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Corewell Health Rehabilitation & Nursing Center -

4118 Kalamazoo Ave SE, Grand Rapids, MI 49508 · Non profit - Corporation · 165 certified beds · (616) 486-7002 Medicare & Medicaid certified

Call the home — (616) 486-7002 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Apr 2025
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • 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
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

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

Location & what’s nearby

Urgent care / clinic
4540 Kalamazoo Ave SE · (616) 281-0666 · Call to confirm hours
Pharmacy
4150 Kalamazoo Ave SE · (616) 591-9595 · Call to confirm hours
Grocery
4301 Kalamazoo Ave SE · (616) 281-8151 · Call to confirm hours
Park
Bark Park0.7 mi
Typically dawn to dusk
Place of worship
4010 Kalamazoo Ave SE · (616) 455-4260

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.0%10.8%15.4%better
Long-stay residents who lose too much weight4.7%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.8%0.9%better
Long-stay residents with a urinary tract infection1.7%1.5%2.0%better
Long-stay residents with depressive symptoms0.3%4.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.6%3.0%3.3%better
Long-stay residents whose ability to walk worsened9.4%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.3%19.4%18.9%worse
Long-stay residents given the seasonal flu vaccine87.9%95.0%95.3%typical
Long-stay residents with pressure ulcers5.2%5.1%4.7%worse
Long-stay residents with worsening bladder/bowel control22.4%20.0%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table13.4%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.7%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine94.6%79.5%79.4%better
Short-stay residents rehospitalized after admission20.4%24.0%22.6%typical
Short-stay residents with an outpatient ER visit15.5%11.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.781.841.67typical
Long-stay outpatient ER visits per 1,000 resident days1.721.641.80typical

§ 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.

59.3% 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 86 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.3%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
60.4%U.S. median 56.6%
Met the expected recovery
0.45U.S. median 0.31
Therapy hours / resident / day
0.26hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 60.4% 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 96 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 0.45 therapist hours per resident per day in 2026Q1 — more than 76% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF59.3%CMS range 48.6–68.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 7.8–16.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge60.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge55.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge51.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.9%CMS range 4.1–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.721.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.32
RN hours/ resident / day
1.08
LPN hours/ resident / day
2.74
Aide hours/ resident / day
5.15
Total nurse hours/ resident / day
0.90
RN hoursweekends
41.1%
Total nursing turnover
17.1%
RN turnover

How full it usually is: this home is certified for 165 beds and averages 145.4 residents a day — about 88% occupied, or roughly 20 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.15 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.32 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.74 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 4.36 hrs/resident/day on weekends vs 5.46 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.49 to 0.90 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% 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

