Medilodge of Gaylord
508 Random Lake, Gaylord, MI 49735 · For profit - Limited Liability company · 96 certified beds · (989) 732-3508 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2025
- it has 2 actual-harm citations
- a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 6.6% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.8% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.1% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.3% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 2.5% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 2.1% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.8% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 36.7% | 19.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 89.3% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.8% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 18.9% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.5% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.6% | 1.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 38.8% | 79.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 16.9% | 24.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 19.2% | 11.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.88 | 1.84 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.17 | 1.64 | 1.80 | worse |
§ 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.
60.6% 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 74 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 62.2% 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 45 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 44% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 48% 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 | 60.6%CMS range 47.5–72.9 | 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 | 9.7%CMS range 7.2–14.4 | 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 | 62.2% | 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 | 57.8% | 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 | 64.4% | 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 | 90.6% | 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 | 1.6% | 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 | 8.3%CMS range 4.1–15.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 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 96 beds and averages 71.9 residents a day — about 75% occupied, or roughly 24 beds typically open. It usually has some room. 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 4.29 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.22 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.60 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 3.67 hrs/resident/day on weekends vs 4.54 on weekdays — 19% thinner on weekends. RN hours go from 1.42 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. 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.
34 citations, most serious first. The 12 most serious are shown; the remaining 22 are one tap away and print in full.
- Actual harm · G2026-02-24 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to Intake 2727226.Based on observation, interview, and record review, the facility failed to act upon a physician's order for one Resident (#2) out of three residents reviewed for quality of care. This deficient practice caused delayed medical treatment for Resident #2 resulting in the need for transfer to an emergency department (ED) due to septic shock (a life-threatening condition which occurs when blood pressure drops to a dangerously low level after an infection).Findings include:Resident #2 (R2)Review of a complaint sent to the State Agency (SA) on 1/29/26, read, in part: .Since June/July of 2025, [R2] has been experiencing an issue with her eye. Staff at the facility were unable to coordinate [R2's] care and this has caused a delay in her service provision. [R2] was not seen for her eye until 9/25/25 [sic] when she was transported via EMS [emergency medical services] to a optometrist. At that time, it was determined that [R2] required emergency services due [to] the infection in her eye progressing. The facility failed to properly service [R2], advocate…
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.
- Actual harm · G2025-08-06 · 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 1234972Based on interview and record review, the facility failed to protect two Residents (#1 and #2) of four resident reviewed for right to be free from sexual abuse. This deficient practice resulted in psychosocial harm including feelings of embarrassment, devastation, anxiety, feelings of being violated, and trauma based on a reasonable person standard.Findings include:Review of a facility five-day investigation summary, submitted to the State Agency (SA) on 7/8/25 at 6:45 p.m., revealed the following: The Director of Nursing (DON) was notified by the Certified Nurses Assistant (CNA) that R1 was found in R2's bed.R2 was wearing her t-shirt and had her brief off.R1 was disrobed from the waist down and kneeling in another resident's bed.Resident #1 (R1)Review of the Minimum Data Set (MDS) assessment, dated 6/14/25, revealed R1 was admitted to the facility on [DATE] with active diagnoses that included: Alzheimer's disease and depression. R1 scored a 2 of 15 on the Brief Interview…
