Clark Retirement Community
1551 Franklin Street SE, Grand Rapids, MI 49506 · Non profit - Corporation · 39 certified beds · (616) 452-1568 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing 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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 2.6% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.6% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.2% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.1% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.5% | 3.0% | 3.3% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 9.6% | 19.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 92.6% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.0% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 33.0% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.4% | 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 | 44.8% | 79.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 16.2% | 24.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 15.9% | 11.7% | 12.0% | 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.
Therapy staffing: this home’s payroll records show 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 39 beds and averages 30.4 residents a day — about 78% occupied, or roughly 9 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 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.30 hrs/resident/day on weekends vs 3.66 on weekdays — 10% thinner on weekends. RN hours go from 0.55 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% 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.
28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2025-07-30 · 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 This citation pertains to intake: 1293524 Based on record review and interview, the facility failed to ensure a safe transfer and implement facility policy to prevent falls in 1 of 4 residents (Resident #2) reviewed for fall prevention, resulting in a fall during a lift transfer resulting in a right fractured humorous for Resident #2, which had impacted the resident's functional status and quality of life with the potential for further injury and falls due to unsafe transfers. Findings include: Resident #2Review of an admission Record revealed Resident #2 was a female with pertinent diagnoses which included fracture of right femur, dementia, quadriplegia (partial or total loss of function in all four limbs and the torso), and polyosteoarthritis (flexible tissue at the ends of the bones wear down). Review of a Minimum Data Set (MDS) assessment for Resident #2, with a reference date of 6/25/25 revealed, .Section GG: Mobility: Chair/bed-to-chair transfer. 01 - Dependent.Review of current Care Plan for Resident #2,…
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 · Gcited before2024-03-21 · 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 This citation pertains to Intake #MI00143296. Based on interview and record review, the facility failed to implement fall interventions (utilize a bedside impact/fall mat) for 1 resident (Resident #100) of 4 residents reviewed for accidents and hazards, resulting in Resident #100 falling out of bed sustaining a soft tissue laceration over the midline frontal scalp, non-displaced facial fractures, and mild displaced angular fracture of the left humeral shoulder and the potential for further accidents and hazards to occur for residents at risk for falls. Findings include. Review of an admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cerebral infarction (stroke). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 1/04/24 revealed a Brief Interview for Mental Status (BIMS) score of 03/15 which indicated Resident #100 was cognitively severely impaired. Review of a Facility Reported Incident (FRI)…
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 · F2025-07-30 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for 8 consecutive hours per day, 7 days per week, resulting in the potential for unmet care needs, resident change of condition to not be properly assessed and negative clinical outcomes. This deficient practice has the potential to impact all 29 residents currently residing in the facility. Findings include:Review of Nursing Schedules for 1/1-3/31/25 revealed the facility did not provide RN coverage for 8 consecutive hours per day, 7 days per week during 5 of 14 weekends included in this timeframe.Review of Nursing Schedules with a reference date of 5/1-7/27/25 revealed the facility did not provide RN coverage for 8 consecutive hours per day during any of the 13 weekends included in this timeframe. During 8 of the weekends in question, the facility had no scheduled RN coverage at all. Review of a Registered Nurse Job Description with a reference date of 2024 revealed POSITION SUMMARY: the Registered Nurse (RN) provides exceptional care.promoting their health.ensuring their safety 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 · Fcited before2025-07-30 · 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 maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings include: On 07/28/25 at 9:40 AM, Observation of the clean utensil storage area found a mechanical scoop stored with stuck on food debris. Further observation found that the bins containing whisks and spoons were found with an increased accumulation of crumb debris. When asked how often this area gets cleaned, Dining Services Director (DSD) W stated they should get done every Tuesday. On 07/28/25 at 10:05 AM, An interview with DSD W found that the tabletop mixer and the slicer get used often. Observation of the mixer found dried stuck on food debris on the back shield and front grate of the mixing under arm. Observation of the slicer found stuck debris that looked like tomato seeds on the top backside of the blade. When asked Chef Y if tomatoes are used on the slicer he stated…
