No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Medilodge of Kalamazoo

1701 S 11th Street, Kalamazoo, MI 49009 · For profit - Limited Liability company · 39 certified beds · (269) 375-2020 Medicare & Medicaid certified

Call the home — (269) 375-2020 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 2024Behavioral-health or dementia-care citation — no harm found (F0744)2 actual-harm citations1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2024
  • it has 2 actual-harm citations
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5629 Stadium Dr Ste B · (269) 544-3270 · Call to confirm hours
Pharmacy
5165 W Main St · (269) 381-0270 · Call to confirm hours
Grocery
1503 Concord Place Dr · (269) 808-5257 · Call to confirm hours
Park
(269) 387-8557 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 3 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 improved from 2 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.6%10.8%15.4%better
Long-stay residents who lose too much weight7.5%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder1.6%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms0.0%4.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.5%3.0%3.3%worse
Long-stay residents whose ability to walk worsened9.4%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication41.5%19.4%18.9%worse
Long-stay residents given the seasonal flu vaccine96.9%95.0%95.3%typical
Long-stay residents with pressure ulcers6.5%5.1%4.7%worse
Long-stay residents with worsening bladder/bowel control21.4%20.0%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table17.0%14.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.6%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine90.1%79.5%79.4%better
Short-stay residents rehospitalized after admission13.2%24.0%22.6%better
Short-stay residents with an outpatient ER visit18.1%11.7%12.0%worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ 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.

56.7% 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 52 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.7%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
0.44U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.44 therapist hours per resident per day in 2026Q1 — more than 74% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.7%CMS range 39.2–69.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 6.0–14.110.7%Oct 2022–Sep 2024no 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified82.6%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.2%CMS range 4.5–15.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.781.02Oct 2022–Sep 2024CMS 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

1.12
RN hours/ resident / day
0.58
LPN hours/ resident / day
1.94
Aide hours/ resident / day
3.64
Total nurse hours/ resident / day
0.74
RN hoursweekends
39.0%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 39 beds and averages 37.1 residents a day — about 95% occupied, or roughly 2 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 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.12 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 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 3.08 hrs/resident/day on weekends vs 3.86 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.27 to 0.74 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% 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

6
deficiencies at the latest standard inspection (2025-07-09)
5
at the previous standard inspection (2024-08-01)

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.

ABCDEFGHIJKL

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.

24 citations, most serious first. The 13 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · G2026-06-11 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    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 #3005153 and #3005264Based on interview and record review the facility failed to ensure a safe discharge for 1 (Resident #103) of 2 residents reviewed for transfer and discharge, when on 5/4/26 at approximately 11:45 pm, Resident #103 was not allowed back into the building upon her return from an evaluation and subsequent diagnosis of a UTI (urinary tract infection) at a local acute care emergency department. This deficient practice resulted in Resident #103 being without food, shelter, medications, or resources for safety; further resulting in Resident #103 experiencing feelings of fear, anger, and mental anguish. Findings include:Resident #103Review of a Face sheet revealed Resident #103 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: acute diastolic (congestive) heart failure (chronic condition where the heart is unable to pump enough blood to meet the body's needs), type 2 diabetes (a metabolic disorder that occurs…

    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
  • Actual harm · Gcited before2025-07-09 · 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 provide positioning for the prevention of pressure wounds in 1 (R1) of 4 residents reviewed for pressure wounds resulting in the development of a pressure wound. Findings include:According to the Minimum Data Set (MDS) dated [DATE], R1 was unable to complete her BIMS (Brief Interview Mental Status) indicating she was severely cognitively impaired. Her diagnoses included traumatic brain injury (TBI), quadriplegia (paralyzed in all four limbs), and contractures. Section GG-Functional Ability and Goals revealed R1 was dependent for all cares including mobility and positioning. Section M-Skin Conditions revealed R1 was at risk for pressure ulcers/wounds. Observed on 7/7/25 at 2:18 PM, R1 in bed lying on her back. Both legs contracted (pulled up) with knees rubbing/resting together with her heels resting directly on the bed. No wedges or padding underneath her heels, knees, or back to position and off-load her from bony prominences. Two leg…