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 · F2026-03-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 store, prepare, and serve food in accordance with professional standards for food service safety for all 70 residents living in the facility. Findings include: During a tour of the dietary department with Registered Dietitian (RD) A and Dietary Manager (DM) Q on 3/17/2026 at 12:18 PM, the following items were noted in the reach in freezer:an opened unsealed plastic bag in a manufacturer's box with beef patties exposed to air, and undated as to opened date and use by (expiration) datea partial bag of frozen formed cookie dough unlabeled and undated as to opened date and use by datea partial bag of frozen premade biscuits unlabeled and undated as to opened date and use by date.a partial bag of frozen hashbrowns unlabeled and undated as to opened date and use by date.The reach-in refrigerator contained an opened thickened apple juice with an opened date of 1/28 and a use by date of 2/3.On 3/17/2026 at 12:49 PM, a tour of the pantry on C Hall with RD A and DM Q, revealed a refrigerator containing an opened quart…
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 · Fcited before2026-03-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure correct implementation of transmission-based precautions (TBP) for one Resident (#87) of one resident reviewed for TBP and to ensure infection prevention and control policies were reviewed on an annual basis with the potential to affect all 70 residents living in the facility.Findings include:Resident #87 (R87) Review of the electronic medical record (EMR) revealed R87 was admitted to the facility on [DATE] and had diagnoses including sepsis due to methicillin susceptible staphylococcus aureus (MSSA) and osteomyelitis of the left ankle and foot. On 3/17/2026 at 1:42 p.m. R87 was observed self-propelling in a wheelchair toward his room from the entry of D-Hall, near the nurses' station. R87 was not wearing a protective gown. Upon observing R87 enter his room, it was noted there was a Center for Disease Control and Prevention (CDC) Contact Precaution sign adhered to the front of R87's door and a cart containing personal protective…
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 · E2026-03-19 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 accurate and timely delivery of medications for four Residents (R13, R28, R29, and R80) of six residents reviewed for medication administration with 5 errors out of 26 opportunities resulting in a medication error rate of 19%. Findings include:Resident #28 (R28)During a medication administration observation for R28 on 3/18/26 at 1:04 PM. Registered Nurse (RN) B administered oxycodone 5 milligrams (mg) one tab by mouth and methocarbamol 500 mg one tab by mouth by to R28. R28's medication was delivered late and R28 only received one oxycodone and was to receive two tabs. (Error #1) Review of R28's medication administration record (MAR), dated March 2026, unveiled the following order:Oxycodone 5 mg give 2 tablets by mouth every 6 hours for moderate to severe pain with scheduled times at 6:00 AM, 12:00 PM, 6:00 PM, and 12:00 AM. Resident #80 (R80)On 3/18/26 at 1:30 PM, an observation was made of RN B providing a medication pass for R80 who was administered peg tube feeding 237 milliliters (ml) via peg tube…
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 before2026-03-19 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to label opened multi-use medications, removed expired medications and ensure storage of medications according to professional standards of practice in two of two medication carts reviewed.Finding include:Review of the D-Hall medication cart with Registered Nurse (RN) R on 03/19/2026 at 8:40 AM, revealed the following: A multi-dose Humalog (rapid-acting insulin) U-100 vial stored inside a clear plastic bag. The vial was observed to be without a protective cap, indicating the medication was opened. The vial was noted to belong to Resident #57 and had a written open date of 2/14/2026 and expiration date of 3/14/2026. RN R confirmed the medication was expired and should have been removed from the active medication supply. An open multi-dose Symbicort 80 mcg (microgram)/4.5 mcg inhaler (medication used to treat asthma and chronic obstructive pulmonary disease). Upon inspection of the inhaler and box the inhaler was stored in, it was noted there was no written date of when the inhaler was opened and first used or when…
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 before2026-03-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to provide an order, care plan interventions and goals for one Resident (Resident #58) of two residents reviewed for indwelling catheters.Findings include:Resident #58 (R58)On 3/17/26 at 12:50 PM, R58 was observed sitting in his wheelchair in the hallway. A urinary catheter drainage bag, attached to the wheelchair beneath the seat, was touching the floor beneath the wheelchair and dragging on the floor when the wheelchair was propelled. On 3/18/2026 at 8:40 AM, an observation was made of R58 sitting in his wheelchair in the lobby near the A-hall entrance. R58 proceeded to self-propel himself the wheelchair down A-hall with his catheter bag dragging on the floor in a privacy bag. R58's privacy bag had visible dust on the front, sides, and back of the privacy bag. On 3/18/26 at 8:42 AM, an interview was conducted with Certified Nurse Aide (CNA) F who was asked if R58's bag should be dragging on the floor collecting dust. CNA F replied, No, absolutely not. Review of R58's order summary, dated 9/17/26 through 3/18/26…
