North Woods Nursing Center
2532 Cadillac Drive, Farwell, MI 48622 · For profit - Limited Liability company · 71 certified beds · (989) 588-9928 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (58%) runs well above the national median (45%)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.9% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 13.0% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.8% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 3.8% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.9% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 13.0% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.9% | 19.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.9% | 5.1% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 22.0% | 20.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.2% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.1% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 13.3% | 24.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.8% | 11.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.11 | 1.84 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.65 | 1.64 | 1.80 | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.6% 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 76 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.9% 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 35 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.6%CMS range 36.1–56.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.1%CMS range 8.3–17.4 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 42.9% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 40.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 22.9% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.4–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 71 beds and averages 64.0 residents a day — about 90% occupied, or roughly 7 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 4.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.82 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 3.76 hrs/resident/day on weekends vs 4.21 on weekdays — 11% thinner on weekends. RN hours go from 0.88 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above 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.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · Fcited before2026-04-08 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to implement an effective and current system of surveillance for staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak, resulting in the potential for an outbreak to go undetected.Findings:During an interview on 04/08/2026 at 11:37 AM, Director of Nursing (DON) reported that Infection Control Preventionist (ICP) A was off on 4/8/26 and she would review the Infection Control Program in her place. DON reported that when a facility employee called off the employee answering the phone would complete the Call off Notice form. DON confirmed that it did not need to be a licensed nurse to complete the form. Once that form was completed it was sent to Human Resources to review/document. If the call-off was illness related the Call off Notice was reviewed by ICP A.DON reported that the Employee Surveillance Log included all facility staff and was to include the symptoms and the onset date, the date last worked, and the unit worked further stating that that information 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.
- Potential for harm · E2026-04-08 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the facility failed to ensure call lights were within reach for one of three residents reviewed (Resident #60) for accommodation of needs. Findings:Resident #60 (R60)Review of an admission Record revealed R60 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses of dementia, high blood pressure and type 2 diabetes. During an observation on 4/06/26 at12:03 PM, R60s call light was draped over the shade of the small lamp that sat on the table near the foot of the bed, out of reach of the resident. During an observation on 4/06/26 at 1:03 PM, staff had just delivered a lunch tray to R60 in her room. After staff left the room, the call light laid over the small lamp shade at the foot of the bed, out of reach of the resident. During observation on 04/07/26 at 8:10 AM and again at 2:20 PM, R60 laid in bed and the call light was draped over the shade of the lamp that sat on the table at the foot of the bed, out of reach of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-08 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were administered in accordance with physician orders and nursing professional standards of practice of 4 residents (Resident #1, #5, #47, and #57) out of 15 residents reviewed for medication administration.Findings: Resident #1 (R1)Review of an admission Record reflected R1 admitted to the facility with diagnoses that included atrial fibrillation, high blood pressure and biventricular heart failure. Review of R1's March 2026 Medication Administration Record (MAR) reflected licensed nurses administered Midodrine HCl Oral Tablet 10 MG (milligrams) (Midodrine HCl) Give 1 tablet by mouth three times a day for Hypotension (low blood pressure) Hold is (sic) SBP (systolic blood pressure) > (greater than) 120 outside of prescribed parameters 7 times (three times on 3/16/26, once on 3/26/26, once on 3/28/26, once on 3/29/26, and once on 3/30/26). Review of an order on R1's April 2026 MAR reflected Midodrine HCl Oral Tablet 10 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.
- Potential for harm · E2026-04-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide 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 implement the facility policy for pressure injury prevention and management for 3 residents (Resident #32, #50, and #55) out of 5 reviewed for pressure injuries.Findings:Resident #32 (R32)Review of an admission Record revealed R32 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: muscle wasting and atrophy. Further review of the record revealed that R32 had a responsible party (guardian/decision maker).Review of R32's Skin assessment dated [DATE] revealed, Open area to right buttocks scar tissue measuring 0.3cm x 0.2cm. Area opened while providing personal care. Clinical coordinator notified, treatment ordered.Review of a handwritten entry in the Physician Communication book dated 3/31/26 revealed, open area to right buttocks. There was a handwritten line through the entry and noted was printed. There was no date or initials documented to reflect when the entry was reviewed or by…
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.
