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Freeman Nursing & Rehabilitation Community

1805 Pyle Drive, Kingsford, MI 49802 · For profit - Limited Liability company · 39 certified beds · (906) 774-1530 Medicare & Medicaid certified

Call the home — (906) 774-1530 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Oct 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (20) — 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.

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

Location & what’s nearby

Urgent care / clinic
913 Olympic St · (906) 282-0491 · Call to confirm hours
Pharmacy
Shopko1.4 mi
500 S Carpenter Ave · (906) 774-7907 · Call to confirm hours
Grocery
1205 W Breen Ave · (906) 774-1323 · Call to confirm hours
Park
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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
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 increased9.7%10.8%15.4%better
Long-stay residents who lose too much weight3.7%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms2.0%4.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.0%3.0%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened7.3%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.8%19.4%18.9%better
Long-stay residents given the seasonal flu vaccine92.9%95.0%95.3%typical
Long-stay residents with pressure ulcers7.5%5.1%4.7%worse
Long-stay residents with worsening bladder/bowel control6.0%20.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table2.1%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine72.2%79.5%79.4%typical
Short-stay residents rehospitalized after admission12.2%24.0%22.6%better
Short-stay residents with an outpatient ER visit0.0%11.7%12.0%check this — see note marked star below the table

* 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.

48.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 50 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.5%U.S. median 51.5%
Got home and stayed home
10.9%U.S. median 10.7%
Went back to hospital
61.9%U.S. median 56.6%
Met the expected recovery
0.48U.S. median 0.31
Therapy hours / resident / day
0.30hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 61.9% 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 21 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 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF48.5%CMS range 38.3–61.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 7.4–17.210.7%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 discharge61.9%56.6%Oct 2024–Sep 2025CMS 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 discharge57.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge57.1%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%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 stay4.2%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 worsened4.2%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 hospitalization7.9%CMS range 4.1–15.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.291.02Oct 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

0.80
RN hours/ resident / day
0.40
LPN hours/ resident / day
1.75
Aide hours/ resident / day
2.95
Total nurse hours/ resident / day
0.59
RN hoursweekends
39.3%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 39 beds and averages 35.1 residents a day — about 90% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.95 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.75 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 2.65 hrs/resident/day on weekends vs 3.08 on weekdays — 14% thinner on weekends. RN hours go from 0.88 to 0.59 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

3
deficiencies at the latest standard inspection (2025-12-11)
7
at the previous standard inspection (2024-10-23)

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.

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.

20 citations, most serious first. The 11 most serious are shown; the remaining 9 are one tap away and print in full.

  • Actual harm · Gcited before2025-12-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to recognize a change in condition for one Resident (Resident #2) of one resident reviewed for hospitalization. This deficient practice resulted in rehospitalization, insertion of an indwelling catheter, and intravenous diuretic therapy.(All times are recorded in Eastern Standard Time unless otherwise indicated.)Findings include:Resident #2 (R2)On 12/9/25 at 12:53 PM, an interview was conducted with R2 in their room while sitting in their recliner. R2 was asked if they had a recent hospitalization and replied, Yes, I needed diuretics because of having too much fluid on me. They even put a catheter in me because I was peeing so much. The food here is so salty. I asked not to have salt added to my tray and I will not eat gravy on my food because there is a lot of salt in gravy. I weigh myself every day at home and make sure I am not gaining too much weight because of my heart. R2's local hospital admission, dated 11/20/25, revealed in part, R2…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-12-11 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    All times are Eastern Daylight Savings Time (EDST) unless otherwise noted.Based on observation, interview, and record review, the facility failed to perform hand hygiene during delivery of food which has the potential to result in the spread of illness and cross contamination among any or all 34 residents in the facility who receive meals.Findings include:During an observation on 12/10/25 at 9:06 a.m., Certified Nursing Assistant (CNA) A retrieved a tray from the food cart and delivered the tray of food to a resident in the dining room. CNA A then walked to the food cart and delivered another tray of food to a resident. CNA A continued to deliver two more trays of food to residents in the dining room and failed to use Alcohol Based Hand Rub (ABHR) [hand sanitizer] or wash her hands between meal tray delivery in the dining room.During an observation on 12/11/25 at 1:06 p.m., CNA A delivered a tray of food to a resident in the dining room and then used the resident's silverware to but up the baked potato. CNA A walked to the food cart and obtained another tray of food to a resident…