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 · F2025-07-30 · 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 that a qualified Infection Preventionist worked at least part-time at the facility, was provided sufficient time to perform the Infection Preventionist role, and to properly assess, implement, and manage the Infection Prevention and Control Program.Findings include:During an interview and record review on 7/29/25 at 10:00 AM, Infection Control Preventionist/Director of Nursing/Unit Manager (ICP/DON) B stated, I am the DON, ICP, and UM not only for the LTC side of the facility but also for AL (Assisted Living). I do MDS (Minimum Data Set) part-time as well. This all takes up a lot of time. I am interrupted by staff from my duties, and it is hard to get everything done with all I have to do.During an interview on 7/29/25 at 4:01 PM, ICP/DON B stated, There is a resident that has been here since sometime in June 2025 that requires the PCV20 vaccine, and I have not ordered it yet. I was going to get the other residents' immunization consent to know how many I needed but I just have not been able to get to them before…
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 · E2025-07-30 · 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 a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in residents' satisfaction of living. Findings include:On 07/28/25 at 1:25 PM, Observation of the 3500 Hall Spa room, with Maintenance Director (MD) X, found a stack of clean towels stored between the sink and the commode open and exposed for contamination. Further review of the shower room found multiple dime size pieces of dried bowel movement on the grate for the shower drain with a used glove and wash cloth found under the shower equipment. When asked if that is where clean linens are normally stored, MD X stated the linen is usually protected in a cabinet or covered cart. On 07/28/25 at 1:31 PM, Observation of the housekeeping closet, next to the pantry room, found that the cold-water line was turned off, indicating a stagnant water line. On 07/28/25 at 1:37 PM, Observation of the soiled utility room found brown and discolored water dispense from the cold-water line on 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 before2025-07-30 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to promote a dignified dining experience for 3 (Resident #21, Resident #4 and Resident #14) of 4 residents reviewed for dignity, resulting in a potential for a reduced quality of life, feelings of frustration, helplessness and a decreased sense of self-worth.Findings include: Resident #21: During an observation on 07/29/25 at 4:41 PM, Resident #21 was placed at the table with Resident #14 and the other female resident who was eating her meal. Resident #21 had a plate covered with a grey top in front of her, she had cooked cinnamon apples in a dessert dish on the table. During an observation on 07/29/25 at 4:45 PM, LPN “J” proceeded to assist Resident #21 by opening her napkin with silverware and removed the top to the plate. LPN “J” proceeded to sit down between Resident #21 and Resident #14 to assist with each with dinner. Review of an admission Record revealed Resident #21 was a female with pertinent diagnoses which included Alzheimer'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 · D2025-07-30 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents maintained their right to self-determination for 1 resident (Resident #32), of 1 reviewed for choices, resulting in feelings of anxiety when staff did not wear a surgical mask while caring for the resident, despite her preference for them to do so.Findings include:Resident #32Review of an admission Record revealed Resident #32 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: history of falls.Review of a Minimum Data Set (MDS) assessment for Resident #32 with a reference date of 7/25/25, revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #32 was moderately cognitively impaired.Review of a Care Plan for Resident #32 with a reference date of 7/29/25, revealed a focus/goal/interventions of: Focus: Resident and family encourage visitors to resident's room utilizing hand sanitizer and PPE (personal protective equipment) before entering residents room. Goal:…
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 before2025-07-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and Centers for Disease Prevention and Control (CDC) guidance to administer pneumococcal vaccinations to residents who consented for immunization, screen and assess residents for eligibility of receiving pneumococcal vaccinations, and offer pneumococcal vaccinations to residents who were eligible to receive it, for 1 of 5 (R19) residents reviewed for pneumococcal vaccinations, resulting in the potential for contracting the virus. Finding include:Review of the facility's Pneumococcal Vaccine policy revision date October 2023, revealed, Policy statement: All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation.upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility.According to the Minimum Data Set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00146821. Based on observation, interview, and record review, the facility failed to effectively develop and implement comprehensive, person centered care plans for 2 residents (Resident #106 and #107), of 8 residents reviewed, resulting in unmet care needs and the potential for negative physical, mental and psychosocial outcomes. Findings include: Resident #106 Review of an admission Record revealed Resident #106 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dysphagia (swallowing disorder) and urinary retention (inability to empty bladder). Review of Resident #106's Orders revealed, Meals: upright in chair, at table. Feeding assist needed. Small bites and sips. Oral care before meals. Would benefit from sippy cup. every day shift for SLP (speech language pathologist: a person who helps with swallowing problems) recommendations. Active 9/21/2024. Review of Resident #106's Nutritional Risk Care Plan revealed, .at nutritional risk…
