Munson Healthcare Crawford Continuing Care Center
1100 Michigan Avenue, Grayling, MI 49738 · Non profit - Corporation · 39 certified beds · (989) 348-0317 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (21% vs 45% nationally) — better care continuity
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0607) — 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $27,600 in federal fines (most recent 2023-10-02)
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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 34.7% | 10.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.0% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.4% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.6% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 12.7% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 36.2% | 12.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 7.7% | 19.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.9% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 40.0% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.6% | 14.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 91.7% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.5% | 24.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 24.4% | 11.7% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
59.1% 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 98 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.8% 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 39 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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 | 59.1%CMS range 51.6–66.4 | 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 | 13.0%CMS range 9.2–17.8 | 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 | 71.8% | 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 | 66.7% | 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 | 43.6% | 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 | 2.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.9–11.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.79 | 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 39 beds and averages 28.7 residents a day — about 74% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.94 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.14 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 4.37 hrs/resident/day on weekends vs 4.65 on weekdays — 6% thinner on weekends. RN hours go from 1.07 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 21% is below 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 unchanged from the previous inspection. 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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Dcited before2026-04-29 · 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
This deficient practice pertains to Intake 2985836.Based on interview and record review, the facility failed to prevent an elopement for one Resident (#1) of three residents reviewed for accident hazards and supervision.Findings include:Resident #1 (R1):Review of R1's electronic medical record (EMR) revealed initial admission to the facility on 8/1/25 with a diagnosis of dementia with behavioral disturbances. Review of R1's most recent Minimum Data Set (MDS) assessment, dated 2/6/26, revealed a Brief Interview for Mental Status (BIMS) score of 2, indicative of severe cognitive impairment.Review of R1's quarterly Elopement Evaluation, dated 3/21/26, revealed a score of 6.0, indicating the resident was, at risk of elopement.Review of the Facility Reported Incident (FRI) included an investigation report submitted to the State Agency (SA) on 4/10/26 at 2:03 PM, which read, in part: On the evening of 4-09-2026, the Director of Nursing (DON) was exiting the facility for the day at 1624 [4:24 PM] and noted [R1] attempting to cross the front parking lot. [R1] has known wandering activities…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-25 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document collaboration among the interdisciplinary team (IDT) and to offer and provide inclusion of resident's or their representatives in the quarterly review of the comprehensive care plan for three Residents (#5, #7 and #13) of 12 residents reviewed and affecting all 19 residents receiving long-term care of a total of 27 residents residing in the facility.Findings include:Resident #5 (R5) During a telephone interview on 3/23/2026 at 12:10 PM, R5's Medical Durable Power of Attorney (MDPOA), Family Member (FM) D reported she was unable to visit R5 as often as she would like but she was able to visit a couple of time per year. When asked if she was able to attend R5's care conferences, FM D reported she was unaware of when R5's care conferences were held and had not been alerted or invited to review the plan of care with the IDT. When asked if she would like the opportunity to meet with the IDT for review of the plan of care, FM D stated, I like 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.