2
deficiencies at the latest standard inspection (2025-09-10)
4
at the previous standard inspection (2024-08-15)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · Ecited before2025-09-10 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the standards of infection control for Kangaroo pumps (a portable, electronic medical device used for enteral feeding), and IV poles cleaning for five residents (R1, R2, R25, R47, and R105) of 5 residents reviewed for tube feeding, and oxygen concentrator cleaning for one resident (R118) of 1 resident reviewed for receiving oxygen, resulting in the potential for cross-contamination and the spread of disease to a vulnerable population.Findings include:R1According to R1's Face Sheet, the resident's diagnoses included skin breakdown at gastrostomy tube site, and presence of gastrostomy for nutrition. Review of R1's Order Summary, printed and provided on 9/8/25 by facility, indicated the resident had a J-tube (a tube inserted into a small part of the stomach) to provide nutrients and medications. Observed on 9/08/2025 at 10:26 AM, R1 had at bedside a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-10 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # 2603853Based on observation, interview and record review, the facility failed to ensure all residents maintained their right to self-determination for 1 (Resident #74) of 1 resident reviewed for choices, resulting in Resident #74 not receiving feeding assistance while others ate around him, missed opportunities to experience joy while eating, and a loss of autonomy.Findings include:Review of Alternative Nutrition and Hydration in Dysphagia Care, American Speech-Language-Hearing Association, https://www.[NAME].org/practice-portal/clinical-topics/adult-dysphagia/alternative-nutrition-and-hydration-in-dysphagia-care/, revealed .Recommendations for supplemental feeding may include pleasure feeding. This option is often limited to the patient consuming tastes or small amounts of food types while following clear precautions; pleasure feeding is administered (or taken) to improve quality of life.Patient autonomy, or the right to self-determination, is a key factor in health care…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-29 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This citation pertains to Intake MI00152599. Based on interview and record review, the facility failed to ensure residents were treated with dignity and respect in 2 (Resident #100, Resident #101) of 4 residents reviewed for abuse, resulting in feelings of diminished self-worth and frustration. Findings include: Resident #100 Review of an admission Record revealed Resident #100 was a male, with pertinent diagnoses which included: diarrhea, anxiety, and cerebral palsy (a disorder that affects movement, muscle tone, or posture). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 3/5/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated Resident #100 was cognitively intact. In an interview on 4/28/25 at 10:05 AM, Resident #100 reported Certified Nurse Aide (CNA) P had yelled at him because he had an accident. Resident #100 reported he had had a bowel movement accident and CNA P came in his room and started yelling because he had had the accident. Resident #100 reported Licensed Practical Nurse (LPN) Q…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-29 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to implement policies and procedures for immediate reporting to the State Agency for 1 (Residents #100) of 4 residents reviewed for abuse reporting, resulting in the potential for further instances of abuse going undetected, unreported, or without thorough investigation. Findings include: Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 3/5/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated Resident #100 was cognitively intact. In an interview on 4/28/25 at 10:05 AM, Resident #100 stated, I had one of the aides that verbally abused me. Resident #100 reported he had had a bowel movement accident. Resident #100 reported the aide (CNA Certified Nurse Aide P) had come in his room and started yelling at him because he had had an accident. Resident #100 reported that he had complained to the facility. Resident #100 reported that a nurse (Licensed Practical Nurse, LPN Q) had witnessed the incident and encouraged him to report it. Resident #100…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain proper infection control practices as evidenced by failure to 1. Ensure proper hand hygiene was completed during incontinence care for 1 (Resident #14); and 2. Ensure proper PPE (personal protective equipment) for enhanced barrier precautions was used during personal cares for 1 (Resident #14) of 15 total sampled residents reviewed for infection control practices resulting in the potential for the introduction of infection, cross-contamination, and/or disease transmission. Findings include: Resident #14 Review of a Face sheet revealed Resident #14 was male and was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Traumatic brain injury (TBI; a brain injury that occurs when a sudden external physical assault happens to the brain), dysphagia (difficulty or the inability to swallow), and neurogenic bladder (a lack of coordination between the brain and the bladder resulting in the inability to…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-05 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake # MI00146599 & MI00146889. Based on observation, interview, and record review, the facility failed to ensure call lights were in reach for 2 (Resident #101 and #102) of 3 residents reviewed for accommodation of needs, resulting in the inability to call for staff assistance and the potential for unmet care needs. Findings include: Resident #101 Review of an admission Record revealed Resident #101 was a female, originally admitted to the facility on [DATE] with pertinent diagnoses which included age related physical debility. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 10/23/24, revealed a Brief Interview for Mental Status (BIMS) score of 12/15, which indicated Resident #101 had moderate cognitive impairment. Review of Resident #101's current Care Plan revealed, .(Resident #101) does not want to experience a fall with major injury .Interventions .Call light within reach .Start date: 1/21/23 . Review of Resident #101's Nursing Note dated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 # MI00146599. Based on observation, interview, and record review, the facility failed to ensure showers were provided per resident preference and plan of care for 1 (Resident #101) of 3 resident reviewed for Activities of Daily Living (ADL) care, resulting in inadequate personal hygiene, missed showers, and dissatisfaction with care and hygiene concerns. Findings include: Resident #101 Review of an admission Record revealed Resident #101 was a female, originally admitted to the facility on [DATE], with pertinent diagnoses which included age related physical debility. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 10/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 12/15, which indicated Resident #101 had moderate cognitive impairment. Review of Resident #101's current Care Plan revealed, (Resident #101) requires assistance with ADL's .Interventions .Showers as scheduled .Start date: 2/7/24 . Review of Resident #101'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-15 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 were assessed for self-administration of medications for 3 (Resident #84, 44 and 74) of 5 residents reviewed for self administration of medication, resulting in unsupervised administration of medications and the potential for mismanagement of medication and potential for adverse side effects. Findings include: Resident #84 Review of an admission Record revealed Resident #84 was originally admitted to the facility on [DATE] with pertinent diagnoses which included vascular dementia without behavioral disturbance. Review of Resident #84's Orders revealed Hydrocodone-acetaminophen (norco) (opioid pain medication) 5-325 mg per tablet. Dose: 1 tablet. Freq (frequency): 3 times daily. Route PO (by mouth) . During an observation and interview on 8/13/24 at 12:40 PM, Resident #84 approached Licensed Practical Nurse (LPN) H and requested her pain medication. LPN H took Resident #84's medication from the medication cart and placed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess, monitor, treat, and implement interventions for a residents with pressure ulcers for 1 (Resident #27) of 3 residents reviewed for pressure ulcers resulting in the worsening condition of a pressure ulcer. Findings include: Resident #27 Review of an admission Record revealed Resident #27 was originally admitted to the facility on [DATE] with pertinent diagnoses which included pressure injury of left buttock, stage 3. Review of a Minimum Data Set (MDS) assessment for Resident #27, with a reference date of 6/4/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #27 was cognitively intact. Review of Resident #27's Care Plan revealed, (Resident #27) has a stage 3 pressure injury . Goal: (Resident #27) will demonstrate improvement in skin integrity AEB (as exhibited by) no signs and symptoms of infection. Interventions: . monitor for s/sx (signs and symptoms) of infection: warmth, redness,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-15 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents with a history of trauma received trauma informed care for 1 (Resident #99) from a total sample of 28 residents, resulting in the potential for exposure to trauma triggers and re-traumatization. Findings include: .According to the National Institute on Mental Health, 2019, PTSD (Post Traumatic Stress Disorder) is a disorder that some people develop after experiencing a shocking, scary, or dangerous event. It is natural to feel afraid during and after a traumatic situation. This fear triggers many split-second changes in the body to respond to danger and help a person avoid danger in the future. The fight or flight response is typical reaction meant to protect a person from harm. Nearly everyone will experience a range of reactions after trauma, yet most people will recover from those symptoms naturally. Those who continue to experience problems may be diagnosed with PTSD. People who have PTSD may feel stressed or frightened even…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · Dcited before2024-08-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to properly implement enhanced barrier precautions for 2 (Resident #35 and Resident #72) of 2 residents sampled for infection control, resulting in the potential for cross contamination and spread of infection. Findings include: Review of Consideration for the Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, published June 2021, by the Centers for Disease Control and Prevention, revealed: Residents in skilled nursing facilities are disproportionately affected by multidrug-resistant organism (MDRO) infections . Resident-to-resident pathogen transmission in skilled nursing facilities occurs, in part, via healthcare personnel, who may transiently carry and spread MDROs on their hands or clothing during resident care activities . Residents who have complex medical needs involving wounds and indwelling medical devices are at higher risk of both acquisition and colonization by MDROs. Resident #35 Review of an admission Record…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate assistance based on therapy recommendations to prevent an accident for 1 of 4 residents (Resident #106) reviewed at risk for falls, resulting in a fall with fracture of left olecranon (elbow) and the potential for a decline in overall health and wellness. Findings include: Review of an admission Record revealed Resident #106 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: falls and hip fracture. Review of Resident #106's Fall Risk Assessment dated 8/25/23 indicated 14, at moderate risk for fall. Review of Resident #106's Fall Report from 11/2/23 at 3:50 PM revealed, .Resident was walking with 4WW (4 wheeled-walker) assisted by CNA (certified nursing assistant) from bathroom to the bed. While aide was moving the bedside table and resident was standing at her 4WW, resident stepped her left foot back and lost balance and fell. Resident sustained a full thickness skin tear to left elbow measuring…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00138935. Based on interview and record review, the facility failed to promote resident dignity in 1 (Resident #101) of 3 residents reviewed for dignity, resulting in feelings of diminished self worth and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well being. Findings include: Review of an admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included depression and heart disease. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 7/28/2023 revealed a Brief Interview for Mental Status (BIMS) which indicated Resident #101 was cognitively intact. Further review of same MDS assessment revealed Resident #101 required assistance with toileting. In an interview on 11/6/2023 at 1:00 PM, Resident #101 described a verbal altercation that took place between herself and Certified Nursing Assistant (CNA) N on 8/4/2023 at approximately 9:20 PM.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-07-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to: 1. Ensure frozen food items were stored under sanitary conditions, and 3. Discard out-of-date and expired resident food items. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected all residents who consume food from the kitchen/pantries. Findings include: During an observation/interview with Nutrition Services Manager (NSM) TT during the initial kitchen tour on 7/10/23 at 10:05 in the Main Kitchen Freezer, noted a moderate amount of ice build-up on the pipes next to the blower fan located above opened, and loosely sealed frozen food product. It was noted that pieces of ice from the ice build-up on the pipes had fallen into the opened boxes of frozen garlic toast, biscuits, and yeast roll dough that were located below the pipes. NSM TT acknowledged visualization of the same, reported product would need to be discarded, and a work order would be created to get the issue fixed. During an observation/interview with NSM TT during 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-12 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #74 Review of a Minimum Data Set (MDS) assessment for Resident #74, with a reference date of 5/12/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #74 was cognitively intact. In an interview on 07/10/23 at 03:23 PM, Resident #74 reported waiting 1-2 hours at times for cares to be provided, after turning on the call light and stated, .I had to pee myself .good thing they give us briefs . Resident #74 reported that at times the nursing staff refuse to assist the aides to answer call lights. In a confidential resident group meeting on 7/11/23 at 3:00 PM, 12 of 13 residents reported that they wait an extended period of time for care needs to be met when turning on their call light. The residents reported that staff turn the call lights off, say they are busy and promise to come back, but they do not. The residents reported that licensed nursing staff often times will not answer call lights when the aides are busy. This citation…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-12 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor resident choice for dining location for 1 resident (Resident #16), of 1 resident reviewed for choices, resulting in the potential for this resident to not meet her highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #16 Review of a Face Sheet revealed Resident #16 admitted to the facility on [DATE] with pertinent diagnoses which included multiple sclerosis, depression, and physical deconditioning. Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 4/28/2023 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #16 was moderately cognitively impaired. Further review of the same MDS assessment revealed Resident #16 required assistance with eating. Review of a Resident Care Summary for Resident #16, dated 7/12/2023, revealed . (Resident #16) prefers to eat breakfast in bed and get out…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement care planned interventions for 1 (Resident #105) of 25 sampled residents resulting in the potential for increased pain, swelling, and contractures (A condition of shortening and hardening of muscles, tendons, or other tissues that often leads to deformity of joints). Findings include: Review of an admission Record revealed Resident #105, was originally admitted to the facility on [DATE] with pertinent diagnoses which included cognitive impairment secondary to a TBI (traumatic brain injury), quadriplegia (paralysis of all four limbs) and osteoporosis (condition which bones become brittle and fragile). Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 3/31/23 revealed the Staff Assessment for Mental Status indicated Resident #105's cognitive skills for daily decision making was severely impaired. Review of Resident #105's Care Assessment Summary indicated, Nursing Activities and Treatment:…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 appropriate Activities of Daily Living (ADL) care, specifically assistance with getting out of bed and incontinence care for 1 resident (Resident #94) of 5 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for residents who are dependent on staff for assistance. Findings include: Resident #94 Review of an admission Record revealed Resident #94 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Cerebral Vascular Accident (stroke) and Hemiplegia and hemiparesis (paralysis) following cerebral infarction affecting left non-dominant side. Review of a Minimum Data Set (MDS) assessment for Resident #94, with a reference date of 6/16/23 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #94 was cognitively intact. Review of the Functional Status 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident safety with bed mobilty, mechanical-lift transfers and eating for 1 resident (Resident #94) of 2 residents reviewed for accident hazards, resulting in the potential for accidents and serious injury. Findings include: Resident #94 Review of an admission Record revealed Resident #94 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Cerebral Vascular Accident (stroke) and Hemiplegia and hemiparesis (paralysis) following cerebral infarction affecting left non-dominant side. Review of a Minimum Data Set (MDS) assessment for Resident #94, with a reference date of 6/16/23 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #94 was cognitively intact. Review of the Functional Status revealed that Resident # 94 required extensive assistance of 1 person for bed mobility (moves side to side, to and from lying…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such 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 observation, interview, and record review the facility failed ensure post dialysis assessment and monitoring for 1 resident (Resident #75) of 1 resident reviewed for dialysis care, resulting in the potential for the resident to not meet her highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #75 Review of a Face Sheet revealed Resident #75 admitted to the facility on [DATE] with pertinent diagnoses which included end stage kidney disease and dialysis. Review of a Minimum Data Set (MDS) assessment for Resident #75, with a reference date of 6/2/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #75 was cognitively intact. Review of current dialysis Care Plan interventions for Resident #75, initiated 9/30/2021, directed nursing staff to obtain vitals and weight upon return from dialysis, observe for and document signs and symptoms of infection to area around access site, observe site…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-07-12 · tag F0585 — failed to handle grievances — widespread
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to 1). clearly identify grievance procedures with the use of signage for residents throughout the facility, 2). inform 13 of 13 residents, who participated in a confidential group meeting, of how to file a written grievance form or that filing a grievance was an option, and 3). implement the facility policy/procedure for grievances, resulting in the potential for care concerns to go unreported and not investigated. Findings include: Review of the facility policy Patient Complaint and Grievance Policy dated 2/7/23 revealed, .1). Patients/Resident representatives/Families are informed how to file a complaint/grievance (including in writing, verbally and anonymously) at the time of admissions and via posting throughout the facility .6). The patient relations or grievance official designee will offer written decision on the grievance to the patient/resident or their representative . In a confidential resident group meeting on 7/11/23 at 3:00 PM, 13 of 13 residents reported that they did not know who to report…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to COREWELL HEALTH — 6 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 →