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 · D2025-02-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00146821 Based on observation, interview, and record review, the facility failed to ensure timely, effective incontinence care was provided for 1 resident (Resident #106) of 3 residents reviewed for bowel and bladder incontinence, resulting in an increased risk for UTI (urinary tract infection) and the potential for skin breakdown. Findings include: Review of an admission Record revealed Resident #106 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: urinary retention (inability to empty bladder). Review of Resident #106's Incontinence Care Plan revealed, .bladder incontinence r/t (related to) dementia, parkinson's (a disorder that effects movement), impaired mobility. date initiated 8/25/24. Interventions: .Check every 2-3 hours and as required for incontinence. Wash, rinse and dry perineum (genitals and anus) .date initiated 8/25/24. In an interview on 2/19/25 at 9:00 AM, Family Member (FM) M reported that Resident #106 sat in his…
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 before2024-08-22 · 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 prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all 35 residents. Findings include: During the initial tour of the kitchen, starting at 9:25 AM on 8/20/24, it was observed that four pans of cooked, whole intact, beef roasts were found on the expediting cart in the preparation walk in cooler dated for 8/20. At this time, there were also a couple pans of beef dated for 8/19, and further review of the walk in cooler found a large container of bean soup (roughly 3 gallons) cooling with two ice wands in the soup. A review of the kitchen's Cooling Log, dated August, found beef roasts that were cooled on 8/19, but none that were logged for being cooked/cooled on 8/20. Further review of the log found the bean soup starting cooling at 8:30 AM this morning (8/20/24), but was unclear if the cooling started at 140F or 190F. At 9:30 AM on 8/20/24, an interview with [NAME] NN found that the beef was all cooked…
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 16 citations
- Potential for harm · Fcited before2024-08-22 · 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 effectively implement Transmission-Based Precautions (TBP) for COVID-19 positive residents and Enhanced Barrier Precautions (EBP) per facility policy and Centers for Disease Control and Prevention (CDC) guidance, in 4 of 7 residents (Resident #3, #20, #17, and #11) reviewed for infection control, with the potential to affect all 36 residents who reside at the facility, resulting in the potential for disease exposure, cross-contamination, and the development and spread of infection to a vulnerable population. Findings include: Review of the policy/procedure Infection Prevention & Control: COVID-19, dated 2/28/24, revealed .Personal Protective Equipment .HCP (Health Care Providers) who enter the room of a resident with suspected or confirmed SARS-CoV-2 (COVID-19) infection should adhere to Standard Precautions and use a NIOSH Approved N95 (mask), gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front 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 · E2024-08-22 · tag F0943 — patternGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide annual required abuse prevention education for all staff members who provide care, services, and supports to the residents. This has the potential to affect all 36 residents residing in the facility at the time of the survey. Findings include: Review of (Vendor) Course Completion Report dated 08/22/24, revealed, 27 employees out of 126 employees had not completed Understanding Abuse and Neglect and/or Recognizing, Reporting, and Preventing Abuse. No Therapy staff or Housekeeping staff listed on the report. Review of Facility Assessment reviewed by the QAA (Quality Assessment and Assurance) Committee on 1/2024, revealed, the abuse and neglect training was provided via the (Vendor) computer module health care education provide to the center staff throughout the year. In an interview on 8/22/24 at 3:27 PM, Administrator A reported in regard to education for abuse and reporting the staff completed the education with the (Vendor) annually. DON B reported the facility provided training through a computer-based program.…
