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Canal View - Houghton County

1100 Quincy Street, Hancock, MI 49930 · Government - City/county · 197 certified beds · (906) 482-5050 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Dec 2023Behavioral-health or dementia-care citation — no harm found (F0744)1 immediate-jeopardy citation$39,988 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $39,988 in federal fines (most recent 2024-03-06)
  • its payroll-based staffing score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
787 Market Street, Suite 9
Pharmacy
Shopko0.9 mi
900 Memorial Rd · (906) 487-9797 · Call to confirm hours
Grocery
1035 Ethel Ave · (906) 482-2030 · Call to confirm hours
Park
Roberts St · Typically dawn to dusk
Place of worship

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 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased21.9%10.8%15.4%worse
Long-stay residents who lose too much weight7.5%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.8%0.9%better
Long-stay residents with a urinary tract infection2.5%1.5%2.0%worse
Long-stay residents with depressive symptoms2.0%4.3%6.5%better
Long-stay residents who were physically restrained0.4%0.1%0.1%worse
Long-stay residents with falls causing major injury4.9%3.0%3.3%worse
Long-stay residents whose ability to walk worsened14.4%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication27.6%19.4%18.9%worse
Long-stay residents given the seasonal flu vaccine96.9%95.0%95.3%typical
Long-stay residents with pressure ulcers3.3%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control22.7%20.0%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table25.1%14.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.3%1.1%1.4%worse
Short-stay residents given the seasonal flu vaccine93.6%79.5%79.4%better
Short-stay residents rehospitalized after admission12.7%24.0%22.6%better
Short-stay residents with an outpatient ER visit23.7%11.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.451.841.67better
Long-stay outpatient ER visits per 1,000 resident days2.301.641.80worse

§ 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.

41.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.2%U.S. median 51.5%
Got home and stayed home
11.7%U.S. median 10.7%
Went back to hospital
57.1%U.S. median 56.6%
Met the expected recovery
0.48U.S. median 0.31
Therapy hours / resident / day
0.33hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 57.1% 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 35 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF41.2%CMS range 28.9–54.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.7%CMS range 8.2–17.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge57.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge54.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge34.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.031.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.30
RN hours/ resident / day
0.35
LPN hours/ resident / day
3.25
Aide hours/ resident / day
4.90
Total nurse hours/ resident / day
0.84
RN hoursweekends
47.0%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 197 beds and averages 131.7 residents a day — about 67% occupied, or roughly 65 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.90 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.30 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.25 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 4.33 hrs/resident/day on weekends vs 5.13 on weekdays — 16% thinner on weekends. RN hours go from 1.49 to 0.84 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% 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

5
deficiencies at the latest standard inspection (2026-01-28)
3
at the previous standard inspection (2024-11-20)

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.

