Resthaven Care Center
280 W 40th St, Holland, MI 49423 · Non profit - Corporation · 145 certified beds · (616) 796-3600 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
- it has a citation for mishandling residents’ money or property (F0568)
- it has 1 actual-harm citation
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.6% | 10.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 2.8% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.5% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 2.0% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 7.1% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.8% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.3% | 19.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 94.7% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.6% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.1% | 14.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 1.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 92.7% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 14.0% | 24.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 13.6% | 11.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.00 | 1.84 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.32 | 1.64 | 1.80 | worse |
§ 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.
55.0% 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 169 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.3% 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 63 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 0.25 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% 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 | 55.0%CMS range 48.1–60.0 | 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 | 10.6%CMS range 7.5–13.9 | 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 | 60.3% | 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 | 55.6% | 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 | 46.0% | 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 | 98.6% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.4% | 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 3.3–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.70 | 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 145 beds and averages 138.4 residents a day — about 95% occupied, or roughly 7 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.33 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.553 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.86 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 3.61 hrs/resident/day on weekends vs 4.62 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.67 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · Gcited before2025-08-05 · 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 # 2574196Based on interview and record review the facility failed to ensure the safety of 1 resident (Resident #1) of 3 residents reviewed for accidents/hazards resulting in Resident #1 having a fall in the facility parking lot while she was left unattended and as a result suffered frontal and temporal lobe hemorrhages, a 4th left rib fracture and a change in capacity.Findings include:Resident #1 (R1)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R1 admitted to the facility on [DATE] with pertinent diagnoses including cerebral infarction (stroke), chronic fatigue and cognitive communication deficit. R1 was in the hospital from [DATE] to 7/16/2025. Brief Interview for Mental Status (BIMS) on 5/5/2025 reflected a score of 10 out of 15 which indicated R1 was moderately cognitively impaired (8-12 is moderate cognitive impairment) prior to the fall and BIMS on 7/21/2025 reflected a score of 7 out of 15 which indicated R1 was severely cognitively…
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 · E2025-06-25 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide quarterly resident trust fund financial statements to 8 of 8 residents utilizing resident trust accounts resulting in the residents not being systematically informed about personal funds. Findings include: Review of electronic correspondence received from Nursing Home Administrator (NHA) A on 6/25/25 at 1:36 PM revealed, We currently have 8 residents utilizing resident trust. In an interview on 6/25/25 at 10:27 AM, Accounting Associate (AA) ZZ reported that resident trust fund financial statements were provided annually and upon request to the residents utilizing resident trust accounts. AA ZZ reported she did not provide quarterly trust fund financial statements but thought Resident Services Coordinator (RSC) V might send them. In an interview on 6/25/25 at 10:46 AM, RSC V reported she did not provide quarterly trust fund financial statements to the residents utilizing resident trust accounts but could let the resident know the balance of their account if they inquired about it. In an interview on 6/25/25 at 1:04…
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 · E2025-06-25 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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, interviews and record review, the facility failed to maintain a comfortable ambient temperature between 71-81 degrees for 20 residents within a memory care unit (Rooms 401-415), resulting in resident's experiencing ambient room temperatures higher than 81 degrees and a potential for overheating and dehydration.Findings include: Review of Heat and Older Adults published by the Centers for Disease Control and Prevention, 6/25/24 revealed People aged 65 years or older are more prone to heat-related health problems .older adults .are more likely to have a chronic medical condition that changes normal body responses to heat .they are more likely to take prescription medicines that affect the body's ability to control