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 · E2024-08-22 · tag F0945 — failed to train staff on abuse prevention — patternInclude as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the 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 training program for all staff in regard to infection prevention and control and Enhanced Barrier Precautions, resulting in the potential for the spread of disease and infection to a vulnerable population. Findings include: In an interview on 8/22/24 at 12:21 PM, Certified Nursing Assistant (CNA) W reported she did not recall receiving any education in regard to Enhanced Barrier Precautions (EBP). CNA W reported she may have received a text, but does not recall the content of the message. In an interview on 8/22/24 at 3:27 PM, with Administrator A and Director of Nursing (DON) B, DON B reported in regard to education for EBP, the facility posted information on the home page for the electronic medical record system. DON B reported this information was visible to the licensed nurses, but was unsure if it was available to the CNA staff or any other departments. No documentation or signature record to indicate which staff reviewed the information posted within the electronic medical record system. DON B…
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 before2024-08-22 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide an environment that promoted and enhanced resident dignity for 1 resident (Resident #13) of 2 reviewed for dignity, resulting in the potential of feelings of frustration, anxiety, embarrassment and loss of self-worth, impacting their quality of life and promoting a negative psychosocial outcome for the residents. Findings include: Resident #13: Review of an admission Record revealed Resident #13 was a male with pertinent diagnoses which included Alzheimer's disease, dementia, heart failure, chronic pain, kidney disease, stage 3, blood in urine, urinary tract infection, edema, duiretic therapy (increased productin of urine) and cellulitis of left lower limb. Review of Care Plan revised on 08/15/24, revealed the focus, .The resident has an ADL self-care performance deficit r/t (related to) Dementia . with the intervention .Toilet Use: The resident is totally dependent on 1-2 staff for toilet use .Encourage the resident to use bell to call for assistance (note: no call light was availabe to the resident…
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 · D2024-08-22 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to report an allegation of neglect in 1 of 1 (Resident #34) of 16 residents reviewed for reporting, resulting in the potential for continued violations involving neglect and/or abuse going unreported. Findings include: Review of an admission Record revealed Resident #34 was a male with pertinent diagnoses which included amyotrophic lateral sclerosis (ALS), heart disease, muscle wasting and atrophy, repeated falls, and obstructive uropathy (obstructing urine flow). Review of Minimum Data Set (MDS) dated [DATE], revealed, .Section F: Preferences for Customary Routine and Activities: .E. How important is it to you to chose your own bedtime? Very important .F. how important is it to you to do your favorite activities? Very important .H. Bladder and Bowel: Urinary Continence: Frequently incontinent .Bowel Continence: Always incontinent . Review of No Type Specified note dated 8/15/2024 at 5:06 PM, revealed, .Investigation: 8/11/24 Allegation (Resident #34)…
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 · D2024-08-22 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse/neglect for 1 of 1 resident (Resident #34) reviewed for abuse, resulting in an allegation of abuse not being identified and thoroughly investigated allowing for the potential for mistreatment and/or abuse. Findings include: Review of an admission Record revealed Resident #34 was a male with pertinent diagnoses which included amyotrophic lateral sclerosis (ALS), heart disease, muscle wasting and atrophy, repeated falls, and obstructive uropathy (obstructing urine flow). Review of Minimum Data Set (MDS) dated [DATE], revealed, .Section F: Preferences for Customary Routine and Activities: .E. How important is it to you to chose your own bedtime? Very important .F. how important is it to you to do your favorite activities? Very important .H. Bladder and Bowel: Urinary Continence: Frequently incontinent .Bowel Continence: Always incontinent . Review of No Type Specified note dated 8/15/2024 at 5:06 PM, revealed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-22 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 1 resident (Resident #28) of 2 residents reviewed for care planning resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being Findings include: .A nursing care plan includes nursing diagnoses, goals and/or expected outcomes, individualized nursing interventions, and a section for evaluation findings .The plan promotes continuity of care and better communication because it informs all health care providers about a patient's needs and interventions and reduces the risk for incomplete, incorrect, or inappropriate care measures. Nurses revise a plan when a patient's status changes .The plan of care communicates nursing care priorities to nurses and other health care providers. It also identifies and coordinates resources for delivering nursing care . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME].…
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 · D2024-08-22 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update/revise a comprehensive care plan after a change in resident condition in 1 of 14 residents (Resident #30) reviewed for comprehensive care plans, resulting in an inaccurate reflection of the resident's status, and the potential for unmet medical, physical, mental, and psychosocial needs. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.18.11, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care . According to [NAME],…