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 before2026-03-19 · 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 ensure physician orders for the administration of supplemental oxygen, completion of respiratory assessments with respiratory treatments, appropriate cleaning and storage of respiratory equipment, and supervision during the administration of respiratory treatments for three Residents (R36, R80, R13) of five residents reviewed for respiratory care services. Findings include:Resident #80 (R80) On 3/17/26 at 3:05 PM, an observation was made of R80's nebulizer mask (a mask that goes over the nose/mouth/tracheostomy to direct vaporized medication into the airway) stored with tubing and mask connected in a bag with visible condensation in the medication cup. An interview was conducted on 3/17/26 at 3:10 PM, with Unit Manager/Registered Nurse (RN) C who was asked if the nebulizer mask was stored properly and replied, No, it should be taken apart rinsed out and left to dry and then stored in the bag apart. During an observation of R80 on 3/18/26…
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 · D2026-03-19 · tag F0847 — isolatedInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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 explain and obtain an acknowledgement of understanding for a binding arbitration agreement for one Resident (R10) of three Residents reviewed for proper execution of the facility's binding arbitration agreement.Findings include:After receiving a list of those residents who had signed the facility arbitration contract titled, ALTERNATIVE DISPUTE RESOLUTION AGREEMENT, three residents were interviewed regarding the arbitration agreement process.On 3/18/2026 at 1:05 PM, R10 was interviewed in his room. R10 stated he remembered nothing regarding an arbitration agreement.The electronic medical record revealed R10 was admitted on [DATE] as his own responsible party. The Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15 indicating R10 was cognitively intact.The ALTERNATIVE DISPUTE RESOLUTION AGREEMENT for R10 was reviewed and the final page had been E-signed (electronically signed) on 6/30/25. Twelve…
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 before2026-03-19 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure communication/documentation occurred for coordination of care for hospice services provided for one Resident (R47) of one Resident reviewed for hospice services.Findings include:A review of the medical record for R47 revealed an admission to the facility with hospice services dated [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] indicated R47 was receiving hospice services. The Resident Roster printed on [DATE] indicated R47 was on hospice. The care plan printed on [DATE] for R47 included a focus of Hospice - Resident has a terminal prognosis with (Name of Hospice) related to end of life diagnosis . Date Initiated: [DATE]During an interview on [DATE] at 3:51 PM, the Registered Nurse (RN) L caring for R47 stated, I have no idea how hospice communicates with the facility. RN L said there were no charting or hospice folders that they were aware of. RN L stated, I get report when they (hospice personnel) have been here. That is all.During…
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 · D2026-03-19 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure eligible residents were offered influenza and pneumococcal vaccines as recommended by the Centers for Disease Control and Prevention (CDC) for 2 residents (#12 and #87) of 5 residents reviewed for vaccination status.Findings Include:Resident #12 (R12)Review of R12's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/22/26 with diagnoses including cerebral infarction (stroke), moderate persistent asthma, dementia, and dysphagia (difficulty swallowing).Review of R12's Michigan Care Improvement Registry (MCIR [a database that documents immunizations administered to individuals in Michigan]) revealed the pneumococcal vaccination was, DUE NOW.Further review of R12's EMR revealed she was not offered a pneumococcal immunization.Resident #87 (R87)Review of R87's EMR revealed initial admission to the facility on 7/19/22 with diagnoses including congestive heart failure (CHF), vascular dementia, and peripheral vascular disease.Review of R87's MCIR revealed the following, Immunization Status 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 · D2026-03-19 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure eligible residents were offered a COVID-19 immunization as recommended by the Centers for Disease Control and Prevention (CDC) for 2 residents (#12 and #87) of 5 residents reviewed for vaccination status.Findings Include:Resident #12 (R12)Review of R12's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/22/26 with diagnoses including cerebral infarction (stroke), moderate persistent asthma, dementia, and dysphagia (difficulty swallowing).Review of R12's Michigan Care Improvement Registry (MCIR [a database that documents immunizations administered to individuals in Michigan]) revealed COVID-19 2025-26 was, DUE NOW.Further review of R12's EMR revealed she was not offered a COVID-19 immunization.Resident #87 (R87)Review of R87's EMR revealed initial admission to the facility on 7/19/22 with diagnoses including congestive heart failure (CHF), vascular dementia, and peripheral vascular disease.Review of R87's MCIR revealed the following, Immunization Status and Shots Needed: Vaccine:…