its temperature or sweat .During an observation on 6/23/25 at 10:21am, a wall mounted oscillating fan was blowing in the common area of the memory care unit but could not be felt in the area where several residents sat.During an observation on 6/23/25 at 11:01am, Resident #112 in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-25 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed provide a dignified environment and assist residents with care needs in 1 (Resident #52) of 2 residents reviewed for dignity, resulting in feelings of frustration and the potential for depression, loss of self-worth, and an overall deterioration of psychological well-being.Findings include:Resident #52 Review of an admission Record revealed Resident #52 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dysphagia (difficulty swallowing) and depression. Review of a Minimum Data Set (MDS) assessment for Resident #52, with a reference date of 5/23/25 revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #7 was severely cognitively impaired. Review of Resident #52's Orders revealed, Aspiration precautions: Sit upright for all PO(by mouth) intake and 30 minutes after, check for oral residue, excellent oral care including denture cleaning, encourage small bites, slow rate,…
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 · D2025-06-25 · 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 documentation of advance directives - code status (resident wishes for life sustaining interventions an emergency) for 1 (Resident #389) of 28 residents reviewed for advance directive - code status documentation resulting in the lack of an order or other documentation for the first 5 days of Resident #389's stay. Findings include:Review of an admission Record revealed Resident #389 was a female who admitted to the facility on [DATE] and had pertinent diagnoses which included: vascular dementia (dementia related to blood flow through narrowed blood vessels) and Alzheimer's disease. Review of a Minimum Data Set (MDS) assessment for Resident #389, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #389 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment).Review of Order Summary for Resident #389 on [DATE] revealed no noted order in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-25 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a Preadmission Screening (PAS) / Annual Resident Review (ARR) Level I Screening Form DCH-3877 was completed annually for 1 (Resident #37) of 2 residents reviewed for preadmission screening / annual resident review screening, resulting in the potential for unmet mental health care needs. Findings include: Review of an admission Record revealed Resident #37 was a male, with pertinent diagnoses which included: anxiety disorder, unspecified; dementia in other diseases classified elsewhere, unspecified severity, with psychotic disturbance; and delusional disorders. Review of a Minimum Data Set (MDS) assessment for Resident #37, with a reference date of 3/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #37 was cognitively intact. Review of an OBRA (Omnibus Budget Reconciliation Act) PASARR Correspondence letter for Resident #37 dated 3/7/23 revealed, .The recipient may be admitted to or remain in the nursing facility and receive mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-25 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 professional standards of nursing were followed for treatment of a skin tear for 1 (Resident #43) of 1 resident reviewed for professional standards of nursing practice. Findings include: Review of an admission Record revealed Resident #43 was a female with pertinent diagnoses which included Alzheimer's disease, dementia with behavioral disturbance, and pressure inducted deep tissue damage of right heel. Review of Care Plan for Resident #43 revised on 6/8/25 revealed the focus, .The resident has potential impairment to skin integrity due to limited mobility and incontinence. She can be resistant and refuse care and toileting at times with combativeness - hitting, kicking - that could cause skin injury and delay in care . with the intervention .Derma Sleeves- to bilateral arms when up . Review of Treatment Administration Record (TAR) for June 2025 revealed, documentation of Resident #43 with bilateral derma sleeves noted as on for day, evening, and night shifts. Review of Order for Resident #43 revealed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-25 · 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 Based on observation, interview, and record review, the facility failed to provide the necessary care and services to prevent, treat, and promote healing of pressure ulcers in 1 of 2 residents (Resident #126) reviewed for pressure ulcers, resulting in the lack of repositioning and implementation of care planned interventions, delayed healing of pressure ulcers for the resident, and the potential for infection and the development of new ulcers.Findings include: Review of an admission Record revealed Resident #126 was a female with pertinent diagnoses which included pressure ulcer of right buttock, stage 3, dementia, diabetes and adult failure to thrive. Review of Care Plan for Resident #126 revised on 06/09/2025, revealed the focus, .The resident has open area to right buttocks. Healing complicated by poor intake, incontinence and diabetes . with the interventions .Administer treatments as ordered and monitor for effectiveness .Assess/record/monitor wound healing Measure length, width and depth where possible.