    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 · G2024-05-23 · 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 MI00143151. Based on interview and record review, the facility failed to provide an environment free from physical abuse from staff to one resident (R105) of six residents reviewed for abuse, resulting in physical abuse, and the potential for continued fear, anxiety, and psychosocial harm. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R105 scored 4/15 (severely cognitively impaired) on her BIMS (Brief Interview Mental Status). Section E-Behavior indicated the resident did not have hallucinations or delusions as potential indicators of psychosis or behavioral symptoms. R105 did direct verbal behavioral symptoms towards others that significantly interfered with resident's care occurring 1 to 3 days during the last reporting period. Review of R105's Care Plan, revised 10/17/23, indicated the resident had an ADL (Activities of Daily Living) self-care performance deficit related to and including dementia, without behavioral disturbance, psychotic disturbance, mood…

    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 · Past Non-Compliance
  • Potential for harm · D2026-06-11 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 #3030592Based on observation, interview, and record review the facility failed to ensure residents were assessed to be appropriate for self-administration of medications for 1 (Resident #104) of 1 resident reviewed for medication administration resulting in medications being left unsecured at resident's bedside, residents self-administering medications without staff assessment, and the potential for negative outcomes from taking/instilling too much or too little medications.Findings include:Resident #104Review of a Face sheet revealed Resident #104 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: fracture of right radius (fracture of the right arm) and type 2 diabetes (a metabolic disorder that occurs when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin).In an observation and interview on 6/9/26 at 9:16 am, Resident #104 was observed pushing the buttons and adjusting his insulin…

    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 · D2026-06-11 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #3030592Based on observation, interview, and record review the facility failed to maintain professional standards of nursing practice for 1 (Resident #104) of 4 resident reviewed for professional nursing standards resulting in ordered medications not being obtained from a pharmacy, no monitoring of home medication use, medications left unsecured at resident's bedside, and the potential for negative outcomes from taking/instilling too much or too little medications.Findings include:Resident #104Review of a Face sheet revealed Resident #104 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: fracture of right radius (fracture of the right arm) and type 2 diabetes (a metabolic disorder that occurs when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin).In an observation and interview on 6/9/26 at 9:16 am, Resident #104 was observed pushing the buttons and adjusting his insulin pump.…

    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 · D2026-06-11 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 #3030592Based on observation, interview and record review, the facility failed to ensure nursing staff were adequately trained and evaluated for competencies specifically related to the management of an insulin pump for 1 (Resident #104) of 1 reviewed for the management of an insulin pump. This deficient practice had the potential to result in ineffective medication therapy, complications, and adverse reactions. Findings include:Resident #104Review of a Face sheet revealed Resident #104 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: fracture of right radius (fracture of the right arm) and type 2 diabetes (a metabolic disorder that occurs when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin).In an observation and interview on 6/9/26 at 9:16 am, Resident #104 was observed pushing the buttons and adjusting his insulin pump. Resident #104 reported he was protective of his pump.…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-07-09 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop policy and procedure to include current standards of practice in regard to pneumococcal (pneumonia) immunizations for 2 (Residents #1 and 10) of 5 residents reviewed for immunizations and the potential for eligible residents to not be offered the PCV21 (Pneumococcal 21-valent Conjugate Vaccine), with the potential of increasing the risk of acquiring, transmitting, or experiencing complications from pneumonia.Findings include:Review of the facility's Pneumococcal Vaccine (Series) policy, Date reviewed/revised: 10/30/2023, stated, It is our (the facility) policy to offer our residents .immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23/PPSV (pneumococcal polysaccharide vaccine)) . There was no mention of PCV21 in the policy or its existence.Resident #1:Review of Resident #1's immunization report, print date 7/8/25, stated Resident #1 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-09 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This citation pertains to intake 2590016.Based on interview and record review the facility failed to ensure the designated resident representative was notified of changes for 1 (Resident #501) of 3 residents reviewed for notification of changes resulting in a resident representative being unaware of x-ray results and falls, a resident representative experienced the feeling of uncertainty of how their family member was being cared for at the facility, and the potential for resident representatives to be unable to make timely care decisions. Findings include:Review of Resident #501's admission record, print date 8/20/25, revealed Resident #501 had diagnoses of senile (exhibiting a decline of cognitive abilities) degeneration of brain, dementia (decline in cognitive function), unspecified psychosis (trouble telling the difference between what's real and what's not), cognitive communication deficit, muscle weakness, anxiety, disorientation, and falls. Resident Representative M was listed first under Resident #501's Contacts indicating he was Resident #501's Responsible…

