Faith Haven Senior Care Centre

Location & what’s nearby

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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.

41.5% 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 70 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 40.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 20 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 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 81 beds and averages 77.5 residents a day — about 96% occupied, or roughly 4 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 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 3.20 hrs/resident/day on weekends vs 3.57 on weekdays — 10% thinner on weekends. RN hours go from 0.56 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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

37 citations, most serious first. The 14 most serious are shown; the remaining 23 are one tap away and print in full.

• Actual harm · Gcited before2026-05-29 · 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 citation pertains to Intake: 3011032Based on observation, interview, and record review the facility failed to prevent the development of pressure ulcers for one resident (R1) out of two residents with pressure ulcers reviewed, resulting in the development of R1 facility acquired stage 4 pressure ulcer that required hospital transfer for sepsis related to wound infection and surgical debridement.Review of the Face Sheet and Minimum Data Set (MDS) with Assessment Reference Date(ARD) of 5/20/26 reflected R1 was a [AGE] year old female admitted to the facility on [DATE] with recent readmission post hospital transfer 5/14/26 related to stage 4 (full thickness tissue loss with exposed muscle, tendon and or bone) pressure ulcer infection, with additional diagnoses that included hemiplegia and hemiparesis aphasia following cerebral infarction effecting non-dominant side, hypertension, protein-calorie malnutrition, vascular dementia, bipolar disorder, postural kyphosis cervicothoracic region, and anxiety . The MDS…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-08-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2575924Based on interview and record review, the facility failed to protect the resident's right to be free from mental abuse and verbal abuse by a staff member. Findings Include:Review of the medical record reflected that R1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic pain syndrome, carpal tunnel syndrome, jaw pain, muscle spasms, restless legs syndrome, opioid dependence, intervertebral disc disorders (a condition that affects the disc between the vertebrae of the spine), adjustment disorder with mixed anxiety and depression, temporomandibular joint disorder (causing pain and dysfunction of the jaw), migraine, post-traumatic stress disorder, dental caries, anxiety disorder, depression, low back pain, and sciatica. The Minimum Data Set (MDS) reflected that R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), a cognitive screening tool. R1 was no longer at the facility.Facility 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-01-17 · 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 Resident #50 According to the clinical record including the Minimum Data Set (MDS) dated [DATE], Resident # 50 (R50) was a [AGE] year old female admitted to the facility with diagnoses that include cerebral vascular accident with right side hemiparesis and hemiplegia affecting the dominant right side. R50 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). During an interview with R50 on 01/10/24 11:38 AM, it was reported she required assistance from 2 staff persons for transfers with the use of a gait belt. R50 stated a few months ago during a weekend the facility was short staffed and Certified Nursing Assistant (CNA) L transferred her to the toilet without the assistance of another CNA. R50 alleged the gait belt was not in the correct position and during the transfer she had severe pain in her ribs that lasted for weeks, and as a result of the pain R50 had missed some physical therapy sessions. When queried if her ribs were fractured, R50 stated she didn't know because…

  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 before2023-11-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI110044 and MI00139379. Based on observation, interview and record review, the facility failed to prevent and treat pressure ulcers, in three of three residents reviewed for pressure ulcers (Resident #1, #2, and #3) resulting in worsening of pressure ulcers (Resident #3), facility acquired pressure ulcers, pain, and unmet needs. Findings include: Resident #3 (R3) In review of R3's admission Nurse assessment dated [DATE], she had a Stage 1 pressure ulcer (alteration of intact skin) on her coccyx (tailbone) and had an indwelling catheter. Physical Therapy Evaluation dated 6/05/23 and diagnoses list revealed R3 fell at home when walking to the bathroom with a cane and sustained a right hip fracture. R3 had the diagnoses of Dementia, diabetes, heart failure, osteoporosis, arthritis and macular degeneration (eye disease). The same evaluation revealed R3 required substantial/maximal assistance in bed mobility and weight bearing status was as tolerated. R3's admission Minimum Data Set…