    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 · D2025-12-11 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 advance directives were reviewed in a timely manner for one Resident (#4) and failed to ensure the documentation of advance directives upon admission for one Resident (#33) of 16 residents reviewed. Findings include:All times recorded in Easter Savings Time (EST), unless otherwise noted. Resident #4 (R4) Review of the electronic medical record (EMR) on 12/9/2025 at 2:30 p.m., revealed R4 was designated as DNR (Do Not Resuscitate). Review of the Medical Treatment Decisions of Resident, signed and dated by R4 on 8/15/2024 revealed the following: I have been informed in writing, in language that I understand, of my rights and all rules and regulations to make decisions concerning medical care, include the right to accept or refuse treatment and the right to formulate and to issue Advanced Directives to be followed if i become incapacitated. In the absence of an advance directive, I understand that any and all life sustaining measures may be used. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-23 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the provision of dignified and respectful care and treatment for four Residents (R15, R24, R131, and R17) of 13 sampled residents reviewed for resident rights. This deficient practice resulted in resident dissatisfaction, frustration, and fear of mistreatment. Findings include: All times are in Eastern Daylight Savings Time (EDST) unless otherwise noted. Resident R15 Review of R15's Minimum Data Set (MDS) assessment, dated 9/18/24, revealed R15 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R15 had clear speech, understood others, and was able to make their needs known. During an interview on 10/22/24 at 7:45 a.m., R15 said she had been told by CNA A that she was not a priority for [them] to provide care for. CNA B also present in the room providing care for R15 was asked if they had ever heard CNA A tell R15 that she was not a priority for [them] to care for. CNA B confirmed R15 had told her CNA A told her (R15) that she was not a priority to [them]. CNA B said CNA A…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-23 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This deficiency pertains to Intake MI00143784. Based on interview and record review, the facility failed to timely report an allegation of abuse to the State Agency for one Resident (R15) of three residents reviewed for abuse. This deficient practice resulted in the potential for continuation of potential abuse for vulnerable facility residents. Findings include: All times are in Eastern Daylight Savings Time (EDST) unless otherwise noted. Review of R15's Minimum Data Set (MDS) assessment, dated 9/18/24, revealed R15 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R15 had clear speech, understood others, and was able to make her needs known. During an interview on 10/21/24 at 3:15 p.m., Resident #15 (R15) was asked if there were any concerns with physical or verbal abuse, or disrespectful care in the provision of care and services by staff. R15 stated, I told [Certified Nurse Aide (CNA) B] first that they were poking their gloved finger in my [vaginal area] . and it hurt . There are a lot of older women in here that are not on 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-23 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This deficiency pertains to Intake MI00143784. Based on interview and record review, the facility failed to timely and fully investigate an allegation of abuse for one Resident (R15) of three residents reviewed for abuse. This deficient practice resulted in the potential for continuation of potential abuse for vulnerable facility residents. Findings include: All times are in Eastern Daylight Savings Time (EDST) unless otherwise noted. Review of R15's Minimum Data Set (MDS) assessment, dated 9/18/24, revealed R15 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R15 had clear speech, understood others, and was able to make her needs known. During an interview on 10/21/24 at 3:15 p.m., Resident #15 (R15) was asked if there were any concerns with physical or verbal abuse, or disrespectful care in the provision of care and services by staff. R15 stated, I told [Certified Nurse Aide (CNA) B] first that they were poking their gloved finger in my [vaginal area] . and it hurt . There are a lot of older women in here that are not on the ball, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to appropriately conduct a gradual dose reduction (GDR) for an antidepressant medication for one Resident (R19) of five residents reviewed for unnecessary medications. This deficient practice resulted in the potential for adverse medication side effects. Findings include: All times are Eastern Daylight Savings Time (EDST) unless otherwise noted Resident #19 (R19) Review of R19's Electronic Medical Record (EMR) revealed admission to the facility on 7/8/22 with diagnoses including anxiety disorder, depression, and adult failure to thrive. Review of her 10/18/24 Brief Interview for Mental Status (BIMS) score on her Minimum Data Set (MDS) assessment revealed an 8/15, indicating moderately impaired cognition. Review of the Consultation Report from [Pharmacy Name} for 9/13/24 read, in part, (R19) has received Lexapro (antidepressant medication) 10 mg (milligrams) daily since Sept (September) 2022. Her last PHQ-9 score from July was 0 indicating no signs/symptoms of depression. According to the (name of Company) progress note from…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-23 · tag F0847 — isolated
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    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 a resident/residents durable power of attorney (DPOA) understood the purpose of binding arbitration agreements (an out of court alternate form of dispute resolution) for one Resident #19 (R19) of three residents reviewed for arbitration. Findings include: Resident #19 (R19) A review of R19's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 7/8/22, with active diagnoses that included anxiety disorder, depression, and hypertension. R19 scored 6 of 15 on the Brief interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. Review of facility arbitration document titled Freeman Resolving Potential Disputes, revealed R19 signed the agreement on 12/29/22. Review of facility document titled Decision Making Capacity Determination, read in part . This form serves as documentation of the determination of [R19's] capacity to participate in medical treatment and decision following examination…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-23 · 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 disinfection of environmental surfaces, appropriate hand hygiene and donning and doffing of gloves to prevent the spread of infection for one Resident (R15) of three residents reviewed for wound care. This deficient practice resulted in the potential for increased transmission of infectious organisms between the environment and/or contaminated hands during wound care. Findings include: All times noted are Eastern Daylight Savings Time (EDST), unless otherwise noted. During observation of R15's thoracic (back) wound on 10/22/24 at approximately 7:50 a.m., revealed the dressing was dated 10/21/24. The dressing was bunched up on the bottom, and not properly sealed onto R15's skin. The black sweatshirt R15 was wearing was visibly soiled with the oozing drainage from the wound, which had saturated the dressing and spilled out onto the sweatshirt. During an interview at this same time, Licensed Practical Nurse (LPN) D was asked about the drainage that had escaped R15's wound dressing unto their clothing. LPN…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-23 · tag F0917 — isolated
    Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide a comfortable mattress and functional, intact shelving for clothing storage for one Resident (R15) of 13 sample residents reviewed for comfortable and functional furniture. This deficient practice resulted in the use of an under-inflated, uncomfortable mattress and a built in four-shelf drawer unit with the third drawer missing. Findings include: All times are Eastern Daylight Savings Time (EDST) unless otherwise noted. Review of R15's Minimum Data Set (MDS) assessment, dated 9/18/24, revealed R15 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R15 had clear speech, understood others, and was able to make her needs known. During an interview on 10/21/24 at 2:52 p.m., when asked about care received in the facility, R15 stated, I am laying on a bed right now, and the lady came in from [Facility Corporation] and said, 'What is wrong with your bed'. I am lying on the springs . They took my good mattress, and I have been laying on this Mattress and [Regional…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-12-01 · 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure a food preparation staff person washed their hands after being potentially contaminated. 2. Failing to demonstrate proper testing of the concentration of sanitizing chemicals in the three compartment sink and wiping buckets. 3. Failing to properly label and date food removed from the original packaging which was re-packaged and frozen. These deficient practices have the potential to result in food borne illness among any and all 26 residents of the facility. Findings include: (All times are reported in EST) 1. On 11/30/23 at approximately 11:45 AM, [NAME] B was observed wiping up something from the floor, with a paper towel, near the three compartment sink. [NAME] B disposed of the paper towel which was used to clean the floor, then donned a pair of gloves and began with food preparation duties without washing her hands. The FDA Food Code 2017 states: 2-301.14 When…