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-25 · 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 Based on observation, interview, and record review, the facility failed to provide adequate supervision and ensure appropriate transfer techniques were implemented for 2 (Resident #96 and Resident #102) of 9 residents reviewed for accidents resulting in an increased risk for falls and injuries. Findings include: Resident #96Review of an admission Record revealed Resident #96 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia (general term for loss of memory, language, problem-solving and thinking abilities that are severe enough to interfere with daily life). Review of a Minimum Data Set (MDS) assessment for Resident #96 with a reference date of 4/21/25, revealed a Brief Interview for Mental Status (BIMS) score of 0/15 which indicated Resident #96 was severely cognitively impaired. Section GG revealed Resident #96 needed supervision or light touching to transfer from sitting to standing. Review of a Care Plan for Resident #96 with a reference date of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-25 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 received food items within their preferences for 1 (Resident #27) of 2 residents reviewed for food, resulting in dissatisfaction and the potential for nutritional decline and gastrointestinal upset. Findings include: Review of Choice on the menu in residential aged care: An underrated tool for maintaining resident autonomy [NAME] PhD, APD, [NAME] L. [NAME] PhD, APD, [NAME] M. [NAME] PhD, Adv APD First published: 25 February 2025, revealed Food and mealtimes are areas where residents want to express their autonomy. In the community, individuals make decisions about food based on preferences, which have been shaped by a lifetime of experiences. Being able to choose foods that align with these preferences is a sign of normality and a continuation of self-identity. Resident #27 Review of an admission Record revealed Resident #27 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to properly sanitized resident shared equipment, specifically a glucometer between uses during medication administration for 1 (Resident #129) of 5 residents observed for medication administration, resulting in the potential for the spread of infection, cross-contamination, and disease transmission. Findings include: Resident #129 Review of an admission Record revealed Resident #129 was a female who admitted to the facility on [DATE] and had pertinent diagnoses which included: Type 1 diabetes (a chronic condition where the pancreas produces little to no insulin for the body). Review of Order Summary for Resident #129 revealed .blood glucose scans QAC (before every meal) and HS (bedtime). Notify physician if blood glucose is less than 60 or over 400 unless individual parameters dictate otherwise four times a day for Type 1 Diabetes with a start date of 3/14/2025. On 6/24/25 at 11:45 am, Licensed Practical Nurse (LPN) C was observed completing…
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 18 citations
- Potential for harm · Fcited before2024-06-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: 1. During the initial tour of the main kitchen, at 11:09 AM on 6/4/24, observation of the Blueair Refrigeration unit found the digital thermometer on the outside stated it was 34F. Upon opening the door it was noticed that the ambient temperature of the unit felt warm and there was no ambient air thermometer in the unit. A temperature of an open half gallon of fat free milk was taken with a digital rapid read thermometer and found to be 55F. When asked how long it had been since the last temperature of the unit was taken, Kitchen Supervisor BB stated that a temperature of 39F was logged at 8:00 AM this morning, when asked if they would have used the outside digital thermometer to record that that temp, KS BB stated yes. When asked what was going to happen to the drinks…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-06-06 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1.) ensure resident shared equipment was properly cleaned and sanitized between each use, 2.) ensure personal protective equipment (PPE) was worn by staff and visitors in care units where required and by staff when caring for 1 (Resident #119) of 29 sampled residents, 3.) ensure clean laundry bins used for transport were free from dirt and debris; and 4.) ensure 1 (Resident #91) of 2 residents sampled for dialysis had a dressing applied to their dialysis access site (an indwelling device). These deficient practices resulted in the increased potential for the spread of infection, bacterial harborage, cross contamination, and disease transmission for residents residing in the facility. Findings include: Resident Shared Equipment During an observation on 6/5/24 at 1:21 PM, noted Licensed Practical Nurse (LPN) LL in the activity room near the front entrance of the facility taking vitals on a resident. After LPN LL had finished taking vitals…
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 · D2024-06-06 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a written notice of transfer for 1 of 2 residents (Resident #98) reviewed for hospitalization, resulting in the potential of residents and/or resident representatives being uninformed of the reason for transfer and their rights, and failed to provide timely notification to a representative of the Office of the State Long-Term Care Ombudsman for emergency transfer of residents being discharged , residents left without an advocate to inform them of their rights, and for the Office of the State Long-T erm Care Ombudsman to be unaware of the facilities practices related to transfers and discharges. | Findings include: Resident #98: Review of an admission Record revealed Resident #98 was a male with pertinent diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms (BPH has frequent urination, weak stream, leaking or dribbling of urine), obstructive and reflux uropathy (urine flow is blocked causing urine to back up…
