nursing (ADON) was asked how often the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-27 · 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 This citation pertains to Intake Numbers 2716028, 2716054 and 2723179.Based on observation, interview and record review, the facility failed to ensure that staff followed 2 resident's (Resident #101 and Resident #104) plans of care for safe transfers of 5 residents reviewed, resulting in falls with a fracture, and a head injury, with hospitalization.Findings Include: Resident #101:Review of the Face Sheet, physician orders and care plans dated 9/2018 through current, revealed Resident #101 was 88 years-old, admitted to the facility on [DATE], had cognitive impairment, required assistance with all Activities of daily Living/ADL's and was a two person assist for all transfers. The residents diagnosis included, Vascular Dementia with behaviors, Stroke with Hemiplegia and weakness of the right side, and Heart Disease. Review of the facility Accident/Incident report dated 12/27/25, revealed on on 12/27/25 at 5:15 a.m., Nursing Assistant/CNA I was assisting the resident to bed by her self. CNA I lifted the resident up…

    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 · Fcited before2025-04-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure clean, reusable medical equipment for one resident (Resident #12) and hand hygiene for one resident (Resident #62), resulting in cross-contamination and the likelihood of further cross-contamination. Findings include. On 4/16/25, at 1:48 PM, an observation of Nurse P at Resident #12's doorway was conducted. Nurse P asked Nurse Q if they had scissors. Nurse Q entered their left pocket, pulled out a pair of scissors and handed them to Nurse P. Nurse P entered Resident #12's room and closed the door. Upon opening Resident #12's door, an observation was made of Nurse P cleaning the scissors with an alcohol pad with their gloved hands. Nurse P was asked if they were using an alcohol pad and Nurse P offered, Yes, its an alcohol pad. On 4/16/25, at 1:55 PM, Nurse Q was asked if the scissors were shared scissors and Nurse Q offered, the scissors were shared. Nurse Q was asked what their normal disinfection process was for reusable scissors…

    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
Show the remaining 13 citations
  • Potential for harm · E2025-04-17 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 update and/or revise individualized, person-centered care plans to reflect changing needs for 4 residents (#6, #39, #52, #62) of 18 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings include: Record review of facility 'Comprehensive Care Plan' dated 11/27/2024 revealed it is the policy of this facility to develop and implement a comprehensive person-center care plan for each resident, consistent with the rights, that includes measures objectives and time frames to meet a resident's medical and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #62: Observation on 04/16/25 at 08:25 AM with Certified Nurse Assistant's R and S revealed that both CNA's applied enhanced barrier precautions of personal Protective equipment (PPE). CNA R walked into the room and pulled the bed away from wall, air mattress was not placed on hold or stopped. Resident rolled 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-17 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 dignity for 2 residents (Resident's #39 and Resident #51) of 3 residents reviewed for dignity (call light response time) and residents from the confidential Resident Council group meeting (held on 4/16/25), regarding call light response times. Findings Include: Resident #51: Review of the Face Sheet, MDS dated 2/24, nurse's progress notes dated 2/1/24 through 4/15/25, revealed Resident #39 was [AGE] years old, mild cognitive impairment, admitted to the facility on [DATE], and dependent on staff for Activities of Daily Living/ADL's. The resident's diagnosis included, high blood pressure, heart failure, lymphedema, unsteadiness, lack of coordination, chronic kidney disease, anxiety disorder, cardiac pacemaker with a history of right breast cancer. During an interview done on 4/15/25 at 10:09 a.m., Resident #51 stated If they (staff) are busy, I do wet my pants sometimes. If its real bad, we go in the hall and yell help. Night is fast…

    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 · D2025-04-17 · tag F0577 — isolated
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    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 inform/educate 13 of 13 residents who attended the confidential group meeting about the location of the survey results and failed to ensure that the recent State Survey and Plan of Correction were readily accessible, affecting all Residents in the facility of a census of 89, resulting in Residents, Resident Representatives, visitors and staff being unable to review the survey results and plan of correction. Findings include: On 4/16/25 at 10:30 AM, an interview was conducted with 13 Confidential Residents in a group meeting. The Residents in the group meeting were asked Without having to ask, are the results of the State inspection available to read? No Resident of the group acknowledged they knew of survey results being available. 13 of 13 Residents reported they did not know what survey results were, that the results were to be available without having to ask for them, or where they would find the results. The majority of the Residents were in wheelchairs. On 4/16/25 at 11:50 AM, an observation was conducted…