    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 9 citations
  • Potential for harm · Fcited before2023-12-01 · tag F0880 — failed to prevent and control infections — widespread
    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 implement a complete infection control program by failure to ensure social distancing of residents in COVID-19 isolation during communal dining, and failure to complete real-time tracking and surveillance of facility infections. This deficient practice resulted in the potential spread of infectious organisms within the facility, including COVID-19, and had the potential to affect all 46 residents. Findings include: All reported times are Eastern Standard Time (EST), unless otherwise noted. During a dining observation on 11/29/23 at 1:13 p.m., R15 was viewed sitting in communal dining room with food in Styrofoam containers, plastic cups, a washable coffee cup, and regular silverware. R15 was sitting with his back less than two feet from the unknown resident directly behind him. Certified Nurse Aide (CNA) O, wearing a surgical mask was observed sitting within three feet of R15. During an interview on 11/29/23 at 1:24 p.m., Registered Nurse (RN) R, who had been assisting residents with their lunch meals, 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 · Ecited before2023-12-01 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide 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 R229 Review of R229's partially completed MDS assessment, dated [DATE], revealed R229 was admitted to the facility on [DATE]. R229 was noted to be a Full Code and Diabetic. Review of R229's admission Record revealed the following, in part: Type I (insulin dependent) diabetes mellitus with diabetic neuropathy, Type 1 diabetes mellitus with ketoacidosis without coma (Admission), dehydration, and anoxic (lack of oxygen) brain damage, not elsewhere classified - r/t (related to) severe hypoglycemia. Review of R229's Care Plans revealed the following, in part: Problem: Resident is at risk of complications R/T DX (diagnosis) diabetes mellitus. Interventions included: [DATE] - Administer medications as ordered. [DATE] - Monitor blood glucose as ordered. [DATE] - Monitor for signs of hyperglycemia (blood glucose elevated; increased thirst; increase urination; increase appetite followed by lack of appetite; nausea, vomiting). [DATE] - Monitor for signs of hypoglycemia (low blood glucose; sweating; cold, clammy skin;…