- Potential for harm · D2026-03-25 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to obtain informed consent for psychoactive medications for one Resident (R10) of five residents reviewed for psychoactive medications.Findings include:A review of R10's electronic medical records (EMR) indicated an admission into the facility on 2/21/2024 with a primary diagnosis of severe vascular dementia with behavioral disturbance (a cognitive decline caused by reduced blood flow to the brain, damaging brain tissue and affecting memory, thinking and behavior). A review of the most recent Minimum Data Set (MDS) assessment with a submission date of 3/16/26 revealed R10 had severely impaired cognition and Section C indicated resident is rarely/never understood. The medical record documented R10 had an appointed responsible party for health care and financial decision making.A review of R10's 'Physician Orders' for March 2026 indicated the antipsychotic medication quetiapine fumarate 25 mg (milligrams) was prescribed and initiated on 7/10/25 and the antidepressant medication sertraline HCl 25 mg was prescribed and initiated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-25 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide written notification of transfer or discharge and the facility bed hold policy for three Residents (#3, #6 and #32) of three residents reviewed for hospitalization. Findings include: Resident #3 (R3 During a room visit on 3/23/2026 at12:06 PM, R3 stated she had been out to hospital when she had experienced chest pain. A review of R3's medical record revealed the resident was sent to the Emergency Department on 2/7/26. The medical record included a facility Transfer Notice dated 2/7/26 with a reason for transfer, transfer location, and signature of the RN completing the form. The space designated for acknowledgement of receipt was unsigned and undated. The medical record also did not contain documentation that an explanation of the facility bed hold policy had been given to R3 or R3's responsible party. Resident #6 (R6) A review of R6's electronic medical record EMR) revealed the resident was transferred to the Emergency Department on 1/05/26 for evaluation of an acute episode of shortness of breath. Further review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-25 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess, monitor and maintain nutritional status of one Resident (R7) of two residents reviewed for nutritional needs.Findings include:Resident #7 (R7)A review of the electronic medical record (EMR) revealed R7 was admitted on [DATE] with a primary diagnosis of Alzheimer's disease. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 2 of 15 indicating severe cognitive impairment.On 3/23/2026 at 12:17 PM, R7 was observed at lunch feeding herself with success.During a telephone interview on 3/23/2026 at 2:23 PM, the Durable Power of Attorney said R7 was a very active person in youth and walked several miles a day but was not active now and was gaining weight and might outgrow her clothes.The facility Registered Dietitian (RD) B reviewed R7's nutritional status quarterly. The last progress note from RD B on 2/7/26 read, Note Text: Quarterly dietary review. Resident is receiving a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-25 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide dining adaptive equipment for three Residents (R28, R30 and R36) of four residents reviewed for dining assistive devices. Findings include: On 3/23/2026 at 12:34 PM, lunch service was observed in the dining room.R28 was observed feeding himself. His hand was shaking and the food on his spoon was not all going into his mouth. Spills were present down the front of the clothing protector R28 was wearing. The meal tray card for R28 included instructions typed in capital letters and red ink indicating LARGER SPOON. The spoon R28 was using was not larger but was a standard teaspoon size. When the dining room staff were asked about the spoon, Certified Nursing Assistant (CNA) E said he should have received a larger spoon.R30 was observed in the dining room with his lunch. The meal tray card for R30 included instructions for a SMALL DIAMETER STRAW which was typed in capital letters and red ink. R30 did not have a straw . CNA G stated R30 did not geta smaller straw and it had been missed. CNA G said R3 needed…
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 before2025-08-20 · 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
This deficient practice pertains to intake 2588223.Based on interview and record review, the facility failed to prevent and readily detect an elopement for one Resident (#1) of three residents reviewed for accident hazards and supervision.Findings include:Resident #1 (R1):Review of R1's electronic medical record (EMR) revealed initial admission to the facility on 8/1/25 with a diagnosis of dementia with behavioral disturbances. Record review of R1's Nursing Clinical admission report, dated 8/1/25, revealed a level of cognitive impairment as, severe impairment (affecting all areas of judgement).Review of R1's Elopement Evaluation, dated 8/1/25, revealed a score of 6.0, indicating the resident was, at risk of elopement.Review of the FRI submitted to the State Agency (SA) on 8/7/25 at 5:15 PM, included an investigation report which read, in part: Resident [R1] was admitted to our department on 8/1/2025 at approximately 11:30 AM. Resident [R1] was noted by staff to be missing at 1600 [4:00 PM]. The resident was found at 1616 [4:16 PM]. Security camera footage was reviewed by security…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-13 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to implement infection prevention and control measures to ensure a safe and sanitary environment for five Residents (#5, #10, #23, #15, and #13) of eight residents reviewed for infection prevention and control. Findings include: Resident #5 (R5 On 2/11/25 at 1:43 PM, R5 was observed with a urinary catheter drainage bag dragging on the floor beneath her wheelchair. There was no barrier beneath the drainage bag. R5's catheter drainage tubing was observed dragging on the floor beneath the wheelchair on 2/12/25 at 8:12 AM and 2/12/25 at 10:33 AM. Resident #10 (R10) On 2/11/25 at 1:13 PM, R10 was observed in a reclining geriatric care in the hallway. A plastic drinking cup with a straw was on the floor without a barrier beneath it next to R10's chair. At approximately 1:30 PM, Registered Nurse (RN) B picked up the cup from the floor and placed it on a mobile overbed table next to R10's chair. RN B did not sanitize the cup or obtain a clean cup of fluid for R10. Resident #23 (R23) R23 was diagnosed with Influenza A on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-13 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