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 · D2024-08-22 · 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 residents' mechanical diet order recommeded by the speech language pathologist was added in a timely manner and the recommended diet was followed for meals; 2. resident was evaluated by therapy and interventions implemented to address positioning were in place in 1 of 1 resident resulting in the potential for aspiration, decreased range of motion and worsening of contractures. Findings include: Resident #28: Review of an admission Record revealed Resident #28 was a female with pertinent diagnoses which included dementia, stroke, and dysphagia (damage to the brain responsible for production and comprehension of speech). Review of Care Plan revised on 8/21/24, revealed the focus, .(Resident #28) is at risk for altered nutrition/hydration status r/t (related to) hypothyroidism with CHF (congestive heart failure) requiring meds which may impact appetite/weight .(Resident #28) also has intolerance to lactose . with the intervention…
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 · D2024-08-22 · 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 provide the necessary care and services, consistent with professional standards of practice to prevent, treat, and promote healing of pressure uclers in 1 of 3 residents (Resident #31) reviewed pressure ulcers, resulting in the lack of repositioning and implementation of care planned interventions, delayed healing of pressure ulcers for the resident, and the potential for infection and the development of new ulcers. Findings include: Positioning interventions redistribute pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces (WOCN, 2010). Change the immobilized patient's position according to tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort (NPUPA, EUPAP, PPPIA, 2014). A standard turning interval of to 2 hours does not always prevent pressure…
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 · D2024-08-22 · 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
Based on interview and record review, the facility failed to attempt a required Gradual Dose Reduction (GDR) of an antidepressant medication, in the absence of a documented contraindication, for 1 (Resident #6) of 5 residents reviewed for unnecessary medications, resulting in the potential that the resident received the medication at an unnecessary dose or for an unnecessary length of time. Findings include: Resident #6 Review of an admission Record revealed Resident #6 was a female, with pertinent diagnoses which included: depression, unspecified and anxiety disorder, unspecified. Review of a current Physician Order for Resident #6 revealed, PAROXETINE 20MG (milligrams) TAB (tablet) Give 1 tablet orally one time a day for Depression Pharmacy Active 4/4/2023 08:00 Review of a pharmacist (pharmacy name omitted) Note To Attending Physician/Prescriber printed 4/10/24 revealed, (Resident #6) is currently receiving Paxil (brand name for Paroxetine) 20mg QD (once a day). She has diagnoses of depression and anxiety. Dosing History: 3/15/23 admitted on 20MG QAM (daily in the morning) .After…
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 before2024-08-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who was eligible for a recommended vaccine was offered that vaccine in a timely manner for 1 resident (Resident #29) of 5 residents reviewed for immunizations, resulting in a delay in the resident to be given the opportunity to receive or decline the pneumococcal vaccination. Findings include: Review of the policy Pneumococcal Vaccine with a revised date of October 2023 revealed, Policy Statement All residents are offered pneumococcal vaccines to aide in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series .7. Administration of the pneumococcal vaccines are made in accordance with 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 before2023-11-01 · 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 1) ensure hand hygiene during meals and incontinence care for 1 (Resident #33) of 1 resident reviewed for activities of daily living, 2) ensure sanitization of shared equipment, and 3) ensure sanitary handling of dirty linens, resulting in the increased potential for the development and transmission of communicable diseases and infection in a vulnerable population. Findings include: Hand hygiene during meals In an observation on 10/30/2023 at 12:42 PM in the 3200 hall common area, Certified Nursing Assistant (CNA) V was sitting between two residents and feeding them lunch. CNA V was alternating between assisting each resident, touching food utensils, clothing, and resident skin with both hands without performing hand sanitizer in between resident contact. In an observation on 10/31/2023 at 8:43 AM in the 3200 hall common area, CNA F switched out gloves in between resident contact while setting up multiple residents for breakfast without…