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 22 citations
- Potential for harm · Dcited before2026-02-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
This citation pertains to Intake 2741948.Based on interview and record review, the facility failed to ensure a medication was administered in the prescribed form for one Resident (#1) of three residents reviewed for quality of care.Findings include:Resident #1 (R1)Review of R1's Electronic Medical Record (EMR) revealed initial admission to the facility on 9/19/25 with diagnoses including malignant neoplasm of the lung (cancer), fracture of T7-78 vertebra, post-laminectomy syndrome (chronic back, neck, or limb pain which remains after spinal surgery), chronic obstructive pulmonary disease (COPD), and retention of urine.On 2/23/26 at 2:49 PM, a telephone interview was conducted with Complainant A regarding R1's care at the facility. Complainant A stated toward the end of R2's life, he was unable to swallow. Complainant A recalled one nurse tried to administer a medication tablet with water which caused R1 to choke. After that point, Complainant A stated the nurse staff would dissolve R1's pills in other medication liquids to form a solution.Review of R1's EMR revealed the following…
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 before2026-02-24 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
This citation pertains to Intake 2741948.Based on interview and record review, the facility failed to ensure prescribed medications were readily available for one Resident (#1) of three residents reviewed for pharmacy services.Findings include:Resident #1 (R1)Review of R1's Electronic Medical Record (EMR) revealed initial admission to the facility on 9/19/25 at 1:47 PM with diagnoses including malignant neoplasm of the lung (cancer), fracture of T7-78 vertebra, post-laminectomy syndrome (chronic back, neck, or limb pain which remains after spinal surgery), chronic obstructive pulmonary disease (COPD), and retention of urine.On 2/23/26 at 2:49 PM, a telephone interview was conducted with Complainant A regarding R1's care at the facility. Complainant A stated R1 went a waited a significant amount of time for physician orders and missed the first dose of several medications as a result.Review of R1's EMR revealed the following physician's orders with a start date of 9/19/25: Morphine Sulfate ER [extended release] Tablet ER 30 MG [milligram]. Give 2 tablets by mouth every 12 hours for…
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 · Fcited before2024-12-17 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to properly store and dispose of expired medications, and log refrigerator temperatures for immunization and insulin medications for one of one medication room and three of three medication carts reviewed for medication storage. Findings include: On 12/15/24 at 12:21 PM, Registered Nurse (RN) L was asked to open the medication room on D-hall. RN L was asked about refrigerator temperature logs and replied, I am not sure. I have never checked the temperature in the refrigerator. I was not aware we needed to do that. Inside the medication room an observation was made of one expired box of eight therapeutic nutrition powder supplement packages with a brand name, lot number 528092S00, and a use by date of 01NOV2024. No temperature log tracking sheet was placed/observed on the vaccination/medication refrigerator at the time of the observation. Review of the D-hall refrigerator temperature binder log, dated February 2024 through December 2024, revealed that temperatures for the medication refrigerator were not being completed twice…
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 · Fcited before2024-12-17 · 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 infection prevention and control program (IPCP) to prevent, recognize, and control infections, and failed to update infection control policies annually. This deficient practice resulted in the potential spread of infectious organisms and disease to all 82 residents residing in the facility. Findings include: On 12/15/24 at 12:43 p.m., the Director of Nursing (DON) was asked the name of the facility's Infection Preventionist (IP). The DON said the facility did not have an IP. The DON explained that someone from another building who was not employed at the facility was keeping up with infection control information at the facility. The DON said Registered Nurse (RN) D was the MDS nurse in the facility and had training in infection prevention and control, and any questions regarding the IPCP should be directed to RN D. The IPCP was reviewed with RN D on 12/17/24 at 9:09 a.m. RN D presented an IPCP binder divided by each month. The divider for December 2024 was empty. RN D was asked where December 2024 information…