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 · D2024-06-06 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification of the bed hold policy upon transfer to the hospital for 1 of 2 residents (Resident #98) reviewed for transfer and discharge requirements, resulting in the potential for residents and/or their representatives to be unaware of their rights in regard to facility bed holds. Findings include: Resident #98: Review of an admission Record revealed Resident #98 was a male with pertinent diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms (BPH has frequent urination, weak stream, leaking or dribbling of urine), obstructive and reflux uropathy (urine flow is blocked causing urine to back up into the kidneys) and bladder neck obstruction, and cystostomy status (suprapubic catheter). Review of current Care Plan for Resident #98, revised on 10/25/22, revealed the focus, .The resident has a suprapubic catheter: due to BPH, urinary retention related to CVA (stroke), and obstructive and reflux uropathy.…
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 before2024-06-06 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 professional standards of practice for physician orders were obtained/followed for two residents (R91 and R291) of two residents reviewed for professional standards of care, resulting in the lack of documentation, and the potential for the worsening of a condition and a delay in treatment. Findings include: R91 According to the Minimum Data Set (MDS) dated [DATE], R91 scored 14/15 (cognitively intact) on his BIMS (Brief Interview Mental Status), required a fistula/port for dialysis for a medical diagnosis of chronic kidney disease stage V. Review of R91's Summary Order, dated 2/23/23, revealed, Change dressing to hemodialysis site daily. Review of R91's Medication Administration Record/Treatment Administration Record (MAR/TAR) dated February 2023 did not contain the order for Change dressing to hemodialysis site daily on it. Subsequently, the order was not added to the resident's MARs/TARs from February 23, 2023, through June 5,…
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 · D2024-06-06 · 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 follow orders for monitoring of blood sugars for 1 resident, (R292), and to follow orders for dressing changes for 1 resident, (R119) resulting in the lack of monitoring and the resident not receiving appropriate interventions with the potential of worsening health status. Findings include: Resident #292: The quality of patient care depends on your ability to communicate with other members of the healthcare team. Regardless of whether documentation is entered electronically or on paper, each member of the health care team needs to document patient information in an accurate, timely, concise, and effective manner to develop and maintain an effective, organized, and comprehensive plan of care. When a plan is not communicated to all members of the health care team. Care becomes fragmented tasks are repeated and delays or omissions in care often occur. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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, interviews, and record review, the facility failed to ensure services to maintain and prevent further decrease in ROM (range of motion) for 1 of 2 residents (Resident #7) reviewed for limited ROM, resulting in the potential for decreased ROM, contractures (hardening of the muscles, tendons, and other tissues) and pain. Findings include: Resident #7 Review of an admission Record revealed Resident #7 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cerebral palsy (a disorder of movement, muscle tone, or posture). Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 4/18/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #7 was cognitively intact. Review of Resident #7's Care Plan revealed, .Restorative: Active Range of Motion Date Initiated: 08/29/2022. Goal: Maintain ROM to Extremities. Revision on: 11/07/2023. Interventions: Notify…
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 · D2024-06-06 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed ensure physician orders were in place for dialysis treatment (the process of removing excess fluid and toxins in people with insufficient kidney function) and monitoring, and post dialysis assessments were documented for 2 residents (Resident #65 and #91) of 2 residents reviewed for dialysis care, resulting in the potential for the resident to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #65 Review of an admission Record revealed Resident #65 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: stage 4 chronic kidney disease. Review of a Minimum Data Set (MDS) assessment for Resident #65, with a reference date of 5/15/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #65 was cognitively intact. In an interview and observation on 06/04/24 at 04:40 PM, Resident #65 reported…
