Huron Woods Nursing Center
1395 South Huron Road, Kawkawlin, MI 48631 · For profit - Corporation · 60 certified beds · (989) 684-3210 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has 2 actual-harm citations
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.7% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 11.4% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.1% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.6% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.4% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.8% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.7% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.0% | 19.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.6% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.8% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.3% | 14.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 90.7% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 13.5% | 24.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 11.7% | 11.7% | 12.0% | typical |
§ 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.
35.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 29.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 24 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 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 35.3%CMS range 25.1–46.9 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 6.6–16.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 29.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 25.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 33.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.9%CMS range 3.6–14.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.80 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 44.0 residents a day — about 73% occupied, or roughly 16 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.38 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.96 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.98 hrs/resident/day on weekends vs 4.54 on weekdays — 12% thinner on weekends. RN hours go from 0.75 to 0.45 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%.
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.
30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · Gcited before2025-05-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Number MI00153102. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure safe transfer utilizing a mechanical lift (device to move a dependent individual from one surface to another) and ensure planned interventions were in place for fall prevention, for one resident (#701) of three residents reviewed, resulting in Resident #701 experiencing a fall during a mechanical lift transfer resulting in an intraventricular hemorrhage (IVH- bleeding into the ventricles of the brain). Findings include: Resident #701 Review of intake documentation revealed a concern that Resident #701 had a fall with head injury while being transferred with a mechanical lift. The intake detailed that the facility did not identify a root cause of the fall/accident and did not report the fall with severe injury to the State Agency. Per the Intake, Resident #701's health had declined since the occurrence, and they are 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.
- Actual harm · Gcited before2023-11-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide supervision to prevent falls and implement meaningful interventions for three residents (Residents #16, Resident #36, Resident #46), resulting in injuries, pain, and hospitalization. Findings include: Record review of the facility 'Accident/Incident Report Fall management' policy, dated 6/2018, revealed the purpose was to establish a standard of accident/incident completion and to evaluate the facility responsibility to make every effort to decrease the likelihood of a recurrence by investigating incidents, understand how they occur and applying appropriate action. Record review of the facility provided form CMS-802 MDS Resident Matrix, dated 11/28/2023, revealed a census of 47. Record review of the category 'Fall (F), Fall with injury (FI) or Fall with Major injury (FMI) noted 18 residents had sustained falls while residing at the facility. That is a 38% fall rate for residents residing in the facility. Resident #16: Record 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.
- Potential for harm · D2026-05-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake Number 2796974. Based on interview and record review, the facility failed to implement physician's orders for one resident (Resident #1) of three residents reviewed, resulting in a chest x-ray not being performed. Findings include:Resident #1 (R!): R1 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction, dysphagia, chronic cough and the need for assistance with personal care. Record review of a progress note from Licensed Practical Nurse (LPN) H, dated 1/14/2026 at 22:40pm, revealed that nursing staff were called to the room of R1. The daughter was observed feeding R1 Tic-Tacs and stated she was checking R1's swallowing abilities. The daughter stated that R1 did seem to be having some issues with swallowing and her lungs sounded bad. At this time the daughter requested a chest x-ray be ordered. The nurse present in the room assessed R1's lungs sounds and noted the lungs were clear to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-02-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include: On 02/18/2026 at 8:44am during the initial kitchen tour with Corporate Dietician F observed the drain line to the ice machine sitting directly in the drain. According to the 2022 Food Code, 5-202.13 Backflow Prevention, Air Gap, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).On 02/18/2026 at 12:25pm during lunch observation, observed a tray with purees individually stored in bowls on the tray line. Puree green beans were temped at 123 F and puree chicken was temped at 127 F using Thermapen. During this observation, [NAME] G was interviewed on what the temperature should be while hot holding, and she answered 135 F. Corporate Dietician F was also interviewed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-19 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents' Advanced Directives' code status was documented and accessible in the medical record for 2 residents (Resident #3 and Resident #5) of 8 residents reviewed for Advanced Directives. Findings Include: Resident #3 (R3):A record review of R3's [NAME] Data Set assessment (MDS) dated [DATE] revealed a brief interview mental status (BIM's) score of 11 of 15, which indicated R3 was moderately cognitively impaired. R53 was admitted to skilled nursing on [DATE] with diagnoses of Inflammatory disorder of scrotum, diabetes mellitus type 2, chronic atrial fibrillation (irregular heartbeat), malignant neoplasm of left main bronchus (left lung cancer), need for assistance with personal care and spinal stenosis of cervical and lumbosacral regions.A record review of R3's physician determination of decision-making capability dated [DATE] revealed that R3 was capable of making medical treatment decisions. A record review of R3's face sheet revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-19 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate notice of non-coverage and maintain documentation for three residents (#56, #58, #59) of five residents reviewed, resulting in the lack of full disclosure related to Medicare rights and the inability to appeal the discharge in the time frame allotted by Medicare. Findings include: Record review of the facility 'Advanced Beneficiary Notice' policy, dated 11/2022, revealed that it is the policy of the facility to prepare and deliver to the resident or resident authorized representative an Advanced Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) when the utilization review entity expects that Medicare probably will not pay for or will not continue to pay for extended care items or services . In an interview and records review on 02/18/2026 at 1:48 PM, Staff A Admissions Director reviewed 5 residents records with the state surveyor for Advanced Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC):Resident #56:Record 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.