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 one Resident (#185) of one resident reviewed for end-of-life care (EOLC) had a care plan and physician's order for terminal care, and appropriate activation of patient advocate/durable power of attorney prior to placing a resident on EOLC. Findings include: Resident #185 (R185) On 2/11/25 at approximately 10:45 AM, Resident R185 was observed in his room with his daughter present. R185's daughter said R185 was admitted to the facility on Thursday (2/6/25) and placed on EOLC on Sunday (2/9/25). R185's medical record was reviewed on 2/12/25 and revealed admission to the facility on 2/6/25 for skilled therapy services. Physician's orders dated 2/6/25 and 2/7/25 directed R185 receive occupational therapy and physical therapy five times per week. Nurses' progress notes dated 2/6/25 at 5:06 PM, 2/6/25 at 10:26 PM, 2/7/25 at 1:26 PM, and 2/7/25 at 9:58 PM documented R185 was alert and oriented times three (A/O X 3 - a normal level of consciousness and orientation). A progress note dated 2/9/25 at 9:30 AM documented, 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 · D2025-02-13 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 assessments and documentation warranting the use of a physical restraint for one Resident (#10) of one resident reviewed for restraints, resulting in the potential for feelings of helplessness, agitation, decreased physical functioning and injury. Findings include: Resident #10 (R10) Review of the Minimum Data Set (MDS) assessment, dated 11/26/2024, revealed R10 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia and Parkinson's Disease. Further review of the MDS assessment revealed R10 was unable to participate in the Brief Interview for Mental Status (BIMS) and was assessed by staff to have severely impaired cognition. On 2/11/25 at 12:10 p.m., R10 was observed at the nurse's station seated in a reclining wheelchair with the leg rest engaged in the up position. R10 was awake and alert, attempting to get out of the chair and had both legs hanging off the right side of the leg rest. R10…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · D2025-02-13 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that Medication Regimen Reviews (MRR) were reviewed, addressed by the Physician, and maintained in the clinical record for two Residents (#3, #23) of five residents reviewed for MRR, resulting in the potential for the administration of unnecessary medications and adverse medication side-effects. Findings include: Resident #3 (R3) Review of the Minimum Data Set (MDS) assessment, dated 12/28/2024, revealed R3 was admitted to the facility on [DATE] and had diagnoses including heart failure and dementia. Further review of the MDS assessment revealed R3 scored two out of 15 (2/15) on the Brief Interview for Mental Status (BIMS), indicating R3 had severe cognitive impairment. Review of R3's electronic medical record (EMR) for August 2024 through January 2025, revealed the following: 1/28/2025 Medication Regimen Review . See Report - Lab Request. It was noted there was no previous MRR documentation found in R3's EMR for the period of August 2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure documentation of target behaviors/symptoms with attempted use of non-pharmacological interventions prior to the administration of as needed (prn) anti-anxiety medication for two Residents (#3, #10) of five residents reviewed for unnecessary medications, resulting in the potential for adverse side effects and decreased quality of life. Findings include: Resident #3 (R3) Review of the Minimum Data Set (MDS) assessment, dated 12/28/2024, revealed R3 was admitted to the facility on [DATE] with diagnoses including dementia and depression. Further review of the MDS assessment revealed R3 scored two out of 15 (2/15) on the Brief Interview for Mental Status (BIMS), indicating R3 had severe cognitive impairment. Review of R3's February 2025 Medication Administration Record (MAR) revealed the following order: Lorazepam [controlled drug used to treat anxiety] Tablet 0.5 MG [milligram]. Give 1 tablet by mouth every 8 hours as needed for anxiety. Start 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 · F2024-07-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 26 residents. Findings include: On 7/2/24 at approximately 8:00 AM the morning meal was observed being served in the dining room. Included was a large pan of fresh cut cantalope melon. The temperature of the melon was measured using a Super fast Thermapen digital thermometer and found to vary between 45ºF and 48ºF. At this time an interview was conducted with Dietary Aide (DA) E related to the preparation of the melon. DA E stated They use some special wash. On 7/2/24 at approximately 8:30 AM an interview was conducted with prep cook (PC) F related to the preparation of the melon. PC F stated the kitchen no longer