RatingThis homeChain avg
Overall 5 of 54.7+0.3 vs chain
Health inspection 4 of 54.3-0.3 vs chain
Staffing 5 of 54.8+0.2 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 5 homes this chain runs (chain average 4.7★, 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 / managerTypeRoleSince
BEG, SIMINIndividualCORPORATE DIRECTORsince 08/18/2020
BRAGG, TALAWNDAIndividualCORPORATE DIRECTORsince 01/01/2022
BUCKLEY, JOHNIndividualCORPORATE DIRECTORsince 08/18/2020
DOORNBOS, MARYIndividualCORPORATE DIRECTORsince 08/18/2020
FERRELL-ROBINSON, LYNNETTEIndividualCORPORATE DIRECTORsince 08/18/2020
HOFMAN, RONALDIndividualCORPORATE DIRECTORsince 08/18/2020
PINK, BILLIndividualCORPORATE DIRECTORsince 08/18/2020
PORT, CHRISTOPHERIndividualCORPORATE DIRECTORsince 08/18/2020
TORRES, JOHANNIEIndividualCORPORATE DIRECTORsince 08/18/2020
WAALKES, ANNICAIndividualCORPORATE DIRECTORsince 08/18/2020
WATSON, SAMIndividualCORPORATE DIRECTORsince 08/18/2020
WILSON, MARKIndividualCORPORATE DIRECTORsince 08/18/2020
COX, MATTHEWIndividualCORPORATE OFFICERsince 07/01/2022
FREESE DECKER, CHRISTINAIndividualCORPORATE OFFICER; ADP OF THE SNFsince 06/05/2025
PAKKALA, KARENIndividualCORPORATE OFFICER; ADP OF THE SNFsince 03/01/2013
COREWELL HEALTHOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/1982
BOETTCHER, IRISIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
BOSS, MICHELLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/19/2020
MARLOW, TAMILAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2020

CMS files one row per role, so the 25 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$21.9M
Net patient revenuemost recent cost report
-11.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 60%Medicare 3%Other / private 37%

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

$516per resident / day
operating cost
$15,675per month
≈ monthly operating cost
$463per day
avg. revenue, all payers

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

What families pay in MI

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.

Typical monthly cost in Michigan
$11,254/mo
Nursing home (semi-private)
$11,969/mo
Nursing home (private)
$5,818/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235035. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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