ABCDEFGHIJKL

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

22 citations, most serious first. The 14 most serious are shown; the remaining 8 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2023-12-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficiency pertains to Facility Reported Incident (FRI) MI00141290. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement which resulted in the likelihood of serious harm, injury, impairment, or death to one Resident (R102) out of one resident reviewed for safety and supervision. Review of the facility Investigation Summary Conclusion: [R102] exited the main door of Woodland Haven (secured Alzheimer's unit) unattended . [R102] was observed to have exited the (main entrance) of the building .He was outside of the building for a total of one minute and thirty-four seconds . Review of R102's Minimum Data Set (MDS) assessment, dated 9/13/23, revealed R102 was admitted to the facility on [DATE] with current, active diagnoses of non-traumatic brain dysfunction, Alzheimer's dementia, and depression. R102 scored 5 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severely impaired cognition. R102 was independent with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-09-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate toileting assistance to prevent a fall, for one Resident (R2) of three residents reviewed for falls. This deficient practice resulted in a fall with major injury, including fractured facial bones and subdural hematoma. Findings include: This deficiency pertains to Intake 2625013,Review of R2's Electronic Medical Record, revealed R2 was admitted to the facility on [DATE], with diagnoses that included the following, in part: Alzheimer's disease with late onset, dementia with agitation, dementia with anxiety, reduced mobility, need for assistance with personal care, stiffness of right hip, stiffness of left hip, and stiffness of right knee. R2 score 0/15 on the Brief Interview for Mental Status (BIMS) performed in August of 2025, reflective of severe cognitive impairment.Review of the Incident Report dated 9/14/25 at 1545 (3:45 p.m.), revealed the following: .Incident Description: . CNA (Certified Nurse Aide) called this nurse into common…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-03-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00142963. Based on observation, interview, and record review the facility failed to provide a safe transfer for one Resident (R1) of three residents reviewed for accidents and hazards. This deficient practice resulted in hospitalization for a right, lower leg fracture. Findings include: Resident #1 (R1) Review of the history and physical from the hospital dated 2/16/24, revealed R1 experienced pain in her leg and then transferred to hospital where an X-ray was performed on right knee. Review of progress note from the hospital records dated 2/17/24, stated R1 sustained a fracture of the proximal tibial metadiaphysis fracture near the knee in the larger of the two bones in the lower leg. The report also stated R1 was in pain despite the use of Morphine and Roxicodone (Oxycodone). Review of the Facility Reported Incident (FRI) Investigative Summary dated 2/15/24, at 10:07 a.m , revealed Certified Nursing Assistant, (CNA) D and CNA E entered the room of R1 to assist with a transfer…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-12-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing of a pressure injury and prevent the development of an additional pressure injury for one resident (R73) of two residents reviewed for wounds. This deficient practice resulted in harm when R73 developed a stage 3 pressure injury to the coccyx in addition to an existing facility-acquired pressure injury on the coccyx. Findings include: Resident 73 (R73) was admitted to the facility on [DATE] with diagnoses that included but were not limited to: need for assistance with personal care, contracture of the right shoulder, contracture of the left shoulder, dependence on wheelchair, symptoms and signs involving cognitive functions and awareness, catatonic schizophrenia, dementia with psychotic disturbance, and others. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R73 as not having any pressure injuries. The MDS assessed R73 with functional limitation in range 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-01-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 1/26/2026 at 1:45 PM, during initial kitchen walk through with Dietary Data Tech D, an open container of sour cream was observed in an upright cooler. Written in marker on the outside of the container was Sour Cream O with a slash mark through the O (for date opened) 1/25/26, then below that X 2-18-26 for a total of 25 days. Dietary Data tech D stated the last date X was the date the product was to be thrown out.On 1/26/2026 at 3:40 PM, a bag of milk was observed in the bulk milk dispenser in the 1st floor kitchen dining area with a dispose by date sticker of 2/3/26, which is a total of 8 days since it was opened. Per Dietary Manager (DM) A this milk was placed in the unit that day (1/26/2026).On 1/27/2026 at 8:25 AM, while on kitchen tour with DM A and Dietician C, the 2 door Hoshizaki reach-in upright cooler was observed with a bag…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-28 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that environmental equipment utilized by residents was maintained in a manner that allowed equipment to be appropriately cleaned and sanitized for seven Residents (#34, #120, #103, #11, #18, #53, & #138) of eight residents reviewed for a clean, sanitary and homelike environment. Findings include:Resident #34 (R34) On 1/26/26 at 3:13 PM, R34 was observed sitting in a wheelchair in her room. The wheelchair had black tape wrapped around the entire perimeter of the hand rims (circular component on the outside of a wheelchair's wheels that allow users to grip and turn the rims to propel the wheelchair forward) on both sides of the wheelchair. The tape was visibly soiled and noted to be frayed in several places along the perimeter of the hand rims. R34 was asked the reason the black tape encompassed the hand rims of her wheelchair. R34 said the tape had been present for months but she did not know the reason the tape was applied. When…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-28 · tag F0810 — pattern