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 · F2024-12-17 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a qualified Infection Preventionist was employed at least part-time in the facility and was present to properly assess, implement, and manage the Infection Prevention and Control Program (IPCP). This deficient practice resulted in the potential for the spread of infection and communicable diseases to all 82 residents in the facility. Findings include: On 12/15/24 at 12:43 p.m., the Director of Nursing (DON) was asked the name of the facility's Infection Preventionist (IP). The DON said the facility did not have an IP. The DON explained that someone from another building who was not employed at the facility was keeping up with infection control information at the facility. The DON said Registered Nurse (RN) D was the MDS nurse in the facility and had training in infection prevention and control, and any questions regarding the IPCP should be directed to RN D. During an interview with RN D on 12/17/24 at 9:09 a.m., RN D was unable to answer questions regarding processes for identifying, monitoring, tracking,…
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 before2024-12-17 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 interview and record review, the facility failed to provide written transfer notifications to the resident/resident's representative and the Office of the State Long-Term care Ombudsman including reason, effective dates, and the location to which the resident was being transferred for four Residents (#5, #16, #33, #43) of seven residents reviewed for transfers out of the facility. Findings include: Resident #5 (R5) The medical record for R5 revealed a transfer to the hospital on [DATE] with readmission on [DATE]. The medical record did not indicate a written notification of transfer in October was given to R5 or sent to the resident's representative. The Resident was on the Office of the State Long-Term care Ombudsman log as transferred but there was no indication on the log if the return was expected and no primary reason for the transfer. (This data was missing for all 16 residents on the October ombudsman log.) On 12/17/24 at 10:41 AM, Administrative Staff F stated the written transfer notice for…
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 before2024-12-17 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 four Residents (#5, #16, #33, and #43) of eight residents reviewed for hospitalization were provided written notice of bed hold when the residents were transferred to the hospital. Findings include: Resident #43 (R43) The medical record for R43 revealed a transfer to the hospital on [DATE]. The medical record did not document issuance of the bed hold policy to R43 or R43's resident representative. Resident #16 (R16) The medical record for R16 revealed a transfer to the hospital on 3/7/24 with readmission on [DATE]. The medical record did not indicate a notice of the resident's bed hold policy had been given to R16 or the resident's representative. Resident #33 (R33) The medical record for R33 revealed a transfer to the hospital on 6/22/24 with readmission on [DATE]. The medical record did not indicate a notice of the resident's bed hold policy had been given to R33 or the resident's representative. Resident #5 (R5) The medical record for R5…
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 · D2024-12-17 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 personal privacy of medical information for one hallway of four hallways reviewed. This deficient practice resulted in Residents privacy being breached. Findings include: On 12/17/24 at 9:38 a.m., an observation was made of the D-hall medical cart computer. The D-hall medical cart computer was left with an open display for Resident 179 (R179), and visible on the computer screen were Physician Orders from the Electronic Medical Record program. The D-hall medical cart also had a clearly visible 'Controlled Substance Log' for R179 used to keep accurate count of controlled substances. Review of the facility's Federal Rights of Nursing Center Residents Requirements for Nursing Facilities given to each resident in the Hospitality Guide upon admission, read, in part, .(3) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records . An interview was conducted with the Director of Nursing (DON) on 12/17/24 at 12:45 p.m. The DON…
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 before2024-12-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 appropriate care was provided for Moisture Associated Skin Damage (MASD) according to professional standards of practice for one Resident (#47) of one resident reviewed for MASD. This deficient practice resulted in the potential for delayed wound healing, worsening of condition and pain. Findings include: Resident #47 (R47) R47 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), neurogenic (nerve originating problem) bladder, and type 2 diabetes. A review of R47's most recent Minimum Data Set (MDS) assessment, dated 10/2/24, revealed R47 scored 2 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. R47 was rated as always incontinent of bowel and bladder. An observation on 12/16/24 at 11:45 a.m., revealed R47 lying in bed, with her lower body covered with a blanket visiting with her Durable Power of Attorney (DPOA). R47's DPOA stated R47 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.