- Potential for harm · D2026-02-19 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that diabetic foot care was provided for one resident (R34) of one resident reviewed for ancillary services. Findings include: Resident #34 (R34):A record review of R34's [NAME] Data Set assessment (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 of 15, which indicated R34 was cognitively intact. R34 was admitted to long term care (LTC) on [DATE] with diagnoses of diabetes mellitus type 2 with diabetic polyneuropathy (nerve damage), difficulty walking, need for assistance with personal care, history of falling, abnormalities with gait and mobility and lack of coordination. On [DATE] at 11:03AM, During an interview with R34 she said that she had asked to be seen by the podiatrist several times and stated that she felt he doesn't have enough time for me. R34 said the podiatrist 'pops in when he gets time' otherwise the staff told me that I needed to be on the calendar to be seen. R34 stated my nails 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.
- Potential for harm · D2026-02-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that oxygen was ordered, and care planned for 1 resident (Resident #9) of 2 residents reviewed for respiratory care. Findings Include: Resident #9: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #9 was admitted to the facility on [DATE] with diagnoses: Heart failure, history of a stroke, left side weakness, hypertension, hypothyroidism, COPD, diabetes, depression and anxiety. The MDS assessment dated [DATE] revealed the resident had mild cognitive decline with a Brief Interview for Mental Status/BIMS score of 12/15 and needed assistance with all care. On 2/17/2026 at 3:39 PM, during a tour of the facility Resident #9 was observed lying in bed awake, an oxygen concentrator was running with oxygen set at 3 liters per minute. The resident was asked if that is what it was normally set at and she said she didn't know.On 2/17/2027 at 3:50 PM, Nurse H was interviewed about Resident #9's oxygen and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-19 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
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 Certified Nursing Assistants (CNA) yearly performance reviews were conducted for two of five CNA's reviewed, resulting in the lack of yearly education training. Findings include: Record review of the facility 'Facility Staffing Template' policy, dated 6/2019, revealed it is the policy of the facility to conduct, document and annually review a facility-wide assessment, which included both the residents' population and the resources the facility needs to care for the residents. (c.) Facility resources needed to provide competent care for residents including staff, staffing plan, staff training/education and competencies, education and training . Record review of the facility 'Facility Assessment', dated 10/13/2025, revealed the facility used computerized training assigned specialized training with lessons to address Alzheimer's disease and pertinent communication strategies with the resident experiencing behavioral health needs. Individualized training will further assist with interventions to specifically…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-19 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to implement an effective in-service nurse aide training program, that ensured continued compliance with educational training of 12 hours required annually for aides employed at the facility for 1 of 5 certified nursing assistants (CNA) resulting in continued non-compliance. Findings include: Record review of the facility 'Facility Assessment', dated 10/13/2025, revealed that the facility used computerized training assigned specialized training with lessons to address Alzheimer's disease and pertinent communication strategies with the resident experiencing behavioral health needs. Individualized training will further assist with interventions to specifically address behavioral training and meaningful interventions. Annual CNA/Nurse skills training is performed by the Corporate Clinical Educator. PCC Behavioral Care Assessment and Infection Prevention features have been implemented to better identify and track resident associated behaviors and infections and trends. Current CNA/Nurse training courses are sufficient and address…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-17 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