used any cleaner for the exterior of the melons prior to slicing. An interview with the Certified Dietary Manager (CDM) A confirmed there was no process to ensure thorough cleaning of the exterior of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-07-08 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all 26 residents. Findings include: Review of the CMS PBJ Staffing Data Report FY (fiscal year) Quarter 2 2024 (January 1- March 31) revealed the metric Failed to have Licensed Nursing Coverage 24 Hours/Day and No RN Hours Triggered with daily infractions from 1/1/24 to 3/31/24. On 7/8/24 at 8:55 AM, an interview was conducted with the Business Office Manager (BOM) P who verified she was responsible for submitting PBJ information to CMS. BOM P was unable to produce confirmation emails from CMS from Quarter 2 2024 indicating the required information had been successfully submitted. Review of PBJ XML Submission Process found at https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission read, in part: .XML Submission Process: After your submitted PBJ data file is successfully received by the CASPER…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-07-08 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to implement an effective Quality Assurance & Performance Improvement (QAPI) program that included development, monitoring, and evaluation of performance indicators, identification of quality issues, and the conducting of distinct performance improvement projects to correct quality deficiencies and maintain sustained compliance. This failure had the potential to affect all 26 residents in the facility. Findings include: On the 7/8/24 at 12:41 PM, an interview was conducted with the Director of Nursing (DON) who verified she was in charge of leading the QAPI process. When asked about a current Performance Improvement Project (PIP), the DON was unable to provide a formal record of a PIP and stated, That's not a concept I was aware of, I guess. The DON could not present evidence of regular review or data analysis collected under the QAPI program including tracking and measuring performance, establishing goals and thresholds for performance improvements, nor monitoring and evaluating the effectiveness of corrective actions. 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 · F2024-07-08 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) attended the Quality Assurance and Performance Improvement (QAPI) meetings on a quarterly basis. This deficient practice resulted in the potential for ineffective interdisciplinary communications regarding facility process with the potential to affect all 26 residents residing in the facility. Findings include: On the 7/8/24 at 12:41 PM, an interview was conducted with the Director of Nursing (DON) regarding the QAPI process. Attendance documents from the previous 3 quarterly meetings were reviewed with the DON which revealed the IP was not in attendance. The DON confirmed the IP does not attend the QAPI meetings and instead, acts as a resource and is stationed in the acute-care portion of the facility. Review of facility policy titled, Quality Assurance and Performance Improvement, revised 7/12/23 read, in part: .The QAA Committee shall be interdisciplinary and shall: 1. Consist at a minimum of: a. The Director of Nursing (DON) Services; b. The Medical Director or his/her designee;…
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 before2024-07-08 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation will have two deficient practice statements: A and B A. Based on interview and record review the facility failed to implement a system for recording and tracking communicable disease during an outbreak of respiratory illness (Covid-19), resulting in the potential for further spread of the virus to 23 un-infected residents. Findings include: During review of the facility's infection surveillance documents on 7/8/2024 at 10:31 a.m., the Director of Nursing (DON) reported the facility had an outbreak of Covid-19 in March 2024. The DON reported she was the acting facility Infection Preventionist. A request was made to review the outbreak investigation and surveillance. The DON stated she did not have a written summary of the outbreak but did have a record she used to present at the facility QAPI (Quality Assurance and Performance Improvement) meetings. Review of the Infection Control Monthly Report, dated 3/2024 and provided by the DON, revealed the following, in part: Covid positive, no hospitalizations, minor symptoms. No further positive after 3/5 [3/05/2024] . There…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-07-08 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a qualified Infection Preventionist worked at least part-time at the facility and was present to properly assess, implement, and manage the Infection Prevention and Control Program resulting in the lack of outbreak surveillance and investigation and tracking of communicable diseases. Findings include: During an interview on 7/8/2024 at 10:31 p.m., the Director of Nursing reported she conducted all infection prevention and control duties for the facility. The DON reported she was in the process of completing an approved Infection Preventionist course but was having trouble finding the time. The DON stated Registered Nurse (RN) L was also in the process of completing the Infection Preventionist training, but neither the DON nor RN L had completed the courses as of 7/8/2024. The DON stated the hospital affiliate Infection Preventionist, RN Q acted as a resource for the facility Infection Prevention and Control Program. When asked how involved RN Q was in conducting infection prevention and control surveillance for 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 · E2024-07-08 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident in writing with the reason for a transfer out of the facility for three Residents (R82, R186, R27) of three residents reviewed for transfers. Findings include: Resident #82 (R82) A review of the facility census revealed R82 was sent to an acute care hospital with primary diagnosis of acute anemia from 6/10/24-6/21/24. R82 was again sent to an acute care hospital with primary diagnosis of acute blood loss anemia from 6/24/24-6/28/24. A review of R82's progress notes revealed the following: 1. 