Westgate Nursing & Rehabilitation Community

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

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.

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.

39.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 56 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% 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.

Staffing

How full it usually is: this home is certified for 65 beds and averages 55.8 residents a day — about 86% occupied, or roughly 9 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 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.57 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 3.24 hrs/resident/day on weekends vs 3.94 on weekdays — 18% thinner on weekends. RN hours go from 0.82 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

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.

21 citations, most serious first. The 13 most serious are shown; the remaining 8 are one tap away and print in full.

• Actual harm · Gcited before2024-09-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement measures to prevent additional pressure wound and/or prevent the development and worsening of pressure injuries for two Residents (R108 & R7) of five reviewed, resulting in harm for R108 with the development of a stage III pressure wound which worsened, required hospitalization, antibiotics, and wound debridement. Findings Include: (All times are recorded in Eastern Daylight Time.) This citation is related to intake #MI00145848. Resident 108 (R108) Reivew of the complaint intake information from the State Agency, dated 7/23/24, read in part, .They stated he (R108) was doing fine .While driving up to see him on 4/19/24, [Licensed Practical Nurse] (LPN) D] called and said that dad wasn't doing well .She also told us that he has (sic) a pressure wound and she thought it was a Kennedy ulcer, which meant death was imminent within a few days to weeks. When we got there, (LPN D) met us at the door and said that 'we could move him 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-09-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficiency pertains to Complaint Intake #MI00138936 & #MI00137644. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing and prevent the development of pressure ulcers for four Residents (R1, R6, R30 and R51) of four residents reviewed for pressure ulcer care, out of a total sample of 15 residents. This deficient practice resulted in harm with the development of a facility acquired stage 3 pressure ulcer, the potential for delayed wound healing, infection, and deterioration of condition. Findings include: All times documented are Eastern Daylight Savings Time (EDST) unless otherwise noted. Resident #6 (R6) Review of R6's hospital admission documentation, dated 2/1/23, read in part, .visiting diagnoses list pressure injury of left buttocks stage 3 and pressure injury of right buttocks stage 3 - primary diagnosis bilateral pneumonia, sepsis abdominal pain . * Pictures from hospital show a stage three pressure injury to right…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-09-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00139217. All observations and interviews are recorded in Eastern Standard Time (EST). Based on observation, interview and record review, the facility failed to safely transfer one Resident (R56) of three residents reviewed for accidents. This deficient practice resulted in actual harm when R56 fell to the floor and sustained a right hip fracture with subsequent hospitalization, and surgical intervention. Findings include: A review of R56's Narrative and Impression Report, dated 8/29/2023, revealed the following result: 1. Mildly displaced right hip intertrochanteric fracture A review of R56's Emergency Department (ED) Note, dated 8/29/2023 at 12:19 p.m , revealed the following: .Patient has a great deal of chronic debility, lives in a local skilled nursing facility. She had some type of fall 4 days ago. Was seen in the ER by myself 3 days ago, but at times complaining of pain in her right ribs and right knee. X-rays of the right knee were negative for any sign of fracture. Per…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-12-04 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to prepare food in accordance with professional standards for food service safety resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include:On 12/2/2025 at 2:15 PM, during a kitchen tour with the Certified Dietary Manager (CDM) F it was noted that the drain line from the three-compartment sink extends down into the bowl drain causing an improper air gap. This drain line and the receiving bowl drain were noted soiled with excess food debris. When asked, CDM F stated that all dirty kitchen utensils that do not go through the dish machine are washed, rinsed and sanitized in this three-compartment sink. At 2:17 PM on 12/2/2025 it was noted the drain line on the vegetable wash sink was also indirectly connected to the bowl drain below it. CDM F stated that this sink was used for washing the facilities' vegetables before food preparation. At this time, it was also noted that the drain line for the facility ice machine located beside the vegetable…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-04 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to securely store medications in two of two medication carts reviewed for medication storage. (All times are recorded in Eastern Standard Time unless otherwise indicated.) Findings include: On 12/3/25 at 6:20 AM, an unattended pill cup was left on the South medication cart with one chewable 81 milligrams (mg) tablet of Aspirin. Licensed Practical Nurse (LPN) D was asked about the medication after she returned to the cart after the observation and stated she made a mistake and should have locked it up or taken it with her when she went to get the doorbell alarm.On 12/3/25 at 7:00 AM, an observation was made of the South medication cart for medication storage, and the following was observed:a. Various debris of paper and medication powder in the second drawer.b. One loose oblong capsule identified as gabapentin 300 mg with marking (IP 102) and beige in color.c. One loose round tablet identified as torsemide 10 mg with marking (PA 916) and white in color. d. One loose oblong tablet identified as valsartan and sacubitril 26 mg / 24…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-04 · tag F0808 — failed to follow doctor-ordered diets — pattern
  Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure a correct therapeutic diet was prescribed for two Residents (#26 & #51) of eight residents reviewed for nutritional concerns. This deficient practice resulted in the potential for unmet nutritional needs and associated health complications. Findings include:(All times are recorded in Eastern Standard Time unless otherwise indicated.)Resident #26 (R26)R26 was admitted to the facility 10/2/2025 with diagnoses including failure to thrive, diabetes mellitus (DM), hypertension, and chronic kidney disease. A review of R26's Electronic Medical Record (EMR) revealed the physician had ordered a diet on 10/2/25 of Regular texture, No salt added, No Sugar added, Regular fluids.On 12/03/2025 at 9:20 AM, the breakfast tray for R26 was observed and included a tray with a salt packet despite the card which included the restriction of No Added Salt. Resident #51 (R51)R51 was admitted to the facility 11/7/2025 with diagnoses including congestive heart failure (CHF), chronic kidney disease and diabetes mellitus. A…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-04 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  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 monitor and record the amount of tube feeding administered to one Resident (#45) of one resident reviewed for tube feeding management. (All times are recorded in Eastern Standard Time unless otherwise indicated.) Findings include: Resident #45 (R45) Review of R45's face sheet revealed an admission to the facility on 9/23/25 with diagnoses including malignant neoplasm of esophagus (cancer in the throat), protein-calorie malnutrition, dysphasia (difficulty swallowing), and failure to thrive. Review of R45's admission Minimum Data Set (MDS) assessment dated [DATE] revealed R45's brief interview for mental status (BIMS) assessment was indicative of moderate cognitive impairment. On 12/02/2025 at 4:06 PM, an interview was conducted with R45 in their room. R45 stated he has a history of cancer and has a tube feed (G-tube) for enteral (anything involving the gut) feedings and is scheduled for the evening for feedings. Review of R45's physician order, dated…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-04 · tag F0880 — failed to prevent and control infections — isolated
  Provide 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 ensure implementation of enhanced barrier precautions (EBP) during high contact care activities was performed per standards of practice for one Resident (#6) of one resident reviewed for EBP.Findings include: All times recorded in Eastern Standard Time (EST), unless otherwise noted.Resident #6 (R6)Review of the Minimum Data Set (MDS) assessment, dated 10/17/2025, revealed R6 was admitted to the facility on [DATE] and had diagnoses including paraplegia (paralysis affecting lower half of body), heart failure and chronic obstructive pulmonary disease (COPD). Further review of the MDS assessment revealed R6 required substantial/maximal assistance from staff for bed mobility, lower body dressing and putting on/taking off footwear.An observation on 12/2/2025 at 2:50 p.m. revealed a sign attached to the entryway of R6's room indicating the use of Enhanced Barrier Precautions (EBP) during high contact care activities. The sign indicated staff were…

