Holt Senior Care and Rehab Center
5091 Willoughby Road, Holt, MI 48842 · For profit - Limited Liability company · 101 certified beds · (517) 694-2144 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (22% vs 45% nationally) — better care continuity
- it has 1 actual-harm citation
- a high number of inspection citations overall (16) — 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.1% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.8% | 5.4% | 5.4% | better |
| 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 | 0.3% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.3% | 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 | 1.3% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.8% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.5% | 19.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.5% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 10.2% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.2% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 90.6% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 16.1% | 24.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.0% | 11.7% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.55 | 1.84 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.51 | 1.64 | 1.80 | better |
§ 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.
58.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 136 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.2% 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 55 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 0.29 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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 | 58.5%CMS range 51.4–66.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 8.1–15.5 | 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 | 58.2% | 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 | 40.0% | 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 | 32.7% | 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 | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 7.8%CMS range 4.5–14.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.83 | 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 101 beds and averages 95.4 residents a day — about 94% occupied, or roughly 6 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 3.90 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 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 3.53 hrs/resident/day on weekends vs 4.05 on weekdays — 13% thinner on weekends. RN hours go from 0.87 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 22% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
16 citations, most serious first. The 11 most serious are shown; the remaining 5 are one tap away and print in full.
- Actual harm · G2026-04-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement care planned interventions to prevent falls in 1 of 3 sampled residents (Resident #69) assessed for falls, resulting in repeated falls during staff assisted transfers and the potential for continued falls and/or serious injury. Findings include:Review of the Face Sheet and Minimum Data Set (MDS) with Assessment Reference Date of 1/22/26, reflected R69 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included cerebral infarction with hemiparesis affecting left non-dominant side(left side paralyzed , vascular dementia, left above the knee amputation, atrial fibrillation(heart arrythmia with use of blood thinners), cognitive communication deficit, and major depressive disorder The MDS reflected R69 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for bed mobility, and all transfers.During an observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-09 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, 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 accurate coding of a Minimum Data Set (MDS) assessment for one (R80) of 19 reviewed.Findings include: Review of the medical record reflected R80 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included end stage renal disease and dependence on renal dialysis. The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/3/25, reflected R80 received dialysis. The Quarterly MDS, with an ARD of 1/27/26, reflected R80 was not coded as receiving dialysis. On 04/09/2026 at 11:40 AM, R80 was observed lying in bed. A Physician's Order, with a revision date of 4/16/25, reflected R80's scheduled dialysis days were Monday, Wednesday, Friday and as needed. In an interview on 04/08/2026 at 3:36 PM, MDS Nurse H acknowledged R80's Quarterly MDS, with an ARD of 1/27/26, should have been coded for receiving dialysis.
- Potential for harm · D2026-04-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure comprehensive care plans were accurate and implemented for two out of 19 residents (Resident #8 & 69).Resident #8 (R8): Review of R8's electronic medical record (EMR) revealed R8 was admitted to the facility on [DATE] with a code status of full code by default. Review of a Code Status Form dated [DATE], revealed R8 was a full code by default and was signed by the Physician and two witnesses. Review of a Code Status Form dated [DATE], revealed R8 was a full code by default and was signed by the Physician and two witnesses. Review of a Code Status Form dated [DATE], revealed R8 was a full code by default and was signed by two witnesses, but no Physician. Review of a Code Status Form dated [DATE], revealed R8 was a DNR (do not resuscitate) and was signed by the Physician and two witnesses. Record review of R8's care plan revealed a care plan in place with a Focus of Advanced Directives:, Advance Directives have been discussed & the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-09 · 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 observation, interview and record review, the facility failed to maintain complete and accurate medical records for one (R2) of 19 reviewed. Findings include:Review of the Face Sheet and Minimum Data Set (MDS) with an Assessment Reference Date 3/12/26, reflected R2 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included cirrhosis of the liver, kidney failure, heart failure, diabetic, anxiety and depression. The MDS reflected R2 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required staff assist with dressing, hygiene, bathing, transfers, and toileting.During an observation on 4/07/2026 at 11:47 AM, R2 was in bed with guest at bedside. R2 reported currently had Hospice services since December and often Hospice services want pain medication given according to there direction and facility staff do not agree and stated, seems like they do not speak to each other.Review of R2 Progress Note,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-09 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 an antibiotic was administered as ordered for one (R4) of five reviewed. Findings include: Review of the medical record revealed R4 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, diabetes, and peripheral vascular disease. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/19/26 revealed R4 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 04/07/26 at 11:30 AM, R4 was observed sitting in her wheelchair in her room. R4 reported she was currently receiving an antibiotic for cellulitis in her right leg. R4's right leg was observed wrapped with a bandage. Review of the Physician's Order dated 3/4/26 and ordered to start on 3/4/36 at 2:00 PM, revealed an order for cephalexin (antibiotic) 500 milligrams (mg) three times a day for 7 days for cellulitis of the right lower extremity. Review of the Medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-09 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 safely transport portable oxygen tank, resulting in the increased likelihood of severe injury, potentially affecting all 92 residents in the facility, staff and visitors.Findings include:During an observation on 4/07/2026 at 12:07 PM, during the initial tour of the facility and screening process, Licensed Practical Nurse (LPN) F was observed carrying a portable oxygen tank down entire Hall C, past Hall C Nurse station and halfway down beginning of Hall C to the oxygen storage closet without oxygen transport cart. LPN F exited the oxygen storage room with portable oxygen tank in a transport cart and wheeled cart down both C Halls and entered room C23. Several Residents and staff were present in both C Halls at the time. During an interview on 4/08/2026 at 5:02 PM, Licensed Practical Nurse (LPN) F reported working at the facility for over two years and had been a nurse for over 30 years. LPN F was queried about how to safely transport portable oxygen tanks. LPN F reported was called to management office on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-15 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure appropriate personal protective equipment (PPE) was utilized for contact precaution and ensure hand hygiene was performed for four (Resident #22, 26, 52, and 57) of reviewed for contact precautions. Findings include: On 1/13/25 at 10:34 AM, a contact precaution sign was observed outside of the room of Resident #22 (R22) and Resident #57 (R57). The contact precaution sign indicated that hand washing prior to entry of the room, as well as donning a gown and gloves (PPE) was necessary prior to entering the room. On 1/13/25 at 10:37 AM, a contact precaution sign was observed outside of the room of Resident #26 (R26) and Resident #52 (R52). The contact precaution sign indicated that hand washing prior to entry of the room, as well as donning a gown and gloves was necessary prior to entering the room. In an interview on 1/13/25 at 10:38, Licensed Practical Nurse (LPN) P stated that both rooms were contact precautions due to a gastroenteritis virus that was affecting the residents. LPN P confirmed that hand…
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 · D2025-01-15 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA) timely for one (Resident #91) of 20 reviewed for Minimum Data Set (MDS). Findings include: Review of the clinical record reflected Resident # 91 (R91) was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and chronic kidney disease. R91's Minimum Data Set (MDS) dated [DATE] reflected a BIMS of 4. Review of R91's monthly physician orders revealed a physician order for hospice dated 12/16/24. Hospice notes dated 12/16/24 revealed R91 was admitted on to hospice care as of 12/16/24. Further review of R91's clinical record revealed the SCSA MDS was initiated on 01/13/25 (incomplete as of 1/14/25). On 01/14/25 at 02:01 PM, during an interview with MDS Nurse D she acknowledge the SCSA MDS should have started in December when R91 was signed onto hospice care. MDS Nurse D offered no explanation why the Significant Change MDS was late.
- Potential for harm · D2025-01-15 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 transmit Minimum Data Set (MDS) assessments to Centers for Medicare & Medicaid Services (CMS) timely for two (Resident #49 and #89) of 20 reviewed. Findings include: Resident #49 (R49): Review of the medical record reflected R49 admitted to the facility on [DATE], with diagnoses that included diabetes and dependence on renal dialysis. R49's MDS history reflected a discharge return not anticipated MDS, with an Assessment Reference Date (ARD) of 8/31/24, which was completed on 9/11/24. The MDS had not been transmitted to CMS. Resident #89 (R89): Review of the medical record reflected R89 admitted to the facility on [DATE], with diagnoses that included aftercare following surgery for neoplasm (abnormal growth of tissue). R89's MDS history reflected a discharge return not anticipated MDS, with an ARD of 8/30/24, which was completed on 9/11/24. The MDS had not been transmitted to CMS. In an interview on 01/14/25 at 2:00 PM, MDS Nurse D reported the facility…
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 before2025-01-15 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, 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 coding on a Minimum Data Set (MDS) assessment for one (Resident #96) of 20 reviewed. Findings include: Review of the medical record reflected Resident #96 (R96) admitted to the facility on [DATE], with diagnoses that included wedge compression fracture of the second thoracic vertebra. The discharge return not anticipated MDS, with an Assessment Reference Date (ARD) of 12/9/24, reflected R96 was coded for discharge to a short-term hospital. A Progress Note for 12/9/24 reflected R96 discharged home. In an interview on 01/15/25 at 12:03 PM, MDS Nurse D reported R96 discharged home, not to the hospital. MDS Nurse D acknowledged there was a coding error on the MDS.
- Potential for harm · D2025-01-15 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to confirm that the Pre-admission Screening And Resident Review (PASARR Level I determination request was sent to the Community Mental Health Service Program (CMHSP) for a level II Omnibus Budget Reconciliation Act (OBRA) evaluation prior to their admission to the facility for 1 residents (#83) of 2 reviewed. Review of the clinical record reflected Resident # 83 (R83) was admitted to the facility on [DATE] with diagnoses that include morbid obesity and bi-polar disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Status Score of 15 out of 15 (cognitively intact). The mood section of the same MDS reflected R83 felt down, depressed or hopeless several days a week. Review of R83's clinical record reflected a 3877 dated 2/26/24 revealed R83 had a mental illness diagnosis and received psychotpic medication that included an anti-psychotic medication. Review of the 3878 dated 2/28/24 and signed by the physician reflected R83 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.