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 1341963. Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure physician supervision of medical care for one (#701) of one resident reviewed, resulting in lack of physician and/or advanced practice Health Care Provider (HCP) assessment and treatment of an alteration in skin integrity. Findings include: Review of Facility Reported Incident (FRI) documentation, submitted on 6/24/25 at 7:37 PM, revealed the facility received a concern from Family Member Witness C on 6/24/25 at 5:40 PM that Resident #701 had called them on 6/23/25 at approximately 10:00 PM and told them that someone had been sexually harming them. The facility completed an investigation and determined there was insufficient evidence to support the occurrence of the alleged event. Record review revealed Resident #701 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of right sided hemiplegia and hemiparesis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number MI00150598. Based on observation, interview and record review, the facility failed to prevent repeated falls for one resident (Resident #101) of 4 sampled residents, resulting in Resident #101 sustaining repeated falls from her wheelchair, Findings include: Resident #101: In an observation and interview on 3/5/2025 at 8:10 AM, Resident #101 was seated up in the resident's room in a wheelchair with the footrest in place. Resident #101 was asked about a fall in February 2025. The Resident stated that yes, she fell from her wheelchair and went to the hospital. Record review of Resident #101's Minimum Data Set (MDS), a quarterly assessment dated [DATE] revealed an elderly female with a Brief Interview of Mental Status (BIMS) of 14 out of 15- indicating cognitively intact. Section I- Active diagnoses included: Medically complex conditions, diabetes, hemiparesis, seizure disorder, anxiety, depression, ischemic cardiomyopathy, dysphagia, insomnia. Section G- Functional Abilities:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · Fcited before2024-11-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility 1) Failed to ensure a clean and sanitary ice machine and 2) Failed to ensure safe service and holding food temperatures during a breakfast meal for all residents who consumed food, resulting in unsafe serving food temperatures with the likelihood of continued unsafe temperature food service. Findings include: On 11/20/24, at 8:00 AM, an observation of the back dining room revealed the breakfast meal was already in the warmer. On 11/20/24, at 8:04 AM, an observation along with [NAME] I who obtained meal temperatures as follows: Sausage Gravy 159 degrees Fahrenheit, Scrambled eggs 132 degrees Fahrenheit [NAME] I was asked if 135 degrees for the scrambled eggs was ok and [NAME] I looked down to the dial and turned it clockwise. [NAME] I was asked if the steam table was off and [NAME] I offered, no, but I thought it was on medium. It's on medium now. [NAME] I again was asked if the scrambled eggs temperature of 135 degrees was ok and [NAME] I stated, I have to go check and left out to the kitchen. A moment later, [NAME] I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to respond to residents' needs timely and in a dignified manner for an anonymous group of residents, resulting in feelings of having to wait, needing to engage call lights over again to get help and call light complaints going unresolved by management. Findings include: On 11/19/24, at 10:35 AM, During the Resident Council task, the following complaints were voiced regarding staff answering call lights: They turn them off and you have to wait for them to come back My call light was on 20 minutes when they canceled it and then I it was 25 more minutes for them to come back and I had to put my light on again. If they don't come back in 10 minutes after canceling my light, I put it back on. Sometimes, they completely forget about you. They will say, I had another call light to answer first some CNA's are hard on ya; they might complain when I have to get up to go the bathroom with me, I need a Hoyer and they need two people. It's hard sometimes to get that second person. In the meantime, I am waiting with the Hoyer connected…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dignified Activities of Daily Living (ADL) care for one resident (Resident #6) of 3 residents reviewed for ADL care, resulting in soiled clothing, bedding and bathroom. Findings include: Resident #6: On 11/18/24, at 1:31 PM, Resident #6's doorway was shut. There was a strong urine/bowel odor noted in the hallway outside the closed door. Upon entry to the room, the odor was noted to stronger. CNA's F entered and was asked if the bedding had been changed recently and CNA's F pulled back the sheets. The mattress was in good clean repair. An observation of the bathroom revealed a large amount of bowel movement on the toilet seat. Resident #6 was not in their room. Resident #6's roommate (husband) entered the room to use the toilet and quickly left back out. CNA's F was asked if the bathroom should be dirty with bowel movement and CNA's F offered, it's usually (Resident #6) and we try to catch (Resident #6) after lunch and that 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.