  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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-11 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard 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 This deficiency pertains to Intake MI00152867. Based on interview, and record review, the facility failed to ensure licensed nursing staff maintained complete and accurate progress notes based on acceptable standards of practice for 1 Resident (R1) of 4 residents reviewed for complete medical records. This deficient practice resulted in lack of documentation in the medical record of the provision of wound care without a physician order, timely wound identification and documentation, and failure to provide notification and documentation of such to the physician and responsible party upon initial discovery of the R1's pressure injury wound. All times noted are Eastern Daylight Savings Time (ESDT) unless otherwise noted. Findings include: A review of intake information MI00152867, received 5/7/25 at 11:29 a.m., which alleged, in part: Complainant states that [Assistant Director of Nursing (ADON) A] and [the Director of Nursing (DON)] have directed staff not to open any more skin events because they do not want this…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-11 · tag F0582 — isolated
  Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  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 a complete Notice of Medicare Non-Coverage (NOMNC) and the Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for two of four residents reviewed for Beneficiary Notice, resulting in resident and/or a resident representative not being informed of the right to appeal and the potential for undue emotional and financial hardships: Findings include: A SNF (Skilled Nursing Facility) Beneficiary Notification Review form was provided to the facility for Residents R209, R210, R211, and R28 to be filled out by facility staff and returned for beneficiary notification review. During an interview on 9/10/24 at 1:30 p.m., the Nursing Home Administrator (NHA) stated there was a problem with the form and asked this surveyor to meet with Corporate-Area Director of Utilization B and Minimum Data Set (MDS)/Registered Nurse (RN) C. During an interview on 9/10/24 at 1:33 p.m., Corporate-Area Director of Utilization B and MDS/RN C revealed the facility had not completed the necessary NOMNC/ABN forms for the residents selected 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.