    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 before2025-03-11 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to 1) Maintain food preparation and kitchen equipment in a sanitary condition, and 2) Ensure that all partly used, opened foods had a use-by date. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (5) At any time during the operation when contamination may have occurred. During the initial kitchen tour done on 3/11/25 at 7:35 AM, accompanied by Dietary [NAME] C, the following observations were made: -At 7:36 a.m., The silver cart used for food storage was found to have dried food splattered on the inside door and on the top shelf. -At 7:37 a.m., a half loaf of bread was found open, with no use-by date on it. -At 7:39 a.m., the large can opener was found…

    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 · F2024-03-13 · tag F0761 — failed to label and store drugs safely — widespread
    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 follow policies and procedures for medication labeling and storage in 3 of 3 Medication carts reviewed, 1 of 2 Medication rooms reviewed and narcotic reconciliation, resulting in opened and undated multi-dose medications, and the disposal of expired medications and altered medication efficiency with the likelihood of misappropriation going unnoticed. Findings include: Record review of the facility 'Administration of Medications' policy dated 10/25/2023 revealed the facility ensures medications are administered by licensed nurses as ordered by the physicians and in accordance with professional standards, in a manner to prevent contamination or infection. Record review of the Center of Disease Control (CDC) https://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html Medication vials should always be discarded whenever sterility is compromised or cannot be confirmed. In addition, the United States Pharmacopeia (USP) General…

    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 · Fcited before2024-03-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to properly wash food contact surfaces, resulting in an increased risk of foodborne illness, affecting all residents that consume food from the kitchen. Findings include: On 3/11/24 at 10:40 AM, during an inspection of the kitchen, Dietary Aide P was observed to be cleaning a meat slicer. At this time, Dietary Aide P was queried on their cleaning process and stated that they use a detergent wiping cloth first, followed by multiple applications of sanitizer wiping cloths. Dietary Aide did not describe using water rinse to clear the detergent before applying sanitizer. According to the 2017 FDA Food Code Section 4-603.16 Rinsing Procedures. Washed UTENSILS and EQUIPMENT shall be rinsed so that abrasives are removed and cleaning chemicals are removed or diluted through the use of water or a detergent-sanitizer solution by using one of the following procedures: (A) Use of a distinct, separate water rinse after washing and before SANITIZING if using: (1) A 3-compartment sink, (2) Alternative manual WAREWASHING…

    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 before2024-03-13 · 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

    Deficient Practice Statement (DPS) One: Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing effective outcome and process surveillance, accurate data collection/documentation/analysis and failed to ensure appropriate Personal Protective Equipment (PPE) utilization and staff knowledge for transmission-based isolation precautions resulting in lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the likelihood for spread of microorganisms and illness to all 71 facility residents. Findings include: On 3/11/24 at 11:46 AM, an isolation cart was observed outside of Resident #45 and Resident #19's room. A sign was present above the cart, directly next to the door with a red hand signaling to stop. There was no signage visible indicating the reason for the red hand sign and/or the type of isolation precautions. An observation of the cart revealed it contained gowns, goggles, and procedural masks. There was no hand sanitizer…

    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 · Dcited before2024-03-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Number MI00143143. Based on interview and record review, the facility failed to prevent staff-to-resident verbal abuse for one resident (Resident #47) of three residents reviewed, resulting in a staff yelling at and calling Resident #47 derogatory names, Resident #47 expressing signs and symptoms of distress and fear, and the likelihood for ongoing psychosocial distress utilizing the reasonable person concept. Findings include: Resident #47: On 3/11/24 at 11:26 AM, Resident #47 was observed in their room in bed. A Hoyer lift was observed in the room. When asked questions, Resident #47 responded but did not provide meaningful responses. Record review revealed Resident #47 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral palsy, intellectual disabilities with cognition of a five- to seven-year-old, epilepsy, heart failure, depression, anxiety, weakness, and pain. Review of the Minimum Data Set (MDS) assessment dated…