- Potential for harm · E2026-04-08 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake 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 and interview, the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living for residents. Findings include: On 04/07/2026 at 10:12AM, observed the drain line for the ice machine in the Nourishment room, had a whitish gel-like substance coming out of the drain line. Dietary Manager (DM) D, present at time of observation, stated that maintenance department was responsible for the cleaning and maintenance of the ice machines. On 04/07/2026 at 3:04PM, Maintenance Supervisor (MS) C observed the gel-like substance coming out of the drain line. MS C noted that this had happened before after the ice machine had been cleaned and believes it might be the cleaning product interacting with minerals in the well water. On 04/07/2026 at 3:05PM, observed in the Nourishment room, a piece of coving (1 foot long) missing from wall, floor juncture next to the ice machine and paint bubbling on wall behind the ice machine. MS C confirmed condition of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 safely transport residents in wheelchairs for 2 residents (Resident #7 and #5) out of 15 residents reviewed for accidents and hazards.Findings:Resident #7 (R7)Review of an admission Record revealed R7 was an [AGE] year-old female, admitted to the facility on [DATE].During an observation on 04/06/2026 at 11:00 AM, Certified Nursing Assistant (CNA) Q was observed propelling R7 in her wheelchair without foot pedals from room [ROOM NUMBER] to the nurses' station.Resident #5 (R5)Review of an admission Record revealed R5 was a [AGE] year-old male, admitted to the facility on [DATE].During an observation on 04/08/2026 at 8:13 AM, CNA L was observed propelling R5 in his wheelchair into his room, his left foot was behind the foot pedal. During an observation on 04/07/2026 at 4:45 PM, while exiting the building with 2 other healthcare surveyors, a facility staff member was observed propelling a resident in her wheelchair down the 100 unit with her…
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.
- Potential for harm · D2026-04-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 change and store oxygen tubing per physician orders and facility policy for three of five residents residents (Resident #42 , Resident #52, and Resident #73) reviewed for oxygen storage.Findings: Resident #42 (R42) Review of an admission Record revealed R42 was a [AGE] year-old female, last admitted to the facility on [DATE] following a four day hospitalization after a fall and was found to be positive for RSV (respiratory syncytial virus). During an observation on 04/06/26 at 10:41 AM, R42 laid in bed resting with her eyes closed. A disposable nebulizer (a machine that converts liquid medicine into fine inhalable mist to treat respiratory conditions) mouthpiece and tubing, dated 03/23/26, laid on the mattress next to R42's pillow. Clear liquid sat in the disposable medication cup. Review of a physician order reflected an order for the breathing treatment .albuterol sulfate inhalation nebulization solution 1.25 mg(milligrams)/3ml…
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.
- Potential for harm · Ecited before2025-03-06 · tag F0880 — failed to prevent and control infections — patternProvide 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 follow infection control practices when providing peri-care for two residents (Resident #46 and Resident #2) of four reviewed for infection control, and when preparing medications for administration to residents. Findings: Resident #46 (R46) Review of an admission Record revealed R46 was a [AGE] year old male, last admitted to the facility on [DATE], with pertinent diagnoses of profound intellectual disabilities, seizure disorder, muscle wasting, dependent on tube feeding for hydration and nutrition, and dependent on total assistance from staff for all care needs. During an observation on 03/04/25 at 10:19 AM, CNA's (certified nurse aides) N and O provided peri care to R46 and the following was noted: (a) R46 was incontinent of urine and two wash clothes were used to clean the residents genitalia and then placed on the residents over bed table, (b) after peri-care was completed CNA N did not remove the contaminated gloves and touched 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.
