Mary Free Bed Sub-Acute Rehabilitation
235 Wealthy Street SE, 5th Floor, Grand Rapids, MI 49503 · Non profit - Corporation · 48 certified beds · (616) 840-8931 Medicare only — no Medicaid
On the public record, this home looks stronger than most — but visit before you decide.
- 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 (4/5)
- 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
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.5% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.3% | 24.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 11.7% | 11.7% | 12.0% | typical |
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.
78.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 651 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.8% 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 338 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 1.56 therapist hours per resident per day in 2026Q1 — more than 99% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 28% 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 | 78.2%CMS range 75.3–80.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 8.1–11.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 56.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 4.6%CMS range 2.9–6.5 | 7.1% | Oct 2023–Sep 2024 | better than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.66 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 48 beds and averages 46.7 residents a day — about 97% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. 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 5.35 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.07 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.70 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 4.39 hrs/resident/day on weekends vs 5.74 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.35 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
11 citations, most serious first — scroll within the box to see all.
- Actual harm · G2025-10-21 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 # 2641086.Based on interview, and record review, the facility failed to ensure residents were free from significant medication errors in 1 of 3 residents (Resident #101) reviewed for significant medication errors, resulting in a change in mental status and hospitalization for Resident #101 when an opioid pain medication was not charted as administered and not documented per physician orders and professional standards of practice.Findings include:Review of an Incident Summary revealed .(Licensed Practical Nurse (LPN) I) did not chart that she administered, but did sign out 20 mg (milligram) Butrans patch on 10/1/25, at 6:22am. Another nurse, (LPN J) signed out and applied another 20 mg Butrans patch on 10/7/25 at 10:14pm .(LPN J) saw that one patch had been signed out by (LPN I) previously 7 days earlier on 10/1/25. (LPN J) looked for the patch, but could not find it on the patient (Resident #101). On 10/8/25, (Resident #101) was lethargic, (LPN I) allegedly took 2 patches off in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-05-13 · 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 ensure that they had Registered Nurse (RN) coverage for at least 8 consecutive hours a day for 2 of 30 days (4/26/26 and 5/9/26) reviewed for RN coverage. Findings include:A review of the Daily Staffing Pattern sheets, dated 4/11/26 to 5/12/26, revealed that Registered Nurse/ Licensed Practical Nurse (RN/LPN) hours were not separated by licensure. The Daily Staffing Pattern Sheets had Total Hours (RN) listed. However, those hours were total nursing hours worked versus RN and/or LPN hours worked.A review of the facility's employee list revealed the facility employed both RN's and LPN's.During an interview on 5/13/26 at 8:45 AM, the Nursing Home Administrator (NHA) stated she thought the Total Hours (RN)on the Daily Staffing Pattern sheets were only RN hours. She stated she was not aware all of the total nursing hours were included in that line item. The NHA stated she would look into it and have the person who does the staffing sheets separate RN and LPN hours.On 5/13/26 at 10:50 AM, the facility provided a breakdown of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-13 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Preadmission Screening (PAS)/Annual Resident Review (ARR) for a resident with a mental disorder for 1 (Resident #7) of one resident reviewed for PASARR.Findings include:Review of a Face Sheet for R7 revealed he admitted on [DATE] with pertinent diagnosis of Asperger's Syndrome, autistic disorder, post-traumatic stress disorder, and depression.Review of the PASARR Level I Screening dated 3/6/26 for R7 showed it classified R7 as a Hospital Exemption Discharge. Section II indicated that R7 had diagnoses of mental illness, had received treatment for mental illness, and had received one or more antipsychotic or antidepressant medications within the last 14 days. It also documented that R7 had a diagnosis of an intellectual disability or a related condition, such as epilepsy, autism, or cerebral palsy, which manifested before age [AGE].In an interview on 5/12/26 at 2:42 PM, Social Worker (SW) E confirmed that another PASARR should have been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-13 · 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 2607622. Based on interview and record review the facility failed to provide adequate supervision to ensure the safety of a severely cognitively impaired resident with a high fall risk for 1 (R86) of 2 resident reviewed for supervision, resulting in the potential for injury. Findings include:Review of a Facility Reported Incident (FRI) dated 8/9/25 for R86 revealed Patient briefly walked outside of the facility unattended. No previous elopement history and patient is used to going outside with his wife. Patient was outside for 15 minutes then returned to the facility, no injuries. The Investigation Summary/Actions Taken: [R86] goes outside nearly every day with wife. He went outside without her and stayed under the awning up front from 12:23 PM to 12:37 PM. [Certified Nursing Assistant (CNA) C] saw him from his room and notified [Registered Nurse (RN) D], while Security was called to bring him in. On admission, [R86] was assessed to not be a risk for elopement.Review of a Face…
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 before2025-04-16 · 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 for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: An initial kitchen/food service tour was conducted on 4/14/25 beginning at 9:26 AM with Director of Dining Services (DDS) X and Clinical Nutrition Manager (CNM) W. The following observations/interviews/record reviews were completed: Food Labeling/Dating/Discarding On 4/14/25 at 9:38 AM in the cooler underneath the juice machine, there was a half-gallon container of 2% milk and a half-gallon container of organic soy milk that were opened but not labeled with an opened date or discard date. DDS X reported the items should have been labeled with opened and discard dates and immediately discarded the items. On 4/14/25 at 9:47 AM in a cooler on the cold service side of the cook's preparation area, there was a jar of grape jelly that was opened but not labeled with an opened date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-16 · 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 have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During a tour of the facility, at 2:38 PM on 4/15/25, it was observed that the hopper in the walk-through Soiled Utility room, in the middle hall, was found with no handles on the faucet and minimal water in the basin of the bowl. This indicates the hopper had not been flushed in a while, once flushed, the basin water raised significantly. Further review of the hopper found that the basin spray hose handles were zip tied closed and not available for use or flushing. During a tour of the spa room, at 2:43 PM on 4/15/25, it was observed that the area that a spa…