    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 · D2023-12-01 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 add or revise nutritional interventions in a timely manner for one (Resident #20) of twelve residents reviewed for care plans. This deficient practice resulted in the potential for unnecessary weight loss. Findings include: All times are documented in Eastern Standard Time (EST) unless otherwise noted. Resident #20 (R20) Review of R20's electronic medical record (EMR) revealed admission to the facility on 2/6/23 with diagnoses including adult failure to thrive, severe unspecified dementia, and Parkinson's disease. Review of R20's Minimum Data Set (MDS) Significant Change assessment dated [DATE] indicated R20 weighed 121 lbs. (pounds). A quarterly MDS assessment dated [DATE] indicated R20 weighed 112 lbs. which represented a 7.44% weight loss in approximately 30 days. Review of Dietary Progress note by the Registered Dietitian (RD) dated 9/19/23 read in part, Wt (weight) review: current wt 111#, signif (significant) wt loss 30, 90, 180 days, 13.4%,…

    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 · D2023-12-01 · 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 treatment and services to prevent new pressure ulcers from developing for one Resident (R14) of one resident reviewed for pressure ulcer care. This deficient practice resulted in two new, facility-acquired pressure injuries to R14's coccyx. Findings include: All times reported are in Eastern Standard Time (EST) unless otherwise noted. During an observation and interview on 11/28/23 at 2:41 p.m., R14 was asked about the presence of any pressure ulcers. R14 stated, I don't know if I have any open areas on my bottom today . My rear is sore . During an observation of her bottom with Certified Nurse Aides (CNAs) L and M, the presence of one Stage II pressure injury to R14's coccyx was observed. CNA L and M said R14 had repeatedly complained about the presence of a hole in the air mattress. CNA M felt underneath the air mattress and stated, I found the hole here, as she guided this Surveyors hand to an under-inflated area in the middle…