  Resident Rights Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2024-09-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure weights were monitored and nutrition interventions implemented for one Resident #41 (R41) of four residents reviewed for weight loss. This deficient resulted in a significant weight loss for R41. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted). Resident #41 (R41) Review of R41's Minimum Data Set (MDS) assessment, dated 6/5/24 revealed admission to the facility on 3/14/23 with active diagnoses which included: dementia, hypertension, fracture, and anemia. R41 scored a 4 of 15 on the Brief interview for Mental Status (BIMS) reflective of severe cognitive impairment. During an observation of R41 on 9/9/24 at 2:52 p.m., R41's clothes appeared large and hung loosely on the Resident. Review of the MDS assessment dated [DATE] revealed R41 weighed 95 pounds. Review of monthly weights revealed R41 weighed 93.7 pounds on 6/1/24 and R41 weighed 86.4 pounds on 7/1/24. This was calculated to be a 7.79%…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2023-09-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure potentially hazardous foods (milk) were stored at proper temperature while waiting to be served. 2. Failing to demonstrate the proper cooling of potentially hazardous foods which were destined to be served at a later date. 3. Failing to properly wash and clean melons prior to slicing through the rind and cutting into sections. These deficient practices have the potential to result in food borne illness among any and all 57 residents of the facility. Findings include: All times are reported in EDT. 1. On 9/13/23 at approximately 8:27 AM, observations were made during the morning meal service. A tray of cups with poured milk was observed sitting on a counter, waiting to be placed on residents' trays. Using a metal stem probe thermocouple thermometer, the temperature of one cup of milk was measured to be 56°F. Five additional cups of milk were measured and found 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-09-14 · tag F0741 — failed to have staff trained for behavioral health — pattern
  Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
  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 dementia-specific care training for employees before assigning them to work independently with residents. This deficient practice resulted in the potential for inappropriate staff-to-resident interactions and unmet resident care needs, potentially effecting facility residents with dementia. Findings include: All time are recorded in Eastern Standard Time (EST) A request was made on 9/13/23 at 12:02 p.m. to the Nursing Home Administrator (NHA) for staffing information for Certified Nurse Aide (CNA) M, CNA P, CNA Q and CNA R which included their criminal background checks, clinical performance evaluations, dementia, and abuse training. On 9/14/23 at approximately 9:00 a.m., documentation for CNA M, CNA P, CNA Q and CNA R was reviewed and revealed the following: CNA M who's hire date was 6/27/23 had a New Hire Dementia Training Post Test which was not signed or dated. CNA P who's hire date was 6/8/23 had a New Hire Dementia Training Post Test which was not signed or dated. CNA Q who's hire date was 6/22/23 had a New…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

$59,566 in federal fines across 3 penalties.

• $44,680 — penalty dated 2024-09-11
• $7,443 — penalty dated 2023-09-14
• $7,443 — penalty dated 2023-09-14

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to ATRIUM CENTERS — 26 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 →

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

CMS files one row per role, so the 42 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.

13 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 $808K paid to related parties — landlords or management companies under common ownership — equal to about 12% 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