    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 · D2025-07-09 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 support meaningful involvement in activities of choice, for 1 (Resident #14) of 12 residents reviewed for meaningful activities resulting in the potential for feelings of boredom, loneliness, and unmet psychosocial needs. Findings include:Review of an admission Record revealed Resident #14 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Alzheimer's disease, anxiety disorder, major depressive disorder, and unspecified dementia, unspecified severity without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety.Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 6/2/2025 revealed a Brief Interview for Mental Status (BIMS) assessment should not be conducted due to Resident #14 is rarely/never understood and Resident #14 has memory problems, Resident #14 cognitive skills for daily decision making are 3. Severely…

    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 before2025-07-09 · 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 Based on observation, interview, and record review the facility failed to provide adequate supervision and ambulation device to prevent falls and fall with injury in 1 (R31) of 4 residents reviewed for accidents resulting in injury and the potential of further falls with injury.Findings include:According to the Minimum Data Set (MDS) dated [DATE], R31 scored 5/15 on her BIMS (Brief Interview Mental Status) indicating she was cognitively impaired. Diagnoses included dementia. Section GG-Functional Abilities and Goals indicated supervision was required for walking from 10 to 150 feet. Review of R31's Incident Report dated 2/22/25 at 11:10 PM indicated the resident had a witnessed fall when her feet got tangled together causing her to hit her head on the floor. Upon assessment the resident was found to have an abrasion to her left forehead. The IDT (interdisciplinary team) met with new interventions including therapy to initiate a walker for safety. Review of R31's Care Plan, ADLS or Falls, print date 7/7/25 did…

    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 before2025-07-09 · 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: 1.) maintain proper infection control practices while utilizing resident shared equipment (a glucometer- a machine that uses a drop of blood to analyze the level of glucose (sugar) in a person's blood stream) during medication administration for 1 (Resident #88) of 5 residents reviewed for medication administration and 2.) ensure appropriate use of Enhanced Barrier Precautions (EBP) in 1 of 12 residents (Resident #1 (R1) reviewed for infection control, resulting in the potential for the spread of infection, cross contamination and disease transmission. Findings include:Resident #88Review of an admission Record revealed Resident #88 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Type 2 diabetes mellitus with complications (a condition when the body is unable to produce or use insulin correctly resulting in high blood sugar). Review of Order Summary for Resident #88 revealed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains in intake MI00152648 Based on observation, interview, and record review, the facility failed to provide assistance with toileting for 1 (Resident #103) of 5 residents reviewed for activities of daily living (ADL) care resulting in the potential for avoidable negative physical outcomes for resident's who are dependent on staff for assistance. Findings include: Review of an admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included difficulty in walking and pain in left foot. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 3/26/25 revealed a Brief Interview for Mental Status (BIMS) score of 8/15 which indicated Resident #103 was moderately cognitively impaired. Review of Resident #103's [NAME] (Care area report for staff to reference to determine what kind of care residents need) revealed, ADL'S: TOILETING: 2 person assist. TRANSFERS: 2 person assist with sit-to-stand . Review of…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · F2024-08-01 · 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 maintain sanitary conditions in the kitchen, resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include: During an initial kitchen tour on 7/30/24 at 8:43am, the reach in refrigerator contained the following expired food items: a container of sour cream with a use by date of 7/24/24, 2 ham sandwiches in plastic bags with use by date of 7/28/24, and 3, 8 count packages of hamburger buns with use by date of 7/24/24. 1 package of hot dog buns dated 6/14/24 was present with no use by date, upon examination, the hot dog buns were hard to the touch. During the initial kitchen tour on 7/30/24 at 8:47am, the reach in freezer in the main kitchen area contained a 3-gallon container of vanilla ice cream that had a torn and damaged cardboard lid placed on top of the opening. The lid had a torn opening across it and did not seal the container, which resulted in an opportunity for the food inside to become contaminated. During the initial kitchen tour 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · Dcited before2024-08-01 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide timely notification to a representative of the Office of the State Long-Term Care Ombudsman for emergency transfer and written notice of transfer for 2 of 2 residents (Resident #2 and #9) reviewed for notification of transfers for hospitalization, resulting in the potential for residents being inappropriately discharged , residents left without an advocate to inform them of their rights, and for the Office of the State Long-Term Care Ombudsman to be unaware of the facilities practices related to transfers and discharges. Findings include: Resident #2: Review of Nurses' Notes dated 12/17/2023 at 3:31 PM, revealed, .Resident is seen sitting on his bed when passing by, resident appears very pale. Resident states where am I? Resident questions why he is here, how he arrived, where he came from. Resident is visibly upset. Vital signs taken- 117/76, pulse 98, respirations 18, temp 98.7, and PSO2 varies from 68-77%. Per NP .- administer oxygen to keep…

