Medilodge of Hillman
631 Caring Street, Hillman, MI 49746 · For profit - Limited Liability company · 39 certified beds · (989) 742-4581 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 3 actual-harm citations
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $47,740 in federal fines (most recent 2025-09-11)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 24% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.4% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.7% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 12.3% | 4.3% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.5% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 14.1% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 30.8% | 19.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 86.5% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.9% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.2% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 27.9% | 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 | 40.5% | 79.5% | 79.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.77 | 1.84 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.75 | 1.64 | 1.80 | typical |
§ 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.
57.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% 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 22 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 57.3%CMS range 44.9–70.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 6.5–14.6 | 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 | 50.0% | 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 | 50.0% | 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 | 45.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 21.9% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 6.9%CMS range 3.2–14.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 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 37.0 residents a day — about 95% occupied, or roughly 2 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.21 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.01 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.44 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.65 hrs/resident/day on weekends vs 4.43 on weekdays — 18% thinner on weekends. RN hours go from 1.14 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 13 most serious are shown; the remaining 10 are one tap away and print in full.
- Actual harm · G2025-09-11 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse in review of two Residents (#26 & #19) of three residents reviewed for abuse. This deficient practice resulted in Resident #19 experiencing ongoing emotional distress, including fear of a sense of safety within the facility when in proximity of Resident #26 who was the one involved in the altercation.Findings include:Resident #19 (R19)A review of R19's Electronic Medical Record (EMR) revealed admission to the facility on 1/17/24, with diagnoses including major depressive disorder, and Post-Traumatic Stress Disorder (PTSD) (a mental health condition that develops after experiencing or witnessing a traumatic event). R19 was noted to have a Brief Interview for Mental Status (BIMS) score of 14/15, indicating cognition was intact.On 9/9/25 during an initial interview at 11:15 AM, R19 stated they were hit on the head and choked by another resident, just the other day. R19 stated the resident who had hit 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.
- Actual harm · Gcited before2025-03-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00150640. Based on interview and record review the facility failed to provide safe and adequate assistance with bed mobility for one Resident (#2) of three residents reviewed for accidents, hazards, and supervision. This deficient practice resulted in a fall with major injury, hospitalization, and death. Findings include: Resident #2 (R2) Review of a complaint submitted to the State Agency (SA) on [DATE], revealed, on [DATE], [Registered Nurse (RN) H] called the complainant and told them [R2] was having a routine brief exchange done by one staff member [Certified Nurse Assistant (CNA) D]. Complainant R stated that they were informed [CNA D] had rolled [R2] on her side. Complainant R stated that they were told that during this incident, [R2] fell out of bed, broke her shoulder and hip, and hit her head. Complainant R stated that [R2] passed away at the hospital on [DATE]. Complainant R stated that prior to this incident, there had always been two people present to change [R2].…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-02-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation is linked to intake MI00141867. Based on observation, interview, and record review, the facility failed to provide pressure ulcer care per professional standards of practice for one Resident (R10) of three reviewed for pressure ulcer care. This deficient practice resulted in the worsening of a facility aquired pressure injury to an unsgateable pressure injury requiring antibiotics. Findings include: R10 R10 developed an in house Moisture Associated Skin Damage area on 11/24/23 which subsequently worsened to stage II, and ultimately progressed to an unstageable pressure injury on 2/5/24 with worsening measurements through 2/26/24. R10 also developed a wound infection, requring treatment with antibiotics. The facility failed to ensure the approriate pressure reducing surface for the bed was in place, failed to provide aspetic (clean technique) wound care, failed to consitently measure and document wound care, and failed to appropriately turn/reposition R10 for pressure relief. On 2/29/24 at 8:30 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-09-11 · tag F0923 — widespreadHave enough outside ventilation via a window or mechanical ventilation, or both.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a safe, comfortable and homelike environment by failing to ensure proper exhaust ventilation in the facility allowing the build-up of foul odors with the potential to affect all residents in the facility.Findings include: On 09/10/2025 at 10:30 AM, observed that the ventilation fan was not working in room [ROOM NUMBER]. A tissue test at the exhaust grille over the toilet noted that it was not pulling air in. During a facility tour with MD I, it was noted that the vent fans were not working in the 100 wing and were also not working in the two hundred wing, rooms 211-217, and rooms 216 through 228.On 09/10/2025 at 11:32 AM, a strong odor of urine was observed in hall 210-217 Eagle Lane.On 09/10/2025 at 12:00 PM, MD I printed a copy of the work history report for the last 12 months, documented weekly, showing that the Exhaust Fans Task had been completed and the task signed off on 9/5/2025.On 09/11/2025 at 11:05 AM, during interview…
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 before2025-09-11 · 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 — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to maintain safe water temperatures at two hand washing sinks which could result in the potential for scalding risk to all residents that use these sinks.Findings include: On 09/09/25 at 11:20 AM, the water temperature at the handwashing sink in the dining room was measured with a rapid read thermometer to be 149 degrees Fahrenheit. The dining room was further observed to be accessible to all residents.On 09/09/2025 at 12:30 PM, the water temperature at the hand sink in the activities room called the Cowboy Lounge was measured with a rapid read thermometer to be 150 degrees Fahrenheit. On 09/10/2025 at 10:18 AM, interview with Head of Maintenance, Staff J noted that the sinks noted were on the same loop as the Laundry and they do not have individual mixing valves installed at the sink fixture.
- Potential for harm · D2025-09-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an adaptive call light to accommodate a physical impairment for one Resident (#14) of one Resident reviewed for accommodations of needs and preferences.Findings include: Resident #14 (R14)Review of R14's Electronic Medical Record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including bipolar disorder, stiffness of the left hand, stiffness of the right hand, cognitive communication deficit, repeated falls, and need for assistance with personal care. Review of R14's most recent Minimum Data Set (MDS) assessment, dated 8/4/25, revealed a Brief Interview for Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment.On 9/9/25 at 11:22 AM, R14 was observed lying in bed. R14's left hand was observed to be contracted into a tight fist. R14's right hand was observed contracted into a tight fist with both the middle and ring fingers extended. A bedside table was positioned to the right of R14…
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 · D2025-09-11 · 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
Based on interview and record review, the facility failed to act upon pharmacist recommendations for one Resident (#2) of five residents reviewed for medication regimen review.Findings include:Resident #2 (R2)Review of R2's Electronic Medical Record (EMR) revealed initial admission to the facility on 3/15/24 with diagnoses including major depressive disorder and bipolar disorder. Review of R2's most recent Minimum Data Set (MDS) assessment, dated 3/23/25, revealed a Brief Interview for Mental Status (BIMS) score of 1, indicative of severe cognitive impairment.Review of R2's EMR revealed the following physician orders:Risperidone Intramuscular Suspension Reconstituted ER [extended release] 50 MG [milligram](Risperidone Microspheres). Inject 50 mg intramuscularly one time a day every 14 day(s), initiated 5/11/24.Ziprasidone HCl Oral Capsule 40 MG (Ziprasidone HCl). Give 1 capsule by mouth two times a day, initiated 5/3/24.Review of a pharmacy recommendation, dated 5/5/25, read, This resident is currently being treated with Risperidone and ziprasidone, both atypical antipsychotics,…
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 before2024-10-09 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 appropriate labeling of inhaled medications in one (East Hall) of two medication carts reviewed for medication storage, resulting in the potential for unrecognized expiration of medications, decreased medication efficacy and adverse side effects of expired medications with the potential to affect all 18 residents residing on the East Hall. Findings include: On 10/08/2024 at 8:33 a.m., the East Hall medication cart was reviewed with Registered Nurse (RN) E. Observation of stored inhaled medications revealed an open box containing a Proair HFA inhaler (inhaled medication used to treat wheezing and shortness of breath). Further observation revealed the inhaler had 27 of 200 doses remaining. The inhaler or the box the inhaler was housed in was not labeled with a resident name, open date or expiration date. Upon inspection, RN E reported she could not determine who the inhaler belonged to, if the medication was expired, or when the medication would expire. Further review of the East Hall medication cart 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.
- Potential for harm · D2024-10-09 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 accurate advanced directive information was in place for one Resident (R16) of 13 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time). Findings include: The medical record revealed R16 was admitted to the facility on [DATE] with diagnoses of dementia, stroke (cerebrovascular accident), and traumatic brain injury. The Minimum Data Set (MDS) assessment, dated 9/8/2024, indicated R16 was classified with a primary diagnosis of Medically Complex Conditions including taking all nourishment via a tube feeding and had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating severe cognitive impairment. The medical record contained: - An ADVANCE DIRECTIVES / MEDICAL TREATMENT DECISIONS form which indicated a Medical Durable Power of Attorney and full resuscitation (full code) dated 9/1/2021. - A DO-NOT-RESUSCITATE ORDER PATIENT ADVOCATED CONSENT form…
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 · D2024-10-09 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the identification and reporting of potential abuse or neglect for one Resident (#93) of two residents reviewed for abuse, resulting in the potential for unidentified abuse or neglect and further exposure to abusive situations. Findings include: Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed R93 was admitted to the facility on [DATE] and had diagnoses including dementia, stroke, right side hemiplegia (paralysis of right side of the body), and right hip fracture. Further review of the MDS data revealed R93 was dependent on staff for transfers and required partial/moderate assistance for rolling left and right in bed. The MDS data indicated R93 had short-term memory impairment and moderately impaired cognitive skills for daily decision making. Review of R93's MDS assessment, dated [DATE], revealed R93 expired in the facility on [DATE]. Review of R93's electronic…
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 · D2024-10-09 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the thorough investigation of potential abuse or neglect for one Resident (#93) of two residents reviewed for abuse, resulting in the potential for unidentified abuse or neglect and further exposure to abusive situations. Findings include: Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed R93 was admitted to the facility on [DATE] and had diagnoses including dementia, stroke, right side hemiplegia (paralysis of right side of the body), and right hip fracture. Further review of the MDS data revealed R93 was dependent on staff for transfers and required partial/moderate assistance for rolling left and right in bed. The MDS data indicated R93 had short-term memory impairment and moderately impaired cognitive skills for daily decision making. Review of R93's MDS assessment, dated [DATE], revealed R93 expired in the facility on [DATE]. Review of R93's electronic medical…
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 before2024-10-09 · 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
Based on observation, interview, and record review, the facility failed to implement fall prevention precautions for one Resident (Resident 20) of three residents reviewed for falls. Findings include: Resident 20 (R20) Review of R20's Electronic Medical Record (EMR), revealed a nursing quarterly/significant change evaluation, dated 9/17/24, indicated R20 had one to two falls in the last 90 days. R20 had fallen on 8/28/24. R20 had a risk fall score of 21, indicating a high risk for falls. Review of R20's care plan, dated 8/7/23, read in part, .Focus .has an ADL (activities of daily living) self-care performance deficit related to dementia, generalized weakness .Interventions: High back wheelchair to promote independence and comfort when up in wheelchair. Ambulation: 1 person assistance with a gait belt .uses a wheelchair for ambulation/transfer .Focus .is at risk for falls/injury related to generalized weakness, high risk of falls, history of falls, impaired cognition with decreased safety awareness .Interventions .Floor alarm mat to right side of bed when resident is in bed, so that…
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 · D2024-10-09 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to administer a blood pressure altering medication within ordered parameters for one Resident (#19) or five residents reviewed for unnecessary medications, resulting in the unwarranted administration of the medication and the potential for adverse side effects. Findings include: Resident #19 (R19) Review of R19's Medication Administration Records (MARs) for September 2024 through October 9, 2024, revealed the following physician order: Midodrine HCL [medication used to treat symptomatic low blood pressure] 10 MG [milligram]. Give 0.5 tablet by mouth three times a day for low blood pressure . hold SBP > 100 [when the top number of the blood pressure is greater than 100] . adjusted per [attending physician] . Start Date: 7/29/2024 . Further revealed the medication was administered outside of the ordered parameters on nine occasions per documentation on the MARs: 9/05/2024, 8:00 a.m., blood pressure 131/81. 9/05/2024, 5:00 p.m., blood pressure 103/67. 9/07/2024, 5:00 p.m., blood pressure 100/64. 9/08/2024, 5:00 p.m., blood…
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 10 citations
- Potential for harm · D2024-10-09 · 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 attempt a gradual dose reduction (GDR) for a psychotropic medication for one Resident (R27) of five residents reviewed for unnecessary medications. Findings include: Review of R27's medical record, revealed an admission date on 5/6/2020 with diagnoses which included major depressive disorder and anxiety disorder. A review of R27's Minimum Data Set (MDS) assessment dated [DATE], revealed a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating fully intact cognition. The medical record noted active Physician's Orders, dated 3/1/22 included: Fluoxetine HCl Capsule 40 mg (milligrams), one tablet a day for depression and busPIRone HCl tablet 10 mg one tablet three times a day for anxiety. During an interview on 10/08/24 at 9:42 AM, the Social Service Designee (Staff A) was asked about the process for GDRs and specifically for the documentation for R27. Staff A stated, The last GDR for busPIRone was on 2/2/2023 and they would look…
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 before2024-02-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation is linked to intake MI00141807. Based on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice for five Residents (R2, R3, R4, R7, and R8) of six residents reviewed for respiratory care. Findings include: On 2/28/24 at 11:30 AM, an observation was made of R8 in the East dining room. R8 was sitting in her wheelchair at a dining table with a portable oxygen tank on the back of her wheelchair and oxygen tubing draped over the back of her wheelchair. R8's oxygen tubing was two inches from touching the floor and was not stored in a plastic bag. On 2/28/24 at 11:32 AM, an observation was made of R8's room. R8 had an oxygen concentrator in her room, her oxygen tubing was connected to the concentrator and her tubing was draped over the arm of her recliner and the nasal cannula was tucked in between the armchair and the seat. On 2/28/24 at 11:33 AM, an observation was made of R7 in his room and lying in bed wearing a nasal cannula connected to an oxygen concentrator. R7's oxygen tubing was undated. Review of R7's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-29 · 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
This citation is linked to intake MI00141807. Based on observation, interview, and record review the facility failed to ensure infection control practices were followed with respiratory equipment/storage and during a wound dressing change per standards of practice. Findings include: On 2/28/24 at 11:30 AM, an observation was made of R8 in the East dining room. R8 was sitting in her wheelchair at a dining table with a portable oxygen tank on the back of her wheelchair and oxygen tubing draped over the back of her wheelchair. R8's oxygen tubing was two inches from touching the floor and was not stored in a plastic bag. On 2/28/24 at 11:32 AM, an observation was made of R8's room. R8 had an oxygen concentrator in her room, her oxygen tubing was connected to the concentrator and her tubing was draped over the arm of her recliner and the nasal cannula was tucked in between the armchair and the seat. On 2/28/24 at 11:40 AM, an observation was made of R2 in his room. R2 had a portable oxygen tank to the right of his door with oxygen tubing coiled up on top of the tank and not stored 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 · D2024-02-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation is linked to intake MI00141867. Based on observation, interview, and record review, the facility to provide indwelling catheter care per standards of practice for two Residents (R5 and R7) of three residents reviewed for catheter care. Findings include: On 2/28/24 at 12:10 PM an observation was made of R5 in his room and lying in his bed. R5 was observed to have an indwelling urinary catheter with a drainage bag hanging off the right side of his bed. R5 was asked if he had a catheter securement device on his leg and pulled back his bed sheet and replied, No. See, I do not have one. On 2/28/24 at 12:30 PM an observation was made of R7 in his room with the Director of Nursing (DON). R7 was observed to have an indwelling urinary catheter with a drainage bag hanging of the right side of his bed. The DON was asked if R7 had a catheter securement device on his leg and the DON stated, He should. The DON then looked at R7's catheter which lacked a catheter securement device on his leg. On 2/28/24 at 12:45 PM an interview was conducted with the DON. When asked if residents 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.
- Potential for harm · Dcited before2024-02-29 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 safe self-administration of medication for one Resident (R5) of three residents reviewed for medication administration. Findings include: On 2/28/24 at 12:10 PM, an observation was made of R5 in his room. R5 was lying in his bed holding a nebulizer treatment in his right hand and was asleep. R5's nebulizer machine was on, and the nebulizer medication cup had condensation inside. R5 was awakened and asked how long he had been asleep and if he completed his nebulizer treatment and replied, The nurse came in about ten or fifteen minutes ago and I was awake then. Review of R5's physician order, dated 2/22/24, revealed an order for albuterol sulfate inhalation nebulizer solution (2.5 mg [milligrams] / 3 ml [milliliters]) 0.083% (Albuterol Sulfate) . 2.5 mg inhale orally via nebulizer three times a day for pneumonia (scheduled at 8:00 AM, 12:00 PM, and 6:00 PM). Review of R5's nursing readmission evaluation, dated 2/7/24, section II. Medications, read in part, .Does the resident wish to self-administer…
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 before2023-10-19 · tag F0755 — failed to provide safe pharmacy services — widespreadProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 consistently document narcotic drug disposition in two of two medication carts during review for medication storage. This deficient practice had the potential to affect the entire facility population and resulted in the potential for drug diversion, misappropriation, and the potential for untreated conditions related availability of medications. Findings include: On 10/18/23 at 8:00 AM, an observation was made of medication administration on the [NAME] Hall with Registered Nurse (RN) H. This surveyor observed the narcotic count book with RN H. The narcotic count book was noted to have several missing narcotic count verification signatures by nurses when a shift-to-shift count of narcotics for this medication cart were completed. RN H was asked why she did not sign off on the medication cart count this morning and if she counted narcotics with the off going nurse from the prior shift. RN H replied, I usually do not sign the book until I take my first narcotic out of the box. I did verify the count with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-19 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 maintain a medication administration error rate less than 5% for two Residents (R33 & R21) of three residents reviewed for medication administration. This deficient practice resulted in the potential for medical complications in resident treatment and conditions. Findings include: On 10/18/23 at 8:00 AM, a medication administration was observed with Registered Nurse (RN) H. The following was observed: Resident #21 (R21) was given (name brand) liquid advanced wound care protein, 30 ml (milliliters), mixed in six ounces of water in a cup, and dispensed orally by mouth. Review of R21's physician order, dated 10/11/23, revealed, (name brand) liquid advanced wound care protein, two times a day for wound healing. R21's order lacked a dose amount or route for his liquid advanced wound care protein. On 10/18/23 at 9:20 AM, a medication administration was observed with RN J. The following was observed: Resident #33 (R33) was given lorazepam 0.5 mg (milligrams), one tab, crushed, mixed with 5 ml of water, 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 · Ecited before2023-10-19 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 securely store medications, for Resident #1 (R1) during review for medication storage. This deficient practice had the potential to result in accidental ingestion of medications not prescribed to two unidentified residents with access and the potential for associated side effects. Findings include: On 10/19/23 at 8:30 AM, an observation was made of RN L preparing medications on the [NAME] Hall medication cart for Resident #1 (R1). RN L had dispensed several medications into the cup including a hydrocodone 7.5 mg (milligram) / 325 mg tablet. During the preparation of R1's medications, RN L had been interrupted by Certified Nurse Aide (CNA) M. CNA M had asked RN L for some paperwork. RN L locked his medication cart and computer screen and left the medication cup on top of the nurses' cart and proceeded to the nurses' station to look for the paperwork. RN L left the medication cup unattended. RN L then left the nurses station and entered the shower room briefly and returned out into the [NAME] Hall. RN L then…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide dressing changes according to physician orders for one Residents (R20) of three residents reviewed for quality of care. This deficient practice resulted in missed dressing changes and the potential for decline in wound status. Findings include: Review of R20's Electronic Medical Record (EMR) revealed an original admission to the facility on [DATE]. R20 had a readmission on [DATE] with diagnoses including type 2 diabetes with neuropathy and skin ulcer, dementia with agitation, muscle weakness, non-pressure chronic ulcer of right lower leg and pain. Review of his 7/17/23 Minimum Data Set (MDS) assessment revealed he scored a score of 14/15 on the Brief Interview for Mental Status (BIMS) score indicating he was cognitively intact. R20 scored a zero for rejection of care (Section E) and required one-to-two-person extensive assist for Activities of Daily Living (ADL's) which included bed mobility, transfers, dressing, and personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-19 · 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 ensure proper administration of oxygen services for one resident (#23) of three residents reviewed for oxygen services. This deficient practice resulted in the potential for respiratory complications. Findings include: Resident #23 (R23) A review of R23's face sheet, revealed an original admission to the facility on 2/16/21, and with the most recent readmission to the facility on 3/14/23. R23 had medical diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), respiratory failure (a serious condition that makes it difficult to breathe), anxiety, and obstructive sleep apnea (intermittent airflow blockage during sleep). On 10/17/23 at 1:00 PM, an observation and interview were made of R23 in his room. R23 had an oxygen concentrator in his room located on the right side of his bed sitting on the floor. R23's oxygen concentrator was running and there was oxygen tubing connected to the concentrator. R23 wore the oxygen tubing via nasal…
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
$47,740 in federal fines across 1 penalty.
- $47,740 — penalty dated 2025-09-11
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.
Part of a chain
This home belongs to MEDILODGE — 53 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.1 | -0.1 vs chain |
| Health inspection | 2 of 5 | 2.7 | -0.7 vs chain |
| Staffing | 5 of 5 | 3.7 | +1.3 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 52 homes this chain runs (chain average 3.1★, per CMS)
Showing 40 of 52; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FIFTEENINONE OPCO GROUP LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/24/2013 |
| B&Y HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/24/2013 |
| B&Y TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/24/2013 |
| CODY HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/24/2013 |
| CRAIG FLASHNER 2007 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/24/2013 |
| NORCROSS, ROBERT | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 06/24/2013 |
| ROGERS, STACEY | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 10/20/2014 |
| KIRK, KRISTINE | Individual | W-2 MANAGING EMPLOYEE | — | since 01/01/2018 |
| GENERATIONS HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/24/2013 |
| PRESTIGE ADMINISTRATIVE SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2016 |
| FLASHNER, CRAIG | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/24/2013 |
| PERLSTEIN, YITZCHOK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/24/2013 |
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 24% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235423. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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