    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 · D2023-12-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 observation, interview, and record review, the facility failed to provide care to prevent contamination of the urinary drainage system for one Resident (R15) of one resident reviewed for catheter care. This deficient practice resulted in the potential for cross-contamination of infectious organisms between the floor and R15's urinary drainage system. Findings include: All times reported are in Eastern Standard Time (EST) unless otherwise noted. Observation on 11/30/23 at 2:17 p.m., found R15 self-propelling in a wheelchair with the urinary drainage bag lying flat on the floor as he moved between several hallways in the facility. The urinary drainage bag was not placed in a dignity cover, and it loudly swished on the floor as the wheelchair made each roll forward. R15 moved from the dining room door entrance on the service hall to his room on the [NAME] Hall of the facility. No staff intervened to reposition the urinary drainage bag off the floor during his locomotion between the hallways. 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 · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement nutrition interventions for two (Resident #12 and Resident #20) of twelve residents reviewed for nutrition and hydration. This deficient practice resulted in significant weight loss and the potential for choking and aspiration. Findings include: All times are documented in Eastern Standard Time (EST) unless otherwise noted. Resident #20 (R20) Review of R20's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, severe unspecified dementia, and Parkinson's disease. Review of the weight history revealed R20 weighed 117.0 lbs. (pounds) on 9/3/23 and weighed 110.6 lbs. on 10/2/23, for a total weight loss of 6.4 lbs. This resulted in a 5.47% weight loss within a 30-day period. On 7/5/23, R20 weighed 132.4 lbs., which represented an additional 15.4 lb. weight loss equating to a 16.47% weight loss in 90 days. Furthermore, R20 weighed 141.2 lbs. on 4/2/23, an additional…

    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 · D2023-12-01 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to provide the appropriate treatment and services to restore oral eating skills of one Resident (R12) of one who was maintained on enteral feedings. This deficient practice resulted in resident dissatisfaction with his quality of life and resorting to stealing of food from the dietary department so he could eat food by mouth rather than via a tube. Findings include: All times are documented in Eastern Standard Time (EST) unless otherwise noted. Review of R12's EMR (Electronic Medical Record) revealed the most recent admission to the facility as 7/31/23 with diagnoses including dysphagia (difficulty swallowing), unspecified severe protein-calorie malnutrition, gastrostomy status (a surgical procedure to insert a tube through the abdomen and into the stomach for feeding), diabetes mellitus and myocardial infarction (heart attack). The Care Plan for R12 revealed a Nutritional Status Problem: (R12) is at Nutritional / Hydration risk and receiving 100% of nutrition and hydration via tube feeding as well as po (by…

    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
  • No harm found · C2023-12-01 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to follow established vendor provided menus on two of two days meals were observed. This deficient practice has the potential to result in inadequate meal nutrition for any and all 26 residents. Findings include: (all reported times are in EST) On 11/29/23 at 1:00 PM observations of the noon meal were made. The steam table contained stainless steel pans with mashed potatoes and a meat/gravy mixture. An interview with CDM (Certified Dietary Manager) was conducted and was learned the meal being served was shepherd pie as the main course. A review of the menus provided revealed the menu for 11/29 was scheduled to be meat loaf, mashed potatoes, gravy, and peas. On 11/30/23 at 9:00 AM, it was observed the steam table contained croissant sandwiches, Canadian bacon, oat meal, and toast. A review of the menu for this specific day identified waffles and French toast as the meal. On 11/30/23 at 1:00 PM it was observed the steam table contained fish nuggets as the main course. A review of the menu provided for 11/30 showed…