    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 before2024-08-01 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification of the facility bed hold policy upon discharge to an acute care hospital for 2 of 2 residents (Resident #2 and #9) reviewed for bed hold, resulting in possible unanticipated expense or the loss of desired room placement in the facility. Findings include: Resident #2: Review of Nurses' Notes dated 12/17/2023 at 3:31 PM, revealed, .Resident is seen sitting on his bed when passing by, resident appears very pale. Resident states where am I? Resident questions why he is here, how he arrived, where he came from. Resident is visibly upset. Vital signs taken- 117/76, pulse 98, respirations 18, temp 98.7, and PSO2 varies from 68-77%. Per NP . - administer oxygen to keep resident >90%, obtain CXR for hypoxia. Resident placed on O2 at 2 L and continues to stat in low 80's. Resident finally reaches 90% when placed on 3L. Resident is advised to rest, use call light when/if he needs to get up and keep O2 on. Resident is then found 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-01 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 that residents with a history of trauma received trauma informed care for 1 (Resident #4) of 12 sampled residents resulting in the potential for exposure to trauma triggers and re-traumatization. Findings include: .According to the National Institute on Mental Health, 2019, PTSD is a disorder that some people develop after experiencing a shocking, scary, or dangerous event. It is natural to feel afraid during and after a traumatic situation. This fear triggers many split-second changes in the body to respond to danger and help a person avoid danger in the future. The fight or flight response is typical reaction meant to protect a person from harm. Nearly everyone will experience a range of reactions after trauma, yet most people will recover from those symptoms naturally. Those who continue to experience problems may be diagnosed with PTSD (Post Traumatic Stress Disorder). People who have PTSD may feel stressed or frightened even when they are…

    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 before2024-08-01 · 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

    Based on observation, interview, and record review the facility failed to ensure infection control practices were maintained for 2 (Resident #38 and Resident #191) of 2 residents reviewed for catheter care, resulting in the catheter bag and/or tubing being left on the floor and an increased risk of cross contamination and infection. Findings include: Review of Guidelines for Prevention of Catheter-Associated Urinary Tract Infections, Infection Control, 3/25/24, https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html, revealed Summary of Recommendations .III. Proper Techniques for Urinary Catheter Maintenance: Recommendation III.B.2, Keep the collecting bag below the level of the bladder . Do not rest the bag on the floor. Resident #38 Review of a Care Plan for Resident # 38, with a reference date of 7/8/24, revealed a focus/goal/interventions: Focus: Resident has an alteration in elimination related to renal insufficiency; urinary retention, admitted with a Foley Catheter, Goal: Resident will show no signs/symptoms of UTI's through the next review.…