- Potential for harm · Dcited before2025-03-06 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain and document vital signs prior to medication administration for 2 of 6 residents (Resident #6 and #51) reviewed for professional standards of practice. Findings: Resident #6 (R6) Review of an admission Record revealed R6 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Review of R6's Order Summary dated 9/11/24 revealed, Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro)-Inject 5 unit subcutaneously with meals for DM (diabetes mellitus) hold if BS <110 (blood sugars less than 110). Blood sugars were to be obtained prior to the insulin administration to ensure R6's blood sugar was not less than 110. This was to be completed prior to the 8:00 AM, 12:00 PM, and 5:00 PM insulin administration. Review of R6's Blood Sugar Summary revealed: *On 01/14/2025 at 9:59 AM R6's blood sugar was 182. There was no blood sugar assessment completed prior to the 8:00 AM lispro administration.…
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.
- Potential for harm · E2024-10-01 · tag F0609 — failed to report abuse allegations — patternTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake M100147294. Based on interviews and record review, the facility failed to ensure facility staff responded to (reported), and investigated, a witnessed staff to resident physical and verbal abuse timely for one resident (R4) of four residents reviewed for abuse, resulting in the staff member working several more shifts exposing (R4) and other vulnerable residents to further possible abuse. Findings include: Review of a Face Sheet revealed R4 admitted to the facility on [DATE] with pertinent diagnoses of dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, claustrophobia, and Alzheimer's. Review of a facility investigation reflected the following information: (a) On 9/23/24 at 7:10 PM, a housekeeping staff member (HK O) reported to the Director of Nursing (DON), who is also the facility abuse coordinator, that she witnessed abuse on 9/12/24, (11 days after witnessing the incident of abuse) and (b) the incident involved Registered Nurse (RN)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · D2024-10-01 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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 M100147294. Based on interview and record review, the facility failed to provide an advanced written notification of a room change and obtain consent for 1 (R4) of 1 resident reviewed, resulting in the potential of a nonconsensual room change and emotional distress for the resident. Findings include: Review of a Face Sheet revealed R4 admitted to the facility on [DATE] with pertinent diagnoses of dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, claustrophobia, and Alzheimer's. Review of an Interdisciplinary progress note dated 9/11/24 (Wednesday) at 6:44 PM for R4 revealed the resident was upset when staff tried to redirect her from entering another resident's room (room [ROOM NUMBER]). R4 became verbally and physically aggressive with staff, declined to let go of the door handle, was shouting at staff and attempting to hit and kick staff. After multiple attempts of redirecting, staff was able to move the resident who was tearful 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.
- Potential for harm · D2024-10-01 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 M100147294. Based on interviews and record review, the facility failed to protect the resident's right to be free from staff to resident verbal and physical abuse for one (R4) of 4 residents reviewed for abuse. Findings include: Review of a Face Sheet revealed R4 admitted to the facility on [DATE] with pertinent diagnoses of dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, claustrophobia, and Alzheimer's. Review of a facility investigation reflected the following information: (a) On 9/23/24 at 7:10 PM, a housekeeping staff member (HK O) reported to the Director of Nursing (DON), who is also the facility abuse coordinator, that she witnessed abuse on 9/12/24, (11 days after witnessing the incident of abuse) and (b) the incident involved Registered Nurse (RN) N holding R4's wrists down in the wheelchair and RN N told R4 I don't work in an insane asylum, I work in a nursing home. On 9/23/24 an allegation of abuse was reported to 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.
- Potential for harm · Ecited before2024-03-27 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 4 of 11 residents (Resident #10, #11, #35, and #30), reviewed for the provision of nursing services, resulting in lack of vital sign and blood sugar assessments prior to medication administration, medications improperly administered, and management of controlled substances. Findings: Resident #10 (R10) Review of an admission Record revealed R10 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R10's Order Summary revealed, Losartan Potassium Oral Tablet 25 MG (Losartan Potassium) Give 0.5 tablet by mouth one time a day for Hold for BP (blood pressure) less than 110/60, HR (heart rate) less than 60 dated 6/24/23. Review of R10's February Medication Administration Record revealed the following: *On 2/7/24 R10's blood pressure was 110/55 and the losartan was administered. *On 2/8/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-27 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that pre-admission screening/annual resident review (PASARR) level I and level II's were completed on admission and at the annual review for 1 of 1 resident (Resident #28) reviewed for PASARR screening/assessment. Findings included: The facility provided a copy of the PASARR Screening policy dated 11/2008, with a last revised date of 5/2015 for review. The policy reflected, d. When a level II evaluation is indicated for Annual Resident Review (ARR), the nursing facility will notify the local CMHSP (Community Mental Health Services Program) of the need for a level II evaluation at least 30 days prior to the due date of the ARR by sending them a new DCH-3877 (PASARR level I evaluation) .The facility assumes responsibility for verifying that required PAS and ARR processes are completed and documented in the resident's record . R28 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R28 was admitted to the facility on [DATE]…
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.