- Potential for harm · Dcited before2024-12-17 · 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 administer supplemental oxygen according to physician orders, change and date respiratory equipment, appropriately store respiratory equipment, and clarify parameters for administration of supplemental oxygen for three Residents (#330, #331, and #43) of seven residents reviewed for respiratory care services. Findings include: Resident #331 (R331) R331 was admitted [DATE] with diagnoses of acute respiratory failure with hypoxia (low levels of oxygen), chronic obstructive pulmonary disease, dependence on supplemental oxygen, and others. On 12/15/24 at 10:56 a.m., R331 was observed wearing a nasal cannula (tube that delivers supplemental oxygen). The nasal cannula tubing was dated 12/3/24. The supplemental oxygen was set at a delivery rate of 10 liters per minute. On 12/15/24 at 10:56 a.m., a Bipap machine (a non-invasive, mechanical breathing device) was observed on R331's nightstand. A hand-written note taped to the machine read: Increase…
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 before2024-12-17 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 interview and record review, the facility failed to timely destroy discontinued scheduled II medication and dispensed medication without a physician order for one Resident (#58) and failed to initiate a stop date on an as needed antianxiety medication for one Resident (#279) of eighteen residents reviewed for pharmacy services. Findings include: Resident #58 (R58) Review of R58's physician order, dated [DATE], revealed the following: Lorazepam tablet 0.5 mg (milligrams), give one tablet by mouth every eight hours as needed for anxiety related to adjustment disorder, with a discontinuation date of [DATE]. R58's as needed antianxiety medication should have been reevaluated after 14 days per the regulation and no evidence of reevaluation could be seen in the Electronic Medical Record (EMAR). Review of R58's controlled substance log, with the medication date received on [DATE], revealed R58 received a dose of the antianxiety medication on [DATE] after the medication was discontinued. Review of R58's…
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 before2024-12-17 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 interview and record review, the facility failed to: 1) ensure non-pharmacological interventions attempted and failed prior to the administration of as needed (prn) anxiolytic medication were documented; 2) ensure appropriate indication for use for an antipsychotic medication; and, 3) ensure consideration of a gradual dose reduction (GDR) of an anti-depressant medication, affecting three Residents (#68, #179, & #20) of five residents reviewed for unnecessary medications. Findings include: Resident #68 (R68) Review of the Minimum Data Set (MDS) assessment, dated 9/16/2024, revealed R68 was admitted to the facility on [DATE] and had diagnoses including dementia with behavioral disturbance, insomnia, hallucinations and depression. Further review of the MDS assessment revealed R68 had severe cognitive impairment. Review of R68's physician orders revealed the following: Diazepam [Valium, a controlled medication used to treat anxiety and insomnia] oral tablet 5 MG [milligram] . Give 1 tablet by mouth every 6…
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 · D2024-12-17 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain an accurate record of wounds for one Resident (#15) of two residents reviewed for wound documentation, resulting in the inaccurate reflection of the resident's condition and the potential for communication of inaccurate medical information to healthcare providers. Findings include: Resident #15 (R15) On 12/15/2024 at 9:14 a.m., R15 was observed lying in bed on her left side wearing an incontinence brief and shirt. Further observation revealed a large dark purple area covering R15's right hip. The center portion of the discolored area appeared boggy (soft, spongy texture indicative of a deep tissue injury). During an interview at the time of the observation, Licensed Practical Nurse (LPN) G reported R15 had three wounds at the present time. When asked the classification of the wounds, LPN G reported R15 was receiving hospice care and had skin failure. Review of R15's Wound Evaluation(s), abstracted from the electronic medical record (EMR), revealed R15 had wounds on rear left trochanter (hip, bony…
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 before2024-08-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 This citation relates to Intake #MI00145643. Based on observation, interview, and record review, the facility failed to ensure comprehensive and timely cardiac and respiratory assessments per professional standards of practice for two residents (R1, R2) of two residents reviewed with cardiac and respiratory conditions. Findings include: Resident 1 (R1): Review of R1's Minimum Data Set (MDS) assessment, dated [DATE], showed R1 was admitted to the facility on [DATE], with diagnoses including status post heart surgery, heart failure, hypertension (high blood pressure), shortness of breath, arteriosclerotic heart disease (hardening of the arteries), longstanding atrial fibrillation (heart rhythm disorder), and mixed hyperlipidemia (elevated cholesterol/fats). The assessment revealed R1 was independent with feeding and grooming, and required maximal assistance for toileting, dressing, bed mobility, and transfers. The cognitive assessment showed R1 was fully oriented with no mental status changes upon admission. 