  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 · E2026-03-19 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record review, the facility failed to ensure that a substantial HS (evening) snack was consistently offered and appropriately distributed to a group of confidential residents that attended the Resident Council Meeting, potentially affecting all residents who receive meals in the facility with 14 or more hours between last evening meal and breakfast the following day, resulting in resident dissatisfaction, frustration and potential for uncontrolled blood sugars, signs and symptoms of hypoglycemia, feeling of hunger, and weight loss.Findings include:During a confidential Resident Council Meeting on 3/18/2026 at 10:00 AM, six residents actively participated. All six attendees of the confidential resident council meeting reported they were not offered or evening snacks. One of six attendees reported had observe bin of cookies at nurse station but no type of options other than cookies and residents had to go to nurse station and ask for them. Five of six residents reported did not know snack were available at all. Review of the facility, Food Council minutes, date…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake 2795434Based on observation, interviews and record review, the facility failed to protect the residents' right to be free from abuse verbal and physical from a staff member (CNA D) for one resident (resident #33) of two reviewed.Findings include: Resident #33 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed R33 was admitted to the facility on [DATE] with diagnoses that includes dementia. R33 scored 03 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and was not interview able. R33 was observed sitting in her wheelchair on 03/17/26 at 8:40am upon approach R33 was pleasantly confused and not able to participate in a reliable interview. Review of the facility reported incident file included, Licensed Practical Nurse (LPN) C's unsigned statement written on a word document. The bottom of the word document had the dated 2/01/2026, it was unclear if that was the date of the incident or the interview with LPN…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-19 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertain to Intake # 2795434 Based on observation, interview and record review, the facility failed to thoroughly investigate allegations of abuse for one resident (resident #33) of two residents reviewed for abuse.Finding include:Resident #33 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed R33 was admitted to the facility on [DATE] with diagnoses that includes dementia. R33 scored 03 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and was not interview able. R33 was observed sitting in her wheelchair on 03/17/26 at 8:40am upon approach R33 was pleasantly confused. Review of the facility reported incident file included a word document with Licensed Practical Nurse (LPN) C's unsigned statement written on a word document. The bottom of the word document had the date of 2/01/2026, it was unclear if the 2/01/26 date was in reference to the date of the incident or the date LPN C was interviewed, the word document did not…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-21 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor 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 This citation pertains to intake 2575924Based on interview and record review, the facility failed to honor the residents right to refuse a hospital transfer in one (Resident one) out of three reviewed for resident rights. Findings include:Review of the medical record reflected that R1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic pain syndrome, carpal tunnel syndrome, jaw pain, muscle spasms, restless legs syndrome, opioid dependence, intervertebral disc disorders (a condition that affects the disc between the vertebrae of the spine), adjustment disorder with mixed anxiety and depression, temporomandibular joint disorder (causing pain and dysfunction of the jaw), migraine, post-traumatic stress disorder, dental caries, anxiety disorder, depression, low back pain, and sciatica. The Minimum Data Set (MDS) reflected that R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), a cognitive screening tool. R1 was no longer at 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-21 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2575924Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.Findings Include:Review of the medical record reflected that R1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic pain syndrome, carpal tunnel syndrome, jaw pain, muscle spasms, restless legs syndrome, opioid dependence, intervertebral disc disorders (a condition that affects the disc between the vertebrae of the spine), adjustment disorder with mixed anxiety and depression, temporomandibular joint disorder (causing pain and dysfunction of the jaw), migraine, post-traumatic stress disorder, dental caries, anxiety disorder, depression, low back pain, and sciatica. The Minimum Data Set (MDS) reflected that R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), a cognitive screening tool. R1…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-01-06 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
  Provide 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, interview and record review, the facility failed to provide restorative services for one residents (R67) of one residents reviewed for restorative care, resulting in the potential for all residents with Restorative Referrals, facility census 77, to decline in their current highest functioning level losing their independence and leading to withdrawal, depression and complications of immobility. Findings Include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R67 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included urinary tract infection, multiple sclerosis(chronic disease of the central nervous system that causes muscle weakness and vision changes), and anxiety disorder. The MDS reflected R67 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact, and she required one person assist with transfers, ambulation and toileting. During an observation and interview on…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-01-06 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During observation of meal service on 01/02/2025 at 11:29 a.m. Culinary Specialist Q was observed temping a cup of coffee. The cup of coffee was covered with plastic wrap. After temping the cup of coffee, Culinary Specialist Q instructed the dietary staff to dump out the four cups of coffee that were pre-poured and covered with a plastic film. Culinary Specialist Q explained that the staff should not pre pour the coffee before service but should obtain the coffee directly from the coffee machine and place the coffee cup on the resident's service food tray. Resident # 61 (R61) Review of the medical record revealed R61 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, and depression. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/18/24 revealed R61 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R61's meal ticket revealed Serve fresh coffee out of machine in a 2 handled cup…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-06 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor 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 observations, interviews and record review, the facility failed to answer call light and provide timely care and services to one residents (R67) of one reviewed, resulting in frustration and embarrassment. Findings included: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R67 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included urinary tract infection, multiple sclerosis(chronic disease of the central nervous system that causes muscle weakness and vision changes), and anxiety disorder. The MDS reflected R67 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact, and she required one person assist with transfers, ambulation and toileting. During an observation and interview on 1/02/25 at 11:42 AM, R67 was laying in bed with call light in reach and appeared able to answer questions without difficulty. R67 complained of having her call light on for over 30 minutes and urgently…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-06 · tag F0565 — failed to support the resident council — isolated
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure that grievances were promptly resolved and/or responded to in a timely manner for 5 of 5 residents that participate in Resident Council (RC) meetings. Findings include: On 01/03/25 11:05 AM during the confidential group meeting, RC members reported management talks about fixing problems but does not put everything in writing and does correct or communicate updates on issues. When asked for the RC members to clarify they reported they talk about cold coffee month after month and offer solutions but it falls on deaf ears. One of the RC members reported that the Nursing Home Administrator (NHA) A attended the December 2024 meeting and the Council requested to discuss the coffee issue. The participants reported NHA A stated someone would start doing test trays to obtain coffee temperatures. The response of the taking a test tray added to the RC members frustration as they have consistently reported the coffee temperatures were cold, they reported they don't need NHA A to take coffee temperatures to validate their…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-06 · tag F0641 — isolated
  Ensure each resident receives an accurate 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 ensure the accuracy of Minimum Data Set (MDS) assessments for three (R64, R66, R89) of 18 reviewed. Findings include: Resident #66 (R66) Review of the medical record revealed R66 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder. The MDS with an Assessment Reference Date (ARD) of [DATE] revealed R66 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Preadmission Screening/Annual Resident Review (PASARR) Level I Screening revealed no mention that R66 had a diagnosis of schizophrenia. The MDS assessments with ARDs of [DATE] and [DATE] revealed R66 was not coded as having a diagnosis of schizophrenia. Review of R66's diagnosis list revealed a diagnosis of schizophrenia was added on [DATE]. Review of the MDS with an ARD of [DATE] revealed R66 was coded with a diagnosis of schizophrenia. In an interview on [DATE] at 9:15 AM, Social…

  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

“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

$15,872 in federal fines across 1 penalty.

• $15,872 — penalty dated 2024-01-17

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 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 →

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

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.

About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $746K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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