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 · D2023-11-01 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 assess and ensure the right to safe self-administration of medication in 1 of 6 residents (Resident #20) reviewed for medication administration, resulting in the potential for unsafe self-administration of medication, medication errors, and medications not being stored in a secure manner. Findings include: Review of an admission Record revealed Resident #20 was a male, with pertinent diagnoses which included diabetes, asthma, narcolepsy (excessive daytime sleepiness), chronic pain, high blood pressure, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #20, with a reference date of 8/3/23, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated he was cognitively intact. In an observation and interview on 10/31/23 at 9:59 AM, Resident #20 was in his room, sitting in his power chair. Observed two inhalers in his room, an Atrovent HFA inhaler and a Fluticasone Propionate/Salmeterol 250/50 mcg (ADVAIR) inhaler, along with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-01 · 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 implement interventions for safe transfers for 1 (Resident #33) of 1 resident reviewed for falls, resulting in the potential for falls and injury and residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an admission Record revealed Resident #33 admitted to the facility on [DATE] with pertinent diagnoses which included heart failure and repeated falls. Review of a Minimum Data Set (MDS) assessment for Resident #33, with a reference date of 9/28/2023 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #33 was moderately cognitively impaired. Further review of same MDS assessment revealed Resident #33 required the assistance of two persons with transfers. In an interview on 10/30/23 at 2:00 PM, Resident #33 reported staff did not always use two persons when transferring her. Review of a current fall…
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 · D2023-11-01 · 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 interview and record review the facility failed to maintain complete and accurate medical records for 1 (Resident #27) of 12 residents reviewed for complete and accurate medical records, resulting in incomplete documentation of advance directives (personal choices of medical treatment options). Findings include: Review of an admission Record revealed Resident #27 had pertinent diagnoses which included unspecified dementia, type 2 diabetes mellitus, and anxiety. Review of Physician Orders on 10/30/23 revealed a DNR (Do Not Resuscitate) order beginning on 3/29/2023. Review of Resident #27's complete medical record revealed no noted Advance Directive form in the medical record. Review of Physician Orders on 10/31/23 revealed a Full Code order beginning on 10/31/2023. During an interview on 10/31/23 at 2:29 PM., Licensed Practical Nurse (LPN) P reported that Resident #27 was a DNR (do not resuscitate). LPN P reported an advanced directive form signed by the resident and/or resident representative and the physician for any resident who wished to be a DNR should be present before…
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 BHI SENIOR LIVING — 9 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 | 2 of 5 | 4.0 | -2.0 vs chain |
| Health inspection | 2 of 5 | 3.9 | -1.9 vs chain |
| Staffing | 2 of 5 | 3.8 | -1.8 vs chain |
| Quality measures | 3 of 5 | 4.2 | -1.2 vs chain |
The other 8 homes this chain runs (chain average 4.0★, 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 |
|---|---|---|---|---|
| BHI RETIREMENT COMMUNITIES INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 01/01/2025 |
| BLOOMSTROM, JOHN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| CALDWELL, JEFFREY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| DALTON, DOUGLASS | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| ELLIS, BRIAN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| HOPPE, GEORGE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/15/2020 |
| JONES, L. DEAN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| KELLY, BETH | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| KOSELKE, ELIZABETH | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2022 |
| KYLLONEN, KELLY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| MAURER, MCKENSEY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| MEREDITH, WENDY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| MILLER, MARK | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2021 |
| MILLER, ROGER | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| MURPHY, KARA | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| ORBAN, GLENN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| RICHARDSON, JANE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| ROBBINS, FRED | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| SEIGEL, JANE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| TERP, JEFFREY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| DATTILO, JOHN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2022 |
| SMITH, PERCELL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| WEIDEMAN II, ROGER | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| BANK OF NY MELLON | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| FIFTH THIRD BANK | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| FORVIS MAZARS, LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2023 |
| HEALTHCARE THERAPY SERVICES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| KAURA, SITA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| RUFFING, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| PLANTE & MORAN PLLC | Organization | ADP OF THE SNF | — | since 01/01/2025 |
CMS files one row per role, so the 67 rows in the source record cover these 30 parties — each is shown once here with every role it holds. Nothing is omitted.
6 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.
This home reported $216K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 235401. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-30, 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 →
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