- Potential for harm · Dcited before2024-03-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 address the root causes of multiple falls and implement meaningful interventions for 1 (Resident #60) of 3 residents reviewed for falls, resulting in repeated falls. Findings include: Resident #60 (R60) Review of a Face Sheet revealed R60 admitted to the facility on [DATE] with pertinent diagnoses of cognitive communication deficit, a fractured femur and generalized muscle weakness, muscle wasting and atrophy. On 1/2/24 she is diagnosed with a wedge compression fracture on T11-T12 vertebra. During an observation on 3/25/24 at 10:17 AM, R60 is in the hallway sitting in her wheelchair and most of her face has black and blue bruising with red eyes. The resident reported she thinks she fell and landed but was not sure exactly how she got there. She thought it happened in the main drag and was nonsensical. In an interview on 3/25/24 at 1:00 PM, Family Member (FM) K reported R60 fell in the beginning of January and fractured her vertebrae, then…
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.
- Potential for harm · D2024-03-27 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 interview and record review, the facility failed to accurately monitor and prevent a significant weight loss for one (Resident #17) of two residents reviewed for nutrition and hydration. This deficient practice resulted in the potential for unmet nutritional needs and unnecessary weight loss. Findings include: Resident #17 (R17) Review of R17 electronic medical record (EMR) revealed admission to the facility on 9/23/23 with diagnoses including dementia and diverticulitis (inflammation of pouches in the digestive track). R17's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicative of moderate cognitive impairment. Review of the weight history revealed R17 weighed 207.4 lbs. (pounds) on 9/24/23 and weighed 185.0 lbs. on 10/24/23, for a total weight loss of 22.4 lbs. This resulted in a 10.8% weight loss within a 30-day period. On 1/12/24, R17 weighed 178.6 lbs., which represented an additional 6.4 lb. weight loss. This equated…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE PEPLINSKI GROUP — 10 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.1 | +0.9 vs chain |
| Health inspection | 3 of 5 | 2.1 | +0.9 vs chain |
| Staffing | 4 of 5 | 3.7 | +0.3 vs chain |
| Quality measures | 4 of 5 | 3.5 | +0.5 vs chain |
The other 9 homes this chain runs (chain average 2.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ACKERMAN, AMY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 01/01/2012 |
| ACKERMAN, RICKY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 10% | since 01/01/2012 |
| BAUMGARTEN, MICHAEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 01/01/2012 |
| BAUMGARTEN, THERESE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 01/01/2012 |
| PEPLINSKI, SHELI | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 01/01/2012 |
| PEPLINSKI, TODD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | 10% | since 01/01/2012 |
| SCHADE, JEFFERY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 10% | since 01/01/2012 |
| SCHADE, TAMARA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 01/01/2012 |
| THOMPSON, BRIAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 10% | since 01/01/2012 |
| THOMPSON, SHELLY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 01/01/2012 |
| PLANTE & MORAN PLLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2012 |
| PAINTER, DAWN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/10/2023 |
| SOLAREWICZ, MACIEJ | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2024 |
| WINKELS, KATHY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2012 |
| NWNC ESTATES, LLC | Organization | ADP OF THE SNF | — | since 01/01/2012 |
| THE PEPLINSKI GROUP INC | Organization | ADP OF THE SNF | — | since 03/10/2025 |
CMS files one row per role, so the 40 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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 71% 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 $957K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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
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.
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 235464. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-08, 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.