    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 · E2023-06-14 · tag F0744 — failed to care for residents with dementia — pattern
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Review of The Needs of Older People with Dementia in Residential Care, Woods & [NAME] (2006), published in the International Journal of Geriatric Psychiatry revealed Determining which activities have high degree of meaningfulness can aide recreation staff in creating programs more likely to promote health and wellness for persons with dementia. Review of Activity Involvement and Quality of Life of People at Different Stages of Dementia in Long Term Care Facilities, [NAME] & Twist (2015), published in Aging Mental Health, revealed Despite a Resident's cognitive status, their activity involvement was significantly related to better scores on care relationships, positive affect, restless tense behavior, social relations and having something to do. Resident #15 Review of an admission Record dated 9/29/17 revealed Resident #15 was admitted to the facility with the following pertinent diagnoses: Alzheimer's Disease (disease characterized by progressive mental deterioration), muscle weakness, cognitive communication…

    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 · D2023-06-14 · tag F0573 — isolated
    Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This citation pertains to Intake # MI00135264. Based on interview and record review, the facility failed to respond timely to a request for medical records in 1 resident (Resident #38) of 1 resident reviewed for medical record requests, resulting in delayed access to a resident's medical records and dissatisfaction with the services provided. Findings include: Review of the policy/procedure Preparing for Release, dated 2017, revealed .To protect the individual's right to privacy by releasing confidential information only to authorized persons/entities, and only in accordance with Facility policy, federal and state laws .Procedure .Require request to be in writing .Facility must provide access to resident the requested records for inspection within 24 hours excluding holidays and weekends .If family member is the legal representative, follow the same process as requested from the resident . Resident #38 Review of an admission Record revealed Resident #38 was a female, with pertinent diagnoses which included Alzheimer's disease, arthritis, depression, and high blood pressure. Noted…

    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 before2023-06-14 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This citation pertains to Intake # MI00135264. Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of the reason for a transfer to the hospital in 3 of 5 residents (Resident #38, #6, & #23) reviewed for transfer and discharge requirements, resulting in the potential for residents and/or their representatives to not be fully informed of the reason for a hospital transfer and their rights in regard to an appeal hearing. Findings include: Review of the policy/procedure Transfer and Discharge, dated 1/1/22, revealed .It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered .Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified) .Complete and send with the resident (or provide as soon as…

    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 before2023-06-14 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This citation pertains to Intake # MI00135264. Based on interview and record review, the facility failed to provide written notification of the bed hold policy upon transfer to the hospital in 3 of 5 residents (Resident #38, #6, & #23) reviewed for transfer and discharge requirements, resulting in the potential for residents and/or their representatives to be unaware of their rights in regard to facility bed holds. Findings include: Review of the policy/procedure Bed Hold Notice Upon Transfer, dated 2/1/22, revealed .At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed .Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies .The duration of the state bed-hold policy, if any, during which the resident is…

    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 · D2023-06-14 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 This citation pertains to Intake # MI00130822. Based on observation, interview, and record review the facility failed to develop and implement person centered care plans for 3 of 12 residents (Resident #15, Resident #27 and Resident #21) reviewed for care plans, resulting in the potential for staff to not know how to care for resident conditions or follow resident care interventions. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #15 Review of an admission Record dated 9/29/17 revealed Resident #15 was admitted to the facility with the following pertinent diagnoses: Alzheimer's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-14 · 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 citation pertains to Intake # MI00130822. Based on observation, interview, and record review the facility failed to prevent the development of an avoidable pressure ulcer for 1 of 12 sampled residents (Resident #15) resulting in the development of a pressure ulcer and the potential for delayed wound healing, pain, infection and overall deterioration in health status. Findings include: Review of a facility policy titled Pressure Injury Prevent and Management, dated 1/2/22, revealed the facility definition of an avoidable pressure ulcer as: Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Section 4 of the policy (Interventions for Prevention…

    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 before2023-06-14 · 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 Based on observation, interview, and record review, the facility failed to provide supervision according to the standards of care and consistently implement adequate and effective interventions to prevent further falls in 1 of 7 residents (Resident #22) reviewed for safety, resulting in the potential for wandering into other residents' rooms, accidents/hazards with the potential for injury and/or resident to resident altercations. Findings include: .One of the biggest safety challenges is preventing falls .3 of every 4 nursing center residents fall each year .Nursing staff must have the knowledge and skills to prevent injury from falls .Previous falls, diminished strength, gait and balance impairments, medications, Alzheimer's disease or dementia, vision impairment and environmental risk factors .Staffing and organization of care. Inadequate staffing may leave residents who are likely to fall without proper supervision .…