    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
  • No harm found · C2023-12-01 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    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 implement written Quality Assurance and Performance Improvement (QAPI) policies and procedures for adverse event monitoring after an insulin dependent Resident #27 (R27) became unresponsive, was sent to the emergency room, and expired that day. This deficient practice resulted in failure to determine root cause of significant change in condition and hospitalization to improve outcomes which could affect the entire facility population. Findings include: All times are documented in Eastern Standard Time (EST) unless otherwise noted. Resident #27 (R27) Review of R27's electronic medical record (EMR) revealed readmission to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease, and sepsis. Record review of R27's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. 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.

    Administration 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.

Part of a chain

This home belongs to ATRIUM CENTERS — 26 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 53.0+2.0 vs chain
Health inspection 4 of 52.7+1.3 vs chain
Staffing 4 of 53.4+0.6 vs chain
Quality measures 5 of 53.7+1.3 vs chain
The other 25 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Marshall Nursing and Rehabilitation CommunityMarshall, MI 1 of 5Mulder Health Care FacilityWest Salem, WI 1 of 5Riverside Nursing CentreGrand Haven, MI 2 of 5Allendale Nursing and Rehabilitation CommunityAllendale, MI 2 of 5Plainwell Pines Nursing and Rehabilitation CommuniPlainwell, MI 2 of 5Roosevelt Park Nursing and Rehabilitation CommunitMuskegon, MI 2 of 5South Haven Nursing and Rehabilitation CommunitySouth Haven, MI 2 of 5The Timbers of Cass CountyDowagiac, MI 2 of 5Tomah Nursing And RehabTomah, WI 2 of 5Westgate Nursing & Rehabilitation CommunityIronwood, MI 3 of 5Austinburg Nsg And Rehab CtrAustinburg, OH 3 of 5Crittenden County Health & Rehabilitation CenterMarion, KY 3 of 5Frederic Nursing And Rehab CommunityFrederic, WI 3 of 5Lincoln Haven Nursing & Rehabilitation CommunityLincoln, MI 3 of 5Prescott Nursing And Rehab CommunityPrescott, WI 3 of 5Salem Springlake Health & Rehabilitation CenterSalem, KY 3 of 5Woodside Village Care CenterMount Gilead, OH 4 of 5Blossom Nursing And Rehab CenterSalem, OH 4 of 5Fairview Nursing and Rehabilitation CommunityCentreville, MI 4 of 5Gladwin Nursing and Rehabilitation CommunityGladwin, MI 4 of 5Grayling Nursing & Rehabilitation CommunityGrayling, MI 4 of 5Heritage Nursing and Rehabilitation CommunityZeeland, MI 4 of 5Lexington Court Care CenterLexington, OH 5 of 5Hillcrest Nursing and Rehabilitation CommunityNorth Muskegon, MI 5 of 5King Nursing & Rehabilitation CommunityHoughton Lake, MI

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
ATRIUM CENTERS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 10/01/2007
FIFTH THIRD BANKOrganization5% OR GREATER MORTGAGE INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 02/26/2015
ALBRIGHT ROSS, SUSANIndividualCORPORATE OFFICERsince 12/24/2017
BAILEY, ESSELIndividualCORPORATE OFFICERsince 08/27/2012
FINNEY, DONALDIndividualCORPORATE OFFICERsince 08/01/2003
AMICUS CAPITAL HOLDINGS INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/18/2021
ATRIUM CENTERS MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/18/2024
ANDERSON, CURTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2025
CHERRY, JILLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
HAYES, PAULIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
LABARGE, TAMMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/18/2018
AMICUS CAPITAL HOLDINGS, INC. EMPLOYEE STOCK OWNERSHIP TRUSTOrganizationADP OF THE SNFsince 08/18/2021
AMICUS PROPERTIES LLCOrganizationADP OF THE SNFsince 01/01/2021
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