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 before2025-04-16 · 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: MI00151227 Based on interview and record review, the facility failed to provide adequate supervision, monitoring, and ensure safety precautions were in place and accurate in 1 of 1 residents (Resident #236) reviewed for elopement resulting in Resident #236 eloping from the facility which could negatively affect the resident's highest practicable physical, mental, and psychosocial well-being. Findings include: Review of Securitas HUGS Infant System revealed, .Real-Time Monitoring: Patient tags are monitored for connectivity to Hugs system .Tag communication verified every 60 seconds .Should the tag not be able to communicate with Hugs systems (tamper, battery, local network outage), the system will lock down the unit . Review of an admission Record revealed Resident #236 was a male with pertinent diagnoses which included dementia with behavioral disturbance, anxiety, cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking 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 before2024-05-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to discard expired food products, monitor cooling potentially hazardous foods, and properly sanitize dishware, resulting in the potential for increased risk of food borne illness, affecting all residents in the facility that consume food. Findings include: On 5/15/24 at 11:10 AM, staff were observed to be washing dishes in the dish machine. A plate simulating thermometer was ran through the dish machine to determine the sanitizing final rinse temperature and was found to be 145 degrees F. A second cycle was ran with the thermometer and the internal rinse temperature was 147 degrees F. At this time, Food Service Director (FSD) D was queried on what steps they need to take next and stated that they will stop using the dish machine and utilize the three-compartment sink. FSD D proceeded to contact maintenance to repair the dish machine. According to the 2017 FDA Food Code Section 4-703.11 Hot Water and Chemical. After being cleaned, EQUIPMENT…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2026-05-13 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to have 2025 Federal and State Agency survey results that are prominent and accessible to the public. Findings include:Review of the Survey binder near the elevator entrance of the facility revealed the last survey available for review was from an annual survey in 2024.In an interview on 5/12/26 at 3:13 PM, the Nursing Home Administrator (NHA) verified that the binder was missing surveys and stated that the surveys had been there, but someone may have removed them. The NHA stated she will add the missing surveys to the binder.Review of the survey history revealed there was a complaint survey conducted with citations and an exit date of 10/21/25 that was not located in the survey book and available for review.
- No harm found · C2024-05-16 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to post required nurse staffing information on a daily basis, for all 39 residents in the facility, resulting in a lack of available staffing information for residents and visitors. Findings include: In multiple observations of the facility hallways and common areas, from 5/14/24 to 5/16/24, no posted nurse staffing information was identified. In an interview on 5/16/24 at 9:07 AM, Interim Administrator A reported the daily nurse staffing information was not posted. Interim Administrator A reported that the facility had experienced a transition with management staff, and the responsibility to post the nurse staffing information was not passed onto the appropriate staff member. Review of the policy/procedure Posting of Direct Care Daily Staffing Numbers, dated 11/1/19, revealed .At the beginning of each shift, the community shall post in a prominent location accessible to residents and visitors and in a clear readable format, the following information: a) Community name b) Current date c) Total number and actual…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-05-16 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to annually review and update the required Facility Assessment, resulting in the potential for unidentified resources necessary to provide care and services to the resident population. Findings include: Review of the Facility Assessment document provided by the facility revealed the Facility Assessment was last completed, updated, or reviewed on 10/12/22. In an interview on 5/16/24 at 11:05 AM, Interim Nursing Home Administrator (NHA) A reported he had only been at the facility since April 2024. Interim NHA A reported he had contacted the former NHA who confirmed the Facility Assessment had not been completed, updated, or reviewed since 10/12/22. Interim NHA A reported he had since started working on an updated Facility Assessment and will review it with the quality team upon completion.
“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 TRINITY HEALTH — 19 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.3 | +0.7 vs chain |
| Health inspection | 4 of 5 | 3.0 | +1.0 vs chain |
| Staffing | 4 of 5 | 4.0 | ≈ chain avg |
| Quality measures | 4 of 5 | 3.7 | +0.3 vs chain |
The other 18 homes this chain runs (chain average 3.3★, 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 |
|---|---|---|---|---|
| MARY FREE BED REHABILITATION HOSPITAL | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 07/01/2015 |
| TRINITY CONTINUING CARE SERVICES | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 07/01/2015 |
| BOWENS, MARCUS | Individual | CORPORATE DIRECTOR | — | since 12/01/2022 |
| BRASSER, BRUCE | Individual | CORPORATE DIRECTOR | — | since 01/01/2015 |
| CHESLEK, INGRID | Individual | CORPORATE DIRECTOR | — | since 02/01/2023 |
| GUZMAN, NATHANIEL | Individual | CORPORATE DIRECTOR | — | since 12/01/2022 |
| JOHNSON, STACEY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 12/01/2022 |
| LATOVICK, PAMELA | Individual | CORPORATE DIRECTOR | — | since 07/01/2018 |
| PENNINGTON, LEEANN | Individual | CORPORATE DIRECTOR | — | since 12/01/2022 |
| TREAT, MEG | Individual | CORPORATE DIRECTOR | — | since 12/01/2022 |
| WANG, RALPH | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 12/01/2022 |
| CUDNEY, KIERSTEN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2022 |
CMS files one row per role, so the 14 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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 $144K 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 2024. 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, FY2024). 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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Michigan Medicaid page for homes that do.
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 235708. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-13, 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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