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 before2024-01-10 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 interview and record review, the facility failed to provide written transfer notifications to the resident and/or resident's representatives including reason, effective dates, and the location to which the resident was being transferred for six Residents (R10, R11, R36, R39, R41, R65) of six residents reviewed for transfers out of the facility. This deficient practice resulted in the potential for residents and/or resident's representatives to be uninformed, as well as a potential for inappropriate discharge/transfers. Findings include: Resident #36 (R36) The medical record for R36 revealed a transfer to the hospital on [DATE] and again on 12/30/23. The medical record did not indicate a written notification of transfer was given to R36 or sent to her representative. Resident #39 (R39) The medical record for R39 revealed a transfer to the hospital on [DATE] and a return on 11/9/23. The medical record did not indicate a written notification of transfer was given to R39 or sent to her representative.…
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 before2024-01-10 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 six residents (R10, R11, R36, R39, R41, R65) of six residents reviewed for hospital discharges, were provided written notification of the bed hold policy upon transfer. This deficient practice resulted in the potential for the residents and/or their responsible parties to be uniformed of the bed hold policy and their rights following a transfer to the hospital. Findings include: Resident #36 (R36) The medical record for R36 revealed a transfer to the hospital on [DATE] and again on 12/30/23. The medical record did not indicate the bed hold policy was provided to R36 or her representative. Resident #39 (R39) The medical record for R39 revealed a transfer to the hospital on [DATE] and a return on 11/9/23. The medical record did not indicate the bed hold policy was provided to R39 or her representative. Resident #41 (R41) During an interview on 1/8/24 at 3:53 PM, R41 stated she had been out to the hospital. The medical record for R41 revealed two…
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 · D2024-01-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 complete treatments as ordered by the physician, adhere to physician's orders for frequency of dressing changes, and maintain infection control practices to promote the healing of pressure injuries for one Resident (#65) of two residents reviewed for pressure injuries. This deficient practice had the potential to result in infections, worsening of existing pressure injuries, and the development of additional wounds. Findings include: Resident #65 (R65) was admitted to the facility on [DATE] with diagnoses that included but were not limited to: urinary tract infection (UTI), muscle weakness, need for assistance with personal care, lack of coordination, convulsions, unspecified lack of expected normal physiological development in childhood, subarachnoid hemorrhage (bleeding in the brain), and cerebral palsy[. An admission Minimum Data Set (MDS) assessment dated [DATE] coded R65 as completely dependent on staff for Activities of Daily living…
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 before2024-01-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a urinary drainage system was maintained in an aseptic manner for one Resident (#65) of 3 residents reviewed for catheters. This deficient practice resulted in the potential spread of infectious organisms, and the potential for R#65 to experience worsening of an existing urinary tract infection. Resident #65 (R65) was admitted to the facility on [DATE] with diagnoses that included but were not limited to: urinary tract infection (UTI), muscle weakness, need for assistance with personal care, lack of coordination, convulsions, unspecified lack of expected normal physiological development in childhood, subarachnoid hemorrhage (bleeding in the brain), and cerebral palsy. An admission Minimum Data Set (MDS) assessment dated [DATE] coded R65 as completely dependent on staff for Activities of Daily living (ADL) or coded 88 meaning the activity could not be attempted due to R65's medical condition and the safety of the resident. The MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-10 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure pharmacist irregularities reported in the monthly medication review were addressed timely in the medical record by the physician for two Residents (R50 & R55) of five residents reviewed for drug regimen reviews. This deficient practice resulted in the potential for unnecessary medications, drug interactions and undesirable medication side effects. Findings include: Resident R50 Review of pharmacy Note to Attending Physician/Prescriber revealed the following pharmacist recommendations: 8/13/2023 - This Resident (R50) currently has an order for lorazepam (anti-anxiety medication) PRN (as needed). Please evaluate current diagnosis, behaviors and usage patterns and evaluate continued need. PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the PRN order . Please consider .If PRN lorazepam is to be continued, please write a new PRN order and include the duration and rationale for continued use. 