- Potential for harm · Dcited before2024-11-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure timely assessment and implementation of interventions for pressure ulcer prevention for one resident (Resident #5) of three residents reviewed for pressure ulcers. Findings include: Resident #5: On 11/18/24 at 2:07 PM, Resident #5 was observed in their room. The Resident was in bed positioned on their back with their eyes open. The Resident's legs and feet were positioned directly against the mattress. When spoke to, Resident #5 responded verbally but did not provide meaningful responses to questions. Record review revealed Resident #5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included heart failure, cerebral infarction (stroke), and urinary retention. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and was dependent upon staff for bed mobility and transferring. The MDS further revealed the Resident was at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and operationalize a comprehensive Restorative Nursing Program (RNP) for two residents (Resident #15 and Resident #30) of three residents reviewed, resulting in a lack of communication and implementation of planned RNP per Therapy recommendations, Resident #15's verbalization of increased pain and decreased Range of Motion (ROM), and Resident #30 developing a contracture (permanent tightening of muscles, tendons, skin, and tissues causing stiff and immobile joints), and the potential for further functional decline, diminished mobility, and unnecessary, increased pain. Findings include: Resident #15: On 11/18/24 at 1:12 PM, Resident #15 was observed sitting in a wheelchair in their room. A walker was observed in the room. An interview was completed at this time. When queried regarding the walker in their room, Resident #15 verbalized they use the walker to go to the bathroom but revealed they are only able to walk when staff 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.
- Potential for harm · Dcited before2024-11-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the availability and provision of fluids to maintain appropriate hydration for one resident (Resident #5) of three residents reviewed, resulting in Resident #5 not having fluids available and verbalizations of thirst. Findings include: Resident #5: On 11/18/24 at 2:07 PM, Resident #5 was observed in their room. The Resident was in bed positioned on their back with their eyes open. The Resident's mouth was open. Resident #5's mouth and tongue were visibly dry, and their lips were chapped. The Resident did not have a beverage in their room. When spoke to, Resident #5 responded verbally but responses were unable to be understood. Record review revealed Resident #5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included heart failure, cerebral infarction (stroke), and urinary retention. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a thyroid hormone medication was given appropriately for one resident (Resident #14) of five residents reviewed for unnecessary medications, resulting in abnormal lab values and complaints of signs and symptoms of hypothyroidism. Findings include: Resident #14: On 11/19/24, at 12:57 PM, Resident #14 was resting in bed eating their lunch. Resident #14 was unsure if they were getting out of bed as they complained of feeling tired that day. On 11/19/24, at 2:23 PM, Resident #14 was resting in bed. They complained of feeling constipated at times, felt tired and wanted to stay in bed. On 11/20/24, at 7:49 AM, The Director of Nursing (DON) was alerted that the resident complained of constipation at times and didn't want to get out of bed as they felt tired in the middle of the day. The DON offered that Resident #14 started a new medication to aide in appetite. The (DON) was asked why Resident #14 was taking their thyroid hormone…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to implement an infection control program including comprehensive outcome surveillance, including monitoring of initial infection signs/symptoms and ongoing surveillance and monitoring of potential infections, resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the likelihood for spread of microorganisms and illness for all 47 facility residents. Findings include: Upon request for facility Infection Control Surveillance Data, the facility provided handwritten Infection Control Resident Surveillance line listing documentation for November 2023 to October 2024. Review of the provided forms revealed each resident listed on the forms received a form of antimicrobial treatment. The columns on the form included Resident/admit date , Room, Unit, Onset, Category, Qualifying signs & Symptoms, Nosocomial (facility acquired) or Community, Treatment and Resolution Date. The forms provided did not include any residents with signs/symptoms of infection who 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.