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adaptive dining equipment for six Residents (#82, #26, #33, #59, #16 & #115) of seven residents reviewed for adaptive dining equipment needs.Findings include: Resident #82 (R82)During the breakfast meal service on 1/27/2026 at 8:52 AM, R82 was observed with a meal tray card indicating a need for adaptive equipment including 2-Handled Spout Cups. R82 did have these adapted cups for two of her beverages but did not for two other beverages. The tray card also indicated a need for Flat Handled [NAME] or [NAME] Utensils. She received regular silverware wrapped in a napkin.During an interview on 1/27/26 at approximately 9:30 AM, R82 confirmed the 2-handled cups were much easier for her to use. She pointed to the beverages in her room on her bedside table in these 2-handled cups.The Electronic Medical Record (EMR) for R82 included a quarterly nutritional assessment dated [DATE] which read in part: Resident is able to feed herself…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to prevent worsening and the development of a pressure ulcer for one Resident (Resident #53) of one resident reviewed for pressure ulcer development.Findings include:Resident #53 (R53)Review of R53's face sheet revealed an admission to the facility on 8/5/25, with diagnoses including heart failure, hypertension, diabetes mellitus, and depression.R53's quarterly minimum data set (MDS) assessment, dated 8/21/25, included Section M Skin which revealed R53 had a risk for developing pressure ulcers.The facility matrix disclosed R53 had developed a facility acquired pressure ulcer stage III which was not present on admission.On 1/27/26 at 10:37 AM, wound care was observed performed on R53 by contracted Physical Therapist (PT) / Wound Care Specialist (WCS) P. R53's pressure ulcer was located on her right sacral area and was circular in shape with some redness of the surrounding skin area. R53 did not have an air mattress on her bed. R53 was wearing an incontinence brief.Review of R53's wound clinic progress note, dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to use foot pedals to safely propel three wheelchair dependent Residents (#33, #115 and #126) of five residents reviewed for safe wheelchair mobility. Findings include: Resident #33 (R33)On 1/27/2026 at 7:56 AM, Certified Nurse Aide (CNA) I was observed transporting R33 into the dining room from the hall. R33 had her feet scraping the floor as CNA I pushed the resident forward. R33 continued to propel herself out of the dining room and at 7:58 AM, Registered Nurse (RN) J redirected R33 by pushing her toward R33's room. No foot pedals were used and R33's feet dragged on the floor as she was pushed. R33 continued to propel herself and then RN J transported R33 back to the dining room, again without using foot pedals.On 1/27/2026 at 8:58 AM, CNA I was observed pushing R33 out of the dining room. CNA I said, Hold your feet up but R33's feet dragged on floor as her wheelchair did not have foot pedals.Resident #115 (R115)On 1/27/2026 at 8:00 AM, CNA H was observed transporting R115 into the dining room from the hall.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficiency pertains to Intake 2574829.Based on observation, interview and record review the facility failed to provide comfort care based on the individual's personalized care plans, for one Resident (R1) of one resident reviewed for quality of care. This deficient practice resulted in unaddressed anxiety and fear related to shortness of breath during the dying process. Findings include: Review of R1's Minimum Data Set (MDS) assessment, dated [DATE], revealed R1 was re-admitted to the facility on [DATE] with active diagnoses that included the following, in part: cancer, septicemia, anxiety disorder, chronic obstructive pulmonary disease (COPD), respiratory failure, parainfluenza virus pneumonia and pulmonary embolism. R1 Scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. The Resident (R1) was placed on Hospice on [DATE] and remained as her own responsible party for medical decisions until [DATE], the day of the Resident's death. An abbreviated survey 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that appropriate interventions were in place to prevent a burn for one Resident #70 (R70) of ten residents reviewed for burns resulting in the potential for further burns, pain and disfigurement. Findings include: Resident #70 (R70) Review of R70's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 7/20/20, with active diagnoses that included: coronary artery disease, hypertension, heart failure, diabetes mellitus, and anxiety disorder. R70 scored a 7 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. Review of facility incident notes, read in part . per video review of the day 10/25/24 .R70 was seating in the dining tower for supper. R70 was observed picking up a bowl from the table and holding it over her chest while spooning something into her mouth. R70 puts the spoon and bowl back on the table and began to fan the clothing protector that was 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-20 · tag F0697 — failed to manage pain — isolated
    Provide 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 provide adequate pain management for one Resident (#30) of two residents reviewed for pain management resulting in R30 experiencing uncontrolled pain during a routine dressing change. Findings include: Resident 30 (R30) Review of R30's face sheet revealed the following diagnosis: low back pain. Review of R30's Minimum Data Set (MDS) assessment, dated 9/4/24, revealed a Brief Interview for Mental Status (BIMS) assessment of 9 (0-15) indicating moderately impaired cognition. R30 had no rejections of care, was dependent on staff for all cares except substantial/maximal assistance for upper body dressing, and had an unhealed pressure ulcer, not present on admission. Review of R30's Electronic Medication Administration Record (EMAR), revealed the following, Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (milligrams per milliliters) Give 0.25 ml by mouth every 2 hours as needed for pain . (5 mg) . Review of R30's Treatment Administration Record (TAR), revealed the following, Pressure