    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 before2024-03-13 · 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 interview and record review, the facility 1) Failed to document abdominal/bowel assessment and treatment for a change of condition for one resident (Resident #279) and 2) Failed to thoroughly assess a resident with new onset pain and swelling, notify the physician and provide timely interventions for one resident (Resident #18) resulting in the likelihood for missed identification and assessment of changes in condition and delays in treatment. Findings include: Record review of the facility 'Pain Assessment and Management Protocol' policy dated 12/27/2023 revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional stands of practice, the comprehensive person-centered care plan, and the residents goal and preferences. The facility utilizes a systematic approach for recognition, assessment, treatment, and monitoring of pain. (2.) Behavioral signs and symptoms that may suggest the presence of pain include but are not limited 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 follow up on a change in nutritional status for one (Resident #12) resulting in weight changes going unassessed with the likelihood of further weight change going unassessed. Findings include. On 3/12/24, at 8:35 AM, Resident #12 was in their bed. On 3/12/24, at 11:30 AM, a record review of Resident #12's electronic medical record revealed an admission on [DATE] with diagnoses that included Parkinson's disease, Dementia and Epilepsy. Resident #12 required assistance with all Activities of Daily Living (ADL) and had severely impaired cognition. A review of weights revealed a 10.4 pound weight gain in three days: 03/03/2024 . Weight: 125.8 lbs (pounds) . 03/06/2024 . Weight: 135.4 lbs . A review of the Nutrition Risk progress notes revealed the last documented assessment was on 02/01/2024. On 3/13/24, at 10:00 AM, the Administrator was asked if the Dietician was available for an interview and the Administrator stated that the Dietician is…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-13 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to properly label and date an Intravenous (IV) medication for one (Resident #32), resulting in the lack of date and time of administration with the likelihood of reuse of IV tubing and/or wrong administration times. Findings include. On 3/11/24, at 4:19 PM, Resident #32 was resting in their bed. There was an intravenous (IV) bag with tubing hanging from an IV pole hooked to an IV pump. There was no date nor time of administration written/labeled on the IV bag. On 3/11/24, at 4:40 PM, a record review of Resident #32's electronic medical record revealed an admission on [DATE] with diagnoses that included bloodstream infection, Sepsis due to Methicillin susceptible Staphylococcus aureus. Resident #32 had intact cognition and required assistance with Activities of Daily Living. A review of the Physicians orders revealed cefazolin recon soln; 2 gram; amt 2 gram; intravenous Special Instructions: Pharmacy to dose r/t sepsis, Every 8 hours 06:00,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-13 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement and operationalize procedures to ensure accurate documentation, reconciliation, and oversight of controlled drugs in one (Two East) of six medication carts resulting in inaccurate narcotic medication documentation and reconciliation. Findings include: On 3/12/24 at 3:55 PM, a tour of the Two East Medication Cart including narcotic medication reconciliation was completed with Registered Nurse (RN) X. The narcotic medication count sheet for Resident #14's Hydromorphone 1 mg (milligram)/mL (milliliter) did not correlate with the amount of Hydromorphone present in the bottle. The sheet indicated there should be 85 mL and the bottle was noted to have greater than 100 mL. When asked, RN X confirmed the amount of medication in the bottle did not correlate with the amount that was supposed to be present per the narcotic medication count/administration record. Further review revealed each staff member had documented they administered 5 mg…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 record review the facility failed to follow up on an as needed (PRN) psychotropic medication (Ativan) for one (Resident #7), resulting in the lack of documented assessment of the need for the continued PRN medication. Findings include. On 3/12/24, at 2:14 PM, a record review of Resident #7's electronic medical record revealed an admission on [DATE] with diagnoses that included Alzheimer's disease, Dementia, and severe degeneration of brain. Resident #7 required extensive assistance with Activities of Daily Living and had severely impaired cognition. A review of the Physician orders revealed the resident was ordered PRN Ativan that began 11/10/2023 and reordered every 14 days. A review of the Physician progress notes from 11/13/2023 through 2/9/2024 revealed no mention of the ongoing need of the PRN Ativan. A review of the facility provided PSYCHOTROPIC MEDICATION USE Revised: 4/26/23 revealed . Residents will not receive PRN psychotropic medications unless necessary to treat a diagnosed specific…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$165,536 in federal fines across 2 penalties. 2 Medicare payment denials on record.

  • $116,805 — penalty dated 2025-03-11
  • $48,731 — penalty dated 2024-03-13
  • Medicare payment denial — starting 2025-05-16 for 29 days
  • Medicare payment denial — starting 2024-04-11 for 11 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.

Who owns this facility

Owner / managerTypeRoleShareSince
COUNTY OF BAYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/01/1966
WEIDMAN, KYLEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/12/2022
MCCARTHY, JACQUELINEIndividualCORPORATE OFFICER; ADP OF THE SNFsince 06/01/2021
AHMED, TAZEENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2018

CMS files one row per role, so the 8 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$14.0M
Net patient revenuemost recent cost report
-64.3%
Operating marginrevenue minus expenses
$38K
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 79%Medicare 6%Other / private 15%

About 79% 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 $38K 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

$738per resident / day
operating cost
$22,426per month
≈ monthly operating cost
$449per 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 235044. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-29, 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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