    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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2025-08-12 for 9 days

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

Part of a chain

This home belongs to MEDILODGE — 53 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.1-1.1 vs chain
Health inspection 2 of 52.7-0.7 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 52 homes this chain runs (chain average 3.1★, per CMS)
1 of 5Medilodge of FarmingtonFarmington, MI 1 of 5Medilodge of Grand BlancGrand Blanc, MI 1 of 5Medilodge of Grand RapidsGrand Rapids, MI 1 of 5Medilodge of HowellHowell, MI 1 of 5Medilodge of MarshallMarshall, MI 1 of 5Medilodge of Montrose IncMontrose, MI 1 of 5Medilodge of MunisingMunising, MI 1 of 5Medilodge of Sault Ste. MarieSault Ste. Marie, MI 1 of 5Medilodge of SouthfieldSouthfield, MI 1 of 5Medilodge of WestwoodKalamazoo, MI 2 of 5Medilodge at the ShoreGrand Haven, MI 2 of 5Medilodge of Capital AreaLansing, MI 2 of 5Medilodge of CheboyganCheboygan, MI 2 of 5Medilodge of East LansingEast Lansing, MI 2 of 5Medilodge of FrankenmuthFrankenmuth, MI 2 of 5Medilodge of GTCTraverse City, MI 2 of 5Medilodge of LudingtonLudington, MI 2 of 5Medilodge of St. ClairEast China, MI 2 of 5Medilodge of Sterling HeightsSterling Heights, MI 2 of 5Medilodge of West BloomfieldWest Bloomfield, MI 3 of 5Medilodge of Campus AreaEast Lansing, MI 3 of 5Medilodge of HillmanHillman, MI 3 of 5Medilodge of LivingstonHowell, MI 3 of 5Medilodge of LivoniaLivonia, MI 3 of 5Medilodge of Mt. PleasantMt. Pleasant, MI 3 of 5Medilodge of PortagePortage, MI 3 of 5Medilodge of ShorelineSterling Heights, MI 3 of 5Medilodge of Tawas CityTawas City, MI 3 of 5Medilodge of TaylorTaylor, MI 3 of 5Medilodge of ZeelandZeeland, MI 3 of 5The Lodge at TaylorTaylor, MI 4 of 5Medilodge of GaylordGaylord, MI 4 of 5Medilodge of HollandHolland, MI 4 of 5Medilodge of LansingLansing, MI 4 of 5Medilodge of LeelanauSuttons Bay, MI 4 of 5Medilodge of MilfordMilford, MI 4 of 5Medilodge of OkemosOkemos, MI 4 of 5Medilodge of RichmondRichmond, MI 4 of 5Medilodge of Traverse CityTraverse City, MI 5 of 5Medilodge of AlpenaAlpena, MI

Showing 40 of 52; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
ARK OPCO GROUP, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2015
B&Y TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2015
CODY HEALTHCARE S CORPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2015
CRAIG FLASHNER 2007 TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2015
NORCROSS, ROBERTIndividualCONTRACTED MANAGING EMPLOYEEsince 07/01/2015
KIRK, KRISTINEIndividualW-2 MANAGING EMPLOYEEsince 09/02/2016
FLASHNER, CRAIGIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2015
PERLSTEIN, YITZCHOKIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2015
NOBLE HEALTHCARE MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2015
PRESTIGE ADMINISTRATIVE SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2016
ROGERS, STACEYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2015

CMS files one row per role, so the 13 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

$4.4M
Net patient revenuemost recent cost report
+6.6%
Operating marginrevenue minus expenses
$247K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 55%Medicare 4%Other / private 41%

This home reported $247K 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

$297per resident / day
operating cost
$9,034per month
≈ monthly operating cost
$318per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Michigan
$11,254/mo
Nursing home (semi-private)
$11,969/mo
Nursing home (private)
$5,818/mo
Assisted living

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 235282. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-09, 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.

What to do next