- Potential for harm · E2023-11-30 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain clean heater vents and windows free of dirty buildup, spider webs and cobwebs for multiple rooms, resulting in dirty buildups on heater vents above residents' beds and dirty windows. Findings include: On 11/28/23, at 9:37 AM, an observation of room [ROOM NUMBER] revealed the heater vent with buildup of dirt with dirt buildup on the ceiling pain approximately a foot around the vent. On 11/28/23, at 9:40 AM, an observation of room [ROOM NUMBER] was noted to have numerous black marks on the wall near bed 1. The toilet seat in the bathroom was discolored yellow and had numerous chips. On 11/28/23, at 10:15 AM, an observation of room [ROOM NUMBER] revealed a large amount of dusty buildup on the heater vent and on the ceiling around the vent. The blind was pulled back to reveal a large amount of spider webs along with dusty buildup. The heater vent was above the resident's bed. On 11/28/23, at 10:38 AM, an observation along with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-30 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow and create a person-centered comprehensive care plan, for one resident (Resident #16), resulting in an unkempt appearance and undocumented showers. Findings include: Record review of the facility 'Care Planning Process: Admission, Comprehensive & Short Term' dated 11/2017 revealed person-centered care: A focus on the resident as the center of control with support provided to the resident for making their own choices. Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities and having an understanding of the resident life before coming to reside in the center. Record review of the facility 'Nursing Assistant Job Description and Performance Standards' undated form revealed the position is to provide direct care to residents, under supervision of a licensed nurse, in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent the development of facility-acquired Stage II pressure ulcers for three resident (Residents #9, Resident #13, Resident #33) while residing at the facility, resulting in Resident #9 acquiring a pressure ulcer of the right/left buttocks , Resident #13 acquiring a pressure ulcer of the upper back, and Resident #33 acquiring a Stage II pressure ulcer of the coccyx with the likelihood for pain and discomfort and prolonged illness. Findings include: Record review of the facility 'Skin at Risk Assessment Documentation, Staging & Treatment' policy dated 1/2020 revealed the purpose was to provide prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors. A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-30 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe medication storage and that narcotic reconciliation was completed for Medication Cart #1 and ensure that expired insulins were disposed of, resulting in an unlocked medication cart and unreconciled narcotics with likelihood of expired insulin use, narcotic diversion and medication theft or misuse. Findings include: On [DATE], at 11:01 AM, an observation of the medication cart for the 100 hall was conducted along with Nurse I. There was an open insulin that was dated 10-19-23. On [DATE], at 11:10 AM, Nurse I was observed at medication cart #2 with both narcotic reconciliation books for both med cart #1 and #2. Nurse I was asked how they reconcile narcotics and Nurse I stated, we count the narcotics at shift change and sign the form. A record review along with Nurse I of the narcotic reconciliation form for med cart #2 revealed no quantity of narcotics counted. There were two signatures noted and Nurse I stated, that the one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is 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 and document Activities of Daily Living (ADL) care for two residents (Residents #16 and Resident #25), resulting in an unkept appearance and lack of personal hygiene, and a possible decrease in mood. Findings include: Record review of the facility 'Nursing Assistant Job Description and Performance Standards' undated form revealed the position is to provide direct care to residents, under supervision of a licensed nurse, in accordance with facility policies and procedures and report resident needs and concerns to licensed nurse . Physically assist residents with toileting, showering, etc (13.) Review care plans and perform care as outlined. (14.) Provide accurate & timely point of care electronic documentation for the care and treatment provided to assigned residents' and the residents response or lack of response to care provided according to policy. Resident #16: Record review of Resident #16's Quarterly Minimum Data Set (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.
- Potential for harm · Dcited before2023-11-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the provision of daily care for one resident (Resident #15) of one resident reviewed, resulting in a lack of concise and accurate shower documentation, Resident #15's hair having a greasy appearance, and feelings of shame and embarrassment utilizing the reasonable person concept. Findings include: Resident #15: On 11/28/23 at 12:56 PM, Resident #15 was observed in their room in bed. The room was dimly lit with the lights off. The Resident had an unkept appearance and their hair was disheveled with a greasy appearance. When asked questions, Resident #15 made eye contact and responded, Uguguguguh but was unable to provide meaningful verbal responses. When asked yes/no questions, Resident #15 did shake their head to indicate a response. When asked if they needed assistance from staff to get out of bed, Resident #15 shook their head yes. When queried if they had brushed their teeth today, Resident #15 shook their head no. Resident #15…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0679 — failed to provide activities — isolatedProvide 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 offer activities per care plan for one resident (Resident #25), resulting in unkempt nails with the likelihood of increased