Show the remaining 5 citations
- Potential for harm · D2024-08-22 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
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 MI00146126: Based on observation, interview and record review the facility failed to meet the needs of residents with regard to the timeliness of providing laboratory services and reporting laboratory results for one residents(R104) of three residents reviewed for medications, resulting in delayed treatment and intervention related to lab results, and impaired coordination of care. Findings include: Resident #104(R104) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included history of deep vein thrombosis/pulmonary embolysis(blood clot), hypertension (high blood pressure), pelvic fracture, dementia, chronic kidney disease, anxiety and depression, The MDS reflected R104 had a BIM (assessment tool) score of 7 which indicated her ability to make daily decisions was severely impaired, and she required maximal physical assist with toileting, bathing, dressing, 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 · D2023-12-20 · 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 accommodate two out of four residents (Resident #81 and 86) with briefs that fit them, resulting in red marks and painful skin irritation. Findings Included: Resident #81 (R81): Review of R81's electronic medical record revealed R81 was recently admitted to the facility on [DATE]. R81 had a diagnosis of, MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIES. Review of a BRIEF INTERVIEW OF MENTAL STATUS assessment dated [DATE], revealed R81 scored a 15 out of 15, which indicated R81 had no impairment in her cognition. In an interview on 12/18/2023 at 9:45 AM, R81 stated that her briefs were too small. R81 said she had asked staff (could not recall names of staff) several times for the larger size brief, but said staff told her corporate had to approve her to have a larger size brief. During the interview an observation of R81's dresser drawer revealed the drawer was full of yellow briefs. The briefs did not have the size marked on them. R81 stated…
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 · D2023-12-20 · 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 pressure ulcers in 1 of 2 residents reviewed for pressure ulcers (Resident #251), resulting in pain, wound treatments, and the potential for additional skin breakdown and infection. Findings include: Resident #251 (R251) During an observation and interview on 12/18/23 at 10:21 AM with R251's family member, R251 was admitted to the facility for rehabilitation after she fell and fractured her left leg at home. R251's family member stated R251 had developed a blister on her left heel while a resident at the facility. R251 was observed lying in bed on her back with her heels directly resting on her mattress. In review of R251's admission assessment dated [DATE], R251 did not have any wounds or reddened areas. R251's Skin assessment dated [DATE] revealed no new wounds. In review of R251's Skin Management Care plan dated 12/08/23, she was at risk for skin breakdown due to weakness, impaired mobility, pain, high blood pressure, lung…
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 · D2023-12-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide supplements and fortified foods to prevent weight loss in one of one residents reviewed for weight loss (Resident #91), resulting in a severe weight loss of 7.8 pounds. Resident #91(R91) admission History and Physical dated 11/09/23 and Dietary Profile dated 11/10/23 revealed R91 had a history of heart disease, kidney disease, arthritis, bone loss, moderate protein-calorie malnutrition and history of gastric bypass 28 years prior. R91 had been admitted to the facility following a hospitalization for pneumonia and respiratory failure. R91 was alert and oriented to person and place only. R91 received supplements twice a day during her hospitalization and took a protein supplement when at home. R91 did not have any swelling of her extremities. R91's current weight was 125 pounds (lbs.) and her ideal body weight was 135 lbs. The same Dietary Profile indicated when R91 was made aware of her current weight of 125 lbs., she responded by asking for pie. Physician's order with start date of 11/09/23 indicated…
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 · D2023-12-20 · 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 follow pharmacy policy and acceptable practice for maintaining controlled medication for two out of five medication carts resulting in the potential for controlled medication diversion. Findings Included: During observation of the Cedar One medication cart on 12/20/2023 at 09:12 a.m. it was observed that the facility Controlled Accountability Record for this medication cart was last signed by only the out going nurse at 06:30 a.m. on the date of 12/20/2023. The signature box for the on coming nurse was blank. In an interview on 12/20/2023 at 09:37 a.m. Licensed Practical Nurse (LPN) M explained that she was the on coming nurse that took control of the Cedar One Medication cart on 12/20/2023 at 06:30 a.m. LPN M explained that it was policy that controlled medication was to be counted between the on coming nurse and the outgoing nurse when there was a change in the nurse that controlled the medication cart. She explained that once the controlled medication count was completed, the numbers are recorded, and both…
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.
Part of a chain
This home belongs to NEXCARE HEALTH SYSTEMS — 20 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 | 5 of 5 | 3.8 | +1.2 vs chain |
| Health inspection | 4 of 5 | 3.4 | +0.6 vs chain |
| Staffing | 4 of 5 | 3.8 | +0.2 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 19 homes this chain runs (chain average 3.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NEXCARE HOLDINGS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/01/2013 |
| PATRICK, MARIE | Individual | W-2 MANAGING EMPLOYEE | — | since 01/01/2009 |
| SANGSTER, TODD | Individual | CORPORATE OFFICER | — | since 11/04/2013 |
| NEXCARE HEALTH SYSTEMS, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2009 |
| PERRY, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/2015 |
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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 235279. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-09, 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.