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 before2024-01-10 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 interview and record review, the facility failed to adhere to 14-day PRN psychotropic and antipsychotic prescription durations and ensure gradual dose reductions were attempted, unless contraindicated, for three Residents (R50, R55, and R27) of five residents reviewed for unnecessary medications. This deficient practice resulted in the potential for the administration of unnecessary medications and risk of medication adverse side effects. Findings include: Resident R50 Review of pharmacy Note to Attending Physician/Prescriber revealed the following pharmacist recommendations: 8/13/2023 - This Resident (R50) currently has an order for lorazepam PRN (as needed). Please evaluate current diagnosis, behaviors and usage patterns and evaluate continued need. PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the PRN order . Please consider .If PRN lorazepam is to be continued, please write…
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 before2024-01-10 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the Hospice Plan of Care was retained in the facility for one Resident (R35) of one resident reviewed for Hospice care. This deficient practice resulted in the potential for lack of continuity of care when the facility was not updated on the care and services planned and provided to R35. Findings include: During an interview on 1/10/24 at 10:45 a.m., R35's Hospice Plan of Care was requested from the Director of Nursing. The DON reviewed the Electronic Medical Record (EMR) and confirmed a Hospice Plan of Care was not scanned into the EMR. The DON stated that the [specific Hospice Agency] was not quite as organized as some of the other Hospice agencies and that is why they did not use them as regularly. The DON said the Hospice agency would be contacted to send the Plan of Care to the facility so that it could be placed into the Resident's Hospice Binder. When asked if she understood that it would be a concern not to have the printed Hospice Plan of Care available for review by facility staff, the DON stated, Yes I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-12-17 · tag F0732 — widespreadPost nurse staffing information every day.
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 daily posting of nurse staffing information, resulting in the inability of residents, resident's representatives and visitors to determine the number of staff available to provide resident care and had the potential to affect all 82 residents in the facility. Findings include: On 12/15/2024 at 9:02 a.m. the facility's, Daily Nurse Staffing Form, was observed posted on the wall in entrance hallway of the facility. Review of the staffing form revealed the form was dated 12/12/2024, three days prior to the observation. During an interview on 12/17/2024 at 11:47 a.m., the facility Staffing Coordinator, Staff A, reported she was responsible for completion and posting of the daily staffing levels using the Daily Nurse Staffing Form. Staff A reported she did not work from 12/13/2024 until 12/16/2024 and nursing staff were responsible for completion and posting of the forms in her absence. The Nursing Home Administrator (NHA), who was present during the interview, stated she was aware of the requirement for…
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 MEDILODGE — 53 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 | 4 of 5 | 3.1 | +0.9 vs chain |
| Health inspection | 2 of 5 | 2.7 | -0.7 vs chain |
| Staffing | 5 of 5 | 3.7 | +1.3 vs chain |
| Quality measures | 5 of 5 | 4.0 | +1.0 vs chain |
The other 52 homes this chain runs (chain average 3.1★, per CMS)
Showing 40 of 52; lowest-rated first.
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 |
|---|---|---|---|---|
| EVEREST OPCO GROUP LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/01/2018 |
| B&Y HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| B&Y TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| CODY HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| CRAIG FLASHNER 2007 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| NORCROSS, ROBERT | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 02/01/2018 |
| ROGERS, STACEY | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 02/01/2018 |
| KIRK, KRISTINE | Individual | W-2 MANAGING EMPLOYEE | — | since 02/01/2018 |
| FLASHNER, CRAIG | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
| PERLSTEIN, YITZCHOK | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
| BLOSSOM HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
| PRESTIGE ADMINISTRATIVE SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
CMS files one row per role, so the 14 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
7 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 $519K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
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 235350. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-19, 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.