behaviors, boredom and overall decreased wellbeing. Findings include: Resident #25: On 11/28/23, at 9:53 AM, Resident #25 was lying in their bed. Their nails were unkept with chips of blue nail polish. The bedside table was in front of the resident over the bed. The blind was closed to not allow the sunshine in. On 11/29/23, at 12:59 PM, a record review of Resident #25's electronic medical record revealed an admission on [DATE] with diagnoses that included stroke, Dementia and Anxiety. Resident #25 had severely impaired cognition and required total assistance with all cares. On 11/29/23, at 1:17 PM, Activity assistant V was interviewed as to how they document activities for Resident #25 and Activity assistant V stated, they chart on the kiosk into the medical record and that there was no other documentation. Activity…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 failed to prevent the development of facility-acquired Urinary Tract Infections (UTI) for two residents (Resident #9, Resident #16), resulting in the likelihood for bladder/kidney injury and/or antibiotic drug resistant organisms (MDRO's). Findings include: Record review of the facility 'Infection Prevention and Control Plan' policy, dated 3/2020, revealed the purpose was to promote functional coordinated process to minimize the risk of endemic and epidemic healthcare associated infections (HAI) in residents and healthcare workers and to optimize use of resources through a strong prevention program. (#3.) Targeted analysis will be conducted on infections that are high risk and/or high volume. HAI's and laboratory reports are monitored. (12.) Activities involved in program development and oversight include but are not limited to: (b.) Implementation and monitoring of infection control policies and procedures. (c.) Monitoring and documentation of infections, including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure supervision with dining and ongoing assessment, monitoring, and documentation/implementation of interventions and recommendations of nutritional needs for two residents (Resident #13 and Resident #15) of three residents reviewed, resulting in a lack of appropriate positioning and supervision when eating, a lack of implementation of Speech Therapy (ST) recommendations for swallowing/eating for Resident #15, a lack of documentation and timely identification/revision of nutritional interventions to prevent significant weight loss for Resident #13, and the likelihood for ongoing weight loss, choking, and a decline in overall health status. Findings include: Resident #13: On 11/28/23 at 1:10 PM, Resident #13 was observed sitting in a Geri Chair (large reclining high back wheelchair with positioning support and solid leg rest) in their room. The back of the Geri chair was not reclined but the leg rest was elevated. The Resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to properly administer 3 inhalers for one resident (Resident #41), resulting in only 1 puff of Albuterol given and not waiting the proper time in between the 3 inhaled medications with the likelihood of decreased efficacy of the medications. Findings include: Resident #41: On 11/29/23, at 8:05 AM, During medication pass task, Nurse J prepared the inhalation (inhalers) medication for Resident #41 and entered the room. Resident #41 was given 1 puff of Albuterol at 8:08 AM, waited 40 seconds and gave the resident their Spiriva inhaler. The resident took 1 puff. Nurse J waited 40 seconds and then gave the resident their Advair inhaler. The resident took 1 puff. The resident was not instructed to take a deep breath during the administration of the inhalers. On 11/29/23, at 2:30 PM, a record review of Resident #41's electronic medical record revealed an admission on [DATE]. A review of the physician orders revealed the following: Albuterol Sulfate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE PEPLINSKI GROUP — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.1 | +0.9 vs chain |
| Health inspection | 3 of 5 | 2.1 | +0.9 vs chain |
| Staffing | 4 of 5 | 3.7 | +0.3 vs chain |
| Quality measures | 3 of 5 | 3.5 | -0.5 vs chain |
The other 9 homes this chain runs (chain average 2.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ACKERMAN, AMY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 01/01/2012 |
| ACKERMAN, RICKY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 10% | since 01/01/2012 |
| BAUMGARTEN, MICHAEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 01/01/2012 |
| BAUMGARTEN, THERESE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 01/01/2012 |
| PEPLINSKI, SHELI | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 01/01/2012 |
| PEPLINSKI, TODD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | 10% | since 01/01/2012 |
| SCHADE, JEFFERY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 10% | since 01/01/2012 |
| SCHADE, TAMARA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 01/01/2012 |
| THOMPSON, BRIAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 10% | since 01/01/2012 |
| THOMPSON, SHELLY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 10% | since 01/01/2012 |
| PLANTE & MORAN PLLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2012 |
| KAMARAJU, PRAVEEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2017 |
| PERUSKI, MICHELE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/20/2024 |
| WINKELS, KATHY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/05/2016 |
| HURON WOODS ESTATES LLC | Organization | ADP OF THE SNF | — | since 01/01/2012 |
| PEPLINSKI PROPERTIES LLC | Organization | ADP OF THE SNF | — | since 01/01/2012 |
| THE PEPLINSKI GROUP INC | Organization | ADP OF THE SNF | — | since 03/10/2025 |
CMS files one row per role, so the 41 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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 75% 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 $933K paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235592. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-19, 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.