injuries to coccyx:…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure expiration dates were present on multi-dose medications and biologicals and failed to remove expired medications from the active supply in one medication cart of four medication carts reviewed, resulting in the potential for administration of expired medications and biologicals and the potential to have a reduced medication effect. Findings include: A review of the 200 Hall medication cart with Licensed Practical Nurse (LPN) C on 11/19/2024 at 1:54 p.m. revealed the following: A multi-dose Trelegy Ellipta (inhaled medication used to treat asthma and chronic obstructive pulmonary disease) 200-62.5-25 MCG (microgram) inhaler with 22 doses out of 30 doses remaining. Further review of the inhaler and the box housing the inhaler revealed no date indicating when the medication was first opened or when the medication would expire. An open insulin aspart (rapid-acting insulin) FlexPen with 75 units out of 100 units remaining. The insulin pen and the clear plastic bag housing the pen contained no legible 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-24 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 utilize appropriate dementia care techniques in the provision of care and services to one Resident (R3) of three residents reviewed for dementia care. This deficient practice resulted in the potential for escalation of behaviors by use of physical force to ensure resident complied with staff care. Findings include: This deficiency pertains to Complaint Intake #MI00143128, which alleged facility staff were being physically aggressive and neglectful of R3 while residing in the facility locked Alzheimer's unit. Observation of surveillance video, in the presence of IT (Information Technology) Director (Staff) E showed the following staff/resident (R3) interactions: 12/16/2023: At 4:39 p.m., R3 had fallen asleep in a straight-backed chair. He was leaning forward as he was sleeping. At 4:40 p.m., two unidentified facility staff members (unknown names) grabbed R3 underneath the armpits (one on each side) and dragged him forcibly across the floor. R3 appeared to be resisting the move, as his feet were out in front 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 8 citations
  • Potential for harm · Fcited before2023-12-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 as evidenced by: 1. Failing to ensure four packages of lunch meat were disposed of after the expiration date stamped by the packager. 2. Failing to ensure resident care staff on the locked units were wearing hair restraints when they entered the kitchen, during meal service. These deficient practices have the potential to result in food borne illness among any and all 124 residents of the facility. Findings include: 1. On 12/05/23 at approximately 1:35 PM, observations were made in the walk in cooler in the main kitchen on ground floor. Four packages of lunch meat were observed on a shelf in the walk in cooler, two containing ham and two containing roast beef. The packages of ham had use by/freeze by date of 11/6/23, and the two roast beef packages had use by/freeze by date of 11/20/23. Both packages were bloated. An interview with…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-12-08 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct 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 — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to complete a comprehensive facility-wide assessment that included an assessment and determination of staffing levels based on resident acuity, and training programs that would be provided to facility staff. This deficient practice resulted in the potential for insufficient staff and staff training necessary to care for residents. Findings include: Review of the 43 page Facility Assessment 2023-2024 provided by the Nursing Home Administrator (NHA) on 12/5/23 at 15:49 (3:49 p.m.) revealed Section II. Staffing, Training, Services & Personnel were all documented as Evaluated with the following Sufficiency Analysis Summary, in part: Staffing patterns have been reviewed on [Staffing Name Program]. The facility continues to utilize [Name Brand] Learning platform for annual and supplemental training . For additional information see attachments . No attachments were present with the Facility Assessment. Staffing levels based on acuity were not delineated in the Facility Assessment, nor were the required staff trainings offered 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-12-08 · tag F0868 — widespread
    Have 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 that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. This deficient practice resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues, placing all 124 residents in the facility at risk for quality care concerns. Findings include: During an interview on 12/08/23 at 11:00 the QAPI process was discussed with the Nursing Home Administrator (NHA). The NHA stated the QAPI team met at least quarterly and as needed to coordinate and evaluate quality assessment program activities. The attendance documents were reviewed for the 1/27/23, 4/27/23, and 10/28/23 meetings. No attendance documentation was found between April and October. The NHA had assumed his role recently and could not speak to the attendance during that time frame. The facility Quality Assurance Performance Improvement (QAPI) Plan dated as last approved 12/2023, read in part The QA & A (Quality Assurance) Committee reports 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-08 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report resident-to-resident incidents involving physical altercations for seven Residents (R50, R52, R66, R84, R119, R102, and R120) of nine residents reviewed for reporting of abuse. This deficient practice had the potential for undetected abuse, and adverse outcomes. Findings include: R50 Review of the Minimum Data Set (MDS) assessment, dated 11/02/23, revealed R50 was admitted to the facility on [DATE], with diagnoses including dementia, anxiety, and depression. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 8/15, which indicated moderate cognitive impairment. R50 required moderate assistance with toileting and was independent with walking and transfers. Review of R50's progress note, dated 10/17/23 at 1:56 p.m., revealed, [R50] was sitting on the couch in the TV (day) room when a male resident [R119] walked behind her and hit her on the top of the head. Staff reports .male resident [R119] started hollering and a CNA…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-08 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to fully investigate resident-to-resident incidents involving physical altercations for seven Residents (R50, R52, R66, R84, R119, R102, and R120) of nine residents reviewed for investigating abuse allegations. This deficient practice had the potential for undetected abuse, and adverse outcomes. Findings include: R50 Review of the Minimum Data Set (MDS) assessment, dated 11/2/23, revealed R50 was admitted to the facility on [DATE], with diagnoses including dementia, anxiety, and depression. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 8/15, which showed R50 had moderate cognitive impairment. R50 required moderate assistance with toileting and was independent with walking and transfers. The behavioral assessment showed no behaviors. Review of R50's progress note, dated 10/17/23 at 1:56 p.m., revealed, [R50] was sitting on the couch in the TV (day) room when a male resident [R119] walked behind her and hit her on the top 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-08 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain medication storage areas free of expired medications and securely store medications, for one of two medication rooms and three of three medication carts reviewed for medication storage. This deficient practice resulted in the potential for administration of lessened efficiency medications. Findings include: On 12/6/23 at 4:30 PM, medication cart B on the first floor was inspected. In the second drawer beneath the medication cards an observation was made of several loose pills identified as; one quetiapine 25 mg (milligrams), one pantoprazole 40 mg, one acetaminophen 325 mg, one baclofen 5 mg, and two other pieces of unidentified pills. In the first drawer an observation was made of a bottle of cetirizine with a worn, unreadable expiration date. Registered Nurse (RN) C confirmed night shift routinely cleaned medication carts, and no loose pills or pieces should be left in the medication cart and should be stored accordingly. On 12/6/23 at 4:45 PM, the medication store room on the first floor 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure the safety of one Resident (R1) of four residents reviewed for falls, safety, and adequate supervision. This deficient practice resulted in the unauthorized exit from the secure Alzheimer's unit and the potential for injury for R1. Findings include: Review of the facility incident investigation report revealed, in part: On 5/21/23, [R1] was observed exiting the building from the north exit door of the dementia unit, on the underside of the building .Upon video review, it was determined that [R1] exited her room at 10:55 (a.m.) . As Resident (R1) emerged from her room, she looked around for a moment and headed straight for the North wing exit door. Resident was out of view on the camera in Woodland (secure Alzheimer's unit) but was seen again at 11:01 exiting the north exterior door under Woodland Haven. It is assumed Resident (R1) was able to navigate the stairwell without any difficulty. You can see her walking out the door with her 4 wheeled walker . (when) asked how…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • No harm found · C2023-12-08 · tag F0732 — widespread
    Post 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 the required accurate daily nursing staffing information. This deficient practice resulted in the inability of residents and visitors to determine the number of nursing staff available to provide resident care and had the potential to affect all 124 facility residents. Findings include: During an observation on 12/6/23 at 1:06 p.m., the staffing posting was observed at the facility entrance with Registered Nurse (RN) R. There was no differentiation between the number of RN's working and the number of Licensed Practical Nurses (LPNs) working, to show whether an RN was scheduled to work in the facility for eight hours a day. This was noted on both the day and the night shift posting for 12/06/23. Review of nursing staff postings, provided by the Director of Nursing (DON), from 11/21/23 through 12/5/23, showed a similar presentation, with no differentiation between RN and LPN coverage during the day and night shifts. During an interview on 12/8/23 at approximately 1:45 p.m., the Assistant Director 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$39,988 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $24,395 — penalty dated 2024-03-06
  • $15,593 — penalty dated 2023-12-08
  • Medicare payment denial — starting 2024-01-05 for 49 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 / managerTypeRoleShareSince
HOUGHTON COUNTY MEDICAL CARE FACILITYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 01/01/1968
HILGERS, CHRISTYIndividualMANAGING CONTROL - GOVERNING BODYsince 11/01/2010
JENICH, EDWARDIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2013
TERVO, JAMESIndividualMANAGING CONTROL - GOVERNING BODYsince 01/01/2020
DESTRAMPE, KARAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/15/2025
KINZEL, TERRYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/24/2025
KURU, ASHLEYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/15/2025
LAPLANDER, ADAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/24/2025

CMS files one row per role, so the 11 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$17.9M
Net patient revenuemost recent cost report
-43.9%
Operating marginrevenue minus expenses
$179K
Related-party expense1% of expenses
Who pays — share of resident-days
Medicaid 48%Medicare 2%Other / private 49%

This home reported $179K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$581per resident / day
operating cost
$17,651per month
≈ monthly operating cost
$403per day
avg. revenue, all payers

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

What families pay in MI

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235031. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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