6/10/24: Guest SpO2 (oxygen saturation) in mid to high 70's on 3 L (liters) while at rest .MD (Medical Director) updated via page .order received to send to ED (Emergency Department) for eval (evaluation) and treat . 2. 6/21/24 admission Details: arrived by ambulance. 3. 6/24/24: .Guest requested pain medication for 7/10 pain, something for nausea and dizziness. Approx (Approximately) 15 min (minutes) later CNA (Certified Nurse Aide) approached…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to safely provide assistance with wheelchair mobility for three Residents (R6, R14, R186) and failed to investigate the root cause of self-injurious behavior for one Resident (R3) of four residents reviewed for accidents and supervision. This deficient practice resulted in the potential for injury related to unsafe wheelchair mobility assistance and the potential for continued self-injurious behavior. Findings include: Resident #6 (R6) On 7/2/24 at approximately 12:30 p.m. during an observation of the lunch meal service in the main dining room, R6 was observed being provided assistance by Certified Nurse Aide (CNA) S to a table while sitting in his wheelchair. R6's wheelchair did not have foot pedals in place, and R6's feet were noted to be scraping on the ground as he was being pushed by CNA S. R6 was noted to be wearing socks with grippers on the bottom. Resident #14 (R14) On 7/2/24 at approximately 12:30 p.m. during an observation 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 · D2024-07-08 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 implement the abuse policy and investigate allegations of abuse for one Resident (R8) of two residents reviewed for abuse, resulting in the potential for continued abuse, fear, anger, and mental anguish. Findings include: R8 was admitted on [DATE] with diagnoses including stroke, dementia, and right-side hemiparesis (weakness). Review of R8's Minimum Data Set (MDS) assessment, dated 3/19/2024, revealed R8 had severe cognitive impairment. Review of R8's Electronic Medical Record (EMR) revealed the following: 5/4/2024 1701 [5:01 p.m.]. Health Status Note. Staff alerted to dining room ([R8] yelling) staff noted a peer close to [R8] within her [sic] personal space (very close). Staff intervened and removed peer from area. No physical contact made by either resident. 4/16/2024 19:00 [7:00 p.m.] Behavior Note .resident was in the dining room after dinner listening to music per his preference. CNA [Certified Nurse Aide] heard yelling and observed [R8] and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan to address safety concerns for one Resident (R3) of 12 residents reviewed for care planning, resulting in the potential for unmet safety needs. Findings include: Review of R3's Minimum Data Set (MDS) assessment, dated 5/29/2024, revealed R3 was admitted on [DATE] and had a primary diagnosis of dementia. Further review of R3's MDS revealed a Staff Assessment for Mental Status indicating R3 had short- and long-term memory problems and had severely impaired cognitive skills for daily decision-making. An observation on 7/2/2024 at 8:41 a.m., revealed R3 in her room, seated in a reclining wheelchair. Further observation revealed a metal pan-type call light positioned on the seat of R3's chair near her left knee. There were no staff present in R3's room at the time of the observation. Review of R3's Electronic Medical Record (EMR) revealed the following clinical progress note: 2/27/2024 5:57…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to administer supplemental oxygen per physician orders for one Resident (#186) of one residents reviewed for respiratory care. Findings include: Resident #186 (R186): Review of R186's electronic medical record (EMR) revealed admission to the facility on 6/15/24 with diagnoses including chronic respiratory failure with hypoxia, dependence on supplemental oxygen, and dementia. Review of R186's admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. On 7/1/24 at 9:44 AM, R186 was observed sitting in a wheelchair in the hallway just outside her room. R186 was observed becoming frustrated with navigating the oxygen tubing and subsequently removed her supplemental oxygen. Registered Nurse (RN) G was observed walking down the corridor and noticed R186 had removed her supplemental oxygen. RN G stated, I guess we'll see how she [R186] does without it [supplemental oxygen]. On 7/2/24 at 9:28 AM, R186 was again observed sitting in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-08 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to assess and manage pain for one Resident (#2) of one resident reviewed for pain management. This deficient practice resulted in untreated pain and unnecessary suffering. Findings include: Resident #2 (R2): Review of R2's electronic medical record (EMR) revealed admission to the facility on 6/11/24 with diagnoses including hypomagnesemia, acute pain due to trauma, and contusion of the left hip and knee. Review of R2's most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. During the initial tour of the facility on 7/1/24 at 9:50 AM, R2 was observed in her room sleeping in her wheelchair. Upon entrance into the room, R2 stated she had a terrible of night of rest due to painful cramps in her legs that had kept her awake. On 7/8/24 at 1:01 PM, an interview was conducted with R2 who stated she had continued leg cramping at night. R2 stated, I was up for almost 3 hours last night with muscle spasms. When asked if her pain was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-08 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to appropriately conduct a gradual dose reduction (GDR) for a psychotropic medication for one Resident (R23) of five residents reviewed for unnecessary medications. This deficient practice resulted in the potential for adverse medication side effects. Findings include: Resident #23 (R23) Review of R23's Electronic Medical Record (EMR) revealed admission to the facility on 8/1/22 with diagnoses including: dementia with behavioral disturbances and delusional disorders. Review of her 4/17/24 Brief Interview for Mental Status (BIMS) score on her Minimum Data Set (MDS) assessment revealed an 8/15, indicating moderately impaired cognition. Review of the Consultant Pharmacist's Medication Regimen Review for 5/1/24 through 5/31/24 read, in part, .(23) Resident is currently due for a GDR evaluation on her olanzapine (antipsychotic medication Zyprexa) 2.5 mg (milligram) qd (every day). Please evaluate (R23) to determine if she is ready for a reduction at this time. If you feel that no GDR should be attempted, please document your…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-08 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure a medication administration error rate of less than five percent, with two errors identified out of 31 opportunities, affecting one Resident (R182) of four residents observed for medication administration, resulting in a medication error rate of 6.45 percent. Findings include: On 7/3/2024 at 7:59 a.m., Registered Nurse (RN) G was observed removing R182's morning medications from the automatic medication dispensing cabinet. RN G reported R182 was scheduled to receive one dose of gabapentin 800 milligrams with his morning medications, but the medication was not available. RN G reported the last dose must have been administered when last scheduled and was not yet restocked. After removing R182's available medications from the automatic dispensing cabinet, RN G reconciled the medications with R182's medication orders in the Medication Administration Record (MAR) and again reported R182 would not be receiving the gabapentin 800 mg as scheduled as she would need to wait for the medication to be refilled. RN G…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$27,600 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $27,600 — penalty dated 2023-10-02
- Medicare payment denial — starting 2023-10-24 for 7 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BLOEM, KENNETH | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2022 |
| DIXON, KATHY | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2022 |
| HOPPE, RUTH | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2022 |
| KING, JENNIFER | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2024 |
| LANPHIER, EDWARD | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2026 |
| MENEGEBIER, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2024 |
| NELSON, TIMOTHY | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2013 |
| NESS, EDWIN | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 02/01/2015 |
| PAGE, ANDREW | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2024 |
| POSTMA, BRIAN | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2022 |
| RECCHIA, DINO | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2024 |
| ROBERTS, OWEN | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2022 |
| ROWLAND, CLAUDIA | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2026 |
| SANDERS, MARY | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2022 |
| SCHULTZ, VINCENT | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2024 |
| TAKANO, SAKURA | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2022 |
| THOMAS, KRISTINE | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2022 |
| VERYSER, THOMAS | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2022 |
| WOOD, ELAINE | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 02/01/2015 |
| ZENNER, BRUCE | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 01/01/2022 |
| KORTH-WHITE, KIRSTEN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | since 11/30/2023 |
| KONOPACKI, PAUL | Individual | CORPORATE OFFICER; TRUSTEE OF THE SNF; ADP OF THE SNF | since 01/01/2024 |
| MUNSON HEALTHCARE | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2015 |
| COTLEAR STUART, HAIM BERNARDO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/03/2024 |
| ELLIOT, BENJAMIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2025 |
CMS files one row per role, so the 53 rows in the source record cover these 25 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.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235201. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-25, 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 →
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