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 before2024-04-18 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake: MI00136097, MI00136440, MI00137896, MI00139274 Based on observation, interview, and record review, the facility failed to provide an environment that promoted a dignified experience and respond to resident call lights timely for 2 residents (Resident #100, Resident #103) of 8 residents, resulting in the feelings of humiliation, embarrassment, concern about receiving a timely response in the event of a medical emergency and a negative psychosocial outcome for the residents impacting their quality of life. Findings include: Resident #100: Review of an admission Record revealed Resident #100 was a male with pertinent diagnoses which included muscle wasting and atrophy, pain in left shoulder, dementia, acquired absence of right leg above knee, diabetes, depression, heart failure, kidney disease, and abdominal pain. Review of current Care Plan for Resident #100, revised on 1/29/24, revealed the focus, .I am at risk for falls r/t (related to) neuropathy, recent above the knee amputation .I do attempt to get up independently at times . 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 · Dcited before2024-04-18 · 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 interview and record review, the facility failed to ensure resident safety during a Hoyer (mechanical life) transfer in 1 of 8 residents (Resident #103), resulting in a fall with minor injury. Findings include: Review of an admission Record revealed Resident #103 was a female with pertinent diagnoses which included cerebral palsy, pain, anxiety, embolism (blood clot), abnormal posture, anemia (blood doesn't have enough red blood cells), and osteoporosis (disease that weakness bones, making them thinner). Review of current Care Plan for Resident #103, revised on 10/27/22, revealed the focus, .Transfer 2A (2 assist) . Note: Care Plan does not indicate Resident #103 required a Hoyer for transfers. Review of Minimum Data Set (MDS) Section GG - Functional Abilities and Goals dated 1/17/24, revealed, .E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) .1. Dependent: Helper does ALL the effort. Resident does none of the effort to complete the activity . In an interview on 4/18/24 at 10:03 AM, Resident #102 who was Resident #103'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 · Fcited before2023-04-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake number MI00133713 Based on observation, interview, and record review the facility failed to: 1. Ensure proper working order of the dish machine; 2. Datemark and discard potentially hazardous foods; 3. Store raw animal product in a manner that decreases contamination of ready to eat foods; and 4. Properly store clean and sanitary items and equipment. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 142 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the main kitchen, at 12:20 PM on 4/24/23, it was observed that the pressure indicator for the rinse cycle was reading between 50 and 55 pressure per square inch (psi). Observation over the course of three cycles, found the rinse pressure stayed in the 50-55 psi range when engaged. When asked if the machine had been working properly, Dining Services Manager (DSM) III stated that a vendor had been out to perform…
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 · F2023-04-26 · tag F0888 — widespreadEnsure staff are vaccinated for COVID-19
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 staff received all required doses of COVID-19 vaccine and maintain complete and accurate records of the COVID-19 vaccination status for all required facility staff. Findings include: A COVID-19 STAFF VACCINATION MATRIX was requested from Nursing Home Administrator (NHA) A during the entrance conference interview on 4/24/23. Review of the COVID-19 STAFF VACCINATION MATRIX submitted to State Agency (SA) by Nursing Home Administrator (NHA) A revealed a total of six (6) staff members (Certified Nurse Aide (CENA)s Q, II and GGG; Diet Aide (DA)s LL and MM and Housekeeping Assistant (HA) DD) were documented as having been partially vaccinated. In an interview on 4/26/23 at 10:07 AM, NHA A reported the 6 facility staff members were not fully vaccinated against COVID-19, nor did they have an approved exemption from receiving the COVID-19 vaccination. In an interview on 4/26/23 at 10:13 AM, Director of Nursing (DON) B reported it was a requirement that all staff were fully vaccinated for COVID-19 or have an approved 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 · D2023-04-26 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure all residents maintained their right to self determination for 1 of 29 residents (Resident #37), reviewed for choices, resulting in frustration with not being able to go to sleep at a preferred bedtime, due to waiting for medication administration and catheter (tube inserted into bladder to drain urine from the body) care to be completed. Findings Include: Resident #37 Review of a Minimum Data Set (MDS) assessment for Resident #37, with a reference date of 2/13/23 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #37 was cognitively intact. Review of Preferences for Customary Routine and Activities with a reference date of 8/14/22 revealed that Resident #37 indicated that being able to choose a bedtime, was very important. In an interview on 04/24/23 at 01:49 PM, Resident #37 reported that she preferred to go to bed early, at about 7:30 PM, but would frequently have trouble getting to sleep and/or staying asleep due to waiting for staff to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake numbers MI00133713 and MI00134025 Based on observation, interview, and record review, the facility failed to provide appropriate Activities of Daily Living (ADL) care for 2 of 29 residents (Resident #30 and #47 ) reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's who are dependent on staff for assistance. Findings Include: Review of an admission Record revealed Resident #30 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: urinary incontinence and constipation. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 1/30/23 revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated Resident #30 was cognitively impaired. Review of the Functional Status revealed that Resident #30 required extensive assistance of 1 staff member for toileting and personal hygiene. Review of Bowel…
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 before2023-04-26 · 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 Based on observation, interview and record review, the facility failed to prevent the development of pressure ulcer for 1 (Resident #52) of 2 sampled residents reviewed for pressure ulcers, resulting in the development of a facility acquired pressure ulcer. Findings include: Review of an admission Record revealed Resident #52 was a male with pertinent diagnoses which included Parkinson's disease, dementia, muscle wasting and atrophy, lack of coordination, stroke, pacemaker, and muscle weakness. Review of current Care Plan for Resident #52, revised on 01/23/2023, revealed the focus, .The resident has an nonhealing, non-blanchable, dark area on his left heel .Moon boots and bridging heels added to care plan .Area did not show signs of healing . with the interventions .Avoid positioning the resident on heel .Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent…
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 before2023-04-26 · 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 numbers MI00135243 and MI00134025. Based on observation, interview, and record review, the facility failed to ensure a safe environment and implement safety interventions for 3 (R191, R134, and R91) of 29 residents reviewed for accidents and hazards, resulting in feelings of being scared (R191), a fall with injury (R134), unsafe transfer (R91), and the increased potential for further feelings of being scared, and falls with injuries. Findings include: R191 According to the Minimum Data Set (MDS) dated [DATE], R191 scored 15/15 (cognitively intact) on her BIMS (Brief Interview Mental Status) required transfers to have limited assistance (Limited Assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one-person physical assistance. The resident's balance during transition from moving seated to standing position was not steady. Review of R191's Concern Form dated 2/28/2023 reported the resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-26 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 interview and record review, the facility failed to maintain a complete and accurate medical record related to Advance Directives / Code Status for 2 of 29 sampled residents (Resident #62 and #80) reviewed for Advance Directives / Code Status, resulting in an incomplete/inconsistent reflection of the resident records and the potential for care wishes not being honored as desired. Findings include: Resident #62 Review of a Face Sheet revealed Resident #62 was a female. Review of Resident #62's Designation of Code Category and Resuscitation Orders signed by Resident #62's responsible party on [DATE] revealed the choice, CATEGORY C: NO CODE OR DO NOT RESUSCITATE DIRECTIVE WITH PREVENTATIVE MEDICATIONS Measures will be taken by using medicines, to maintain breathing and heart function, as medically appropriate. However, if heart or breathing failure does occur, a Code will NOT be called. As always medication will be used to prevent pain or manage discomfort. Y .Intravenous hydration will be used Y .Feeding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-06-06 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to post required nurse staffing information on a daily basis, for all 135 residents in the facility, resulting in a lack of available staffing information for residents and visitors. Findings include: During multiple observations on 06/04/24 from 10:30 AM-5:30 PM throughout the facility halls and common areas, there were no postings found indicating the daily nurse staffing hours. During an observation on 06/05/24 at 08:10 AM there were no postings found indicating the daily nurse staffing hours. In an interview on 06/05/24 at 8:15 AM, Director of Nursing (DON) B reported that she did not know anything about the nurse staffing hours posting. In an interview on 06/05/24 at 8:20 AM, Nursing Home Administrator (NHA) A reported that he did not know anything about the nurse staffing hours posting. In a subsequent interview on 06/05/24 at approximately 10:00 AM, DON B reported that the daily nurse staffing hours posting was the responsibility of the scheduler, but that she had not been working in the facility for…
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
No federal fines in the current CMS record. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2025-08-29 for 5 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| OLD NATIONAL BANK | Organization | 5% OR GREATER MORTGAGE INTEREST | since 07/13/2022 |
| BAUMANN, NATHAN | Individual | CORPORATE DIRECTOR | since 06/01/2019 |
| CARLSON, ROBERT | Individual | CORPORATE DIRECTOR | since 06/16/2020 |
| HOFMEYER, TERRY | Individual | CORPORATE DIRECTOR | since 05/20/2024 |
| KLEINHEKSEL, BARBARA | Individual | CORPORATE DIRECTOR | since 06/05/2020 |
| LUTZ, DAVID | Individual | CORPORATE DIRECTOR | since 06/28/2021 |
| MARTIN, SAMUEL | Individual | CORPORATE DIRECTOR | since 04/27/2015 |
| MULDER, PHILIP | Individual | CORPORATE DIRECTOR | since 06/24/2019 |
| RIEKSE, TOM | Individual | CORPORATE DIRECTOR | since 05/20/2024 |
| STERKEN, ANN | Individual | CORPORATE DIRECTOR | since 06/24/2019 |
| VANDERKLOK, KEVIN | Individual | CORPORATE DIRECTOR | since 06/28/2021 |
| VANPUTTEN, PAM | Individual | CORPORATE DIRECTOR | since 06/01/2022 |
| SCHUCKERT, DEEDRE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/30/2018 |
| BRYHN, NINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/29/2025 |
| BUCHER, JASON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/10/2023 |
CMS files one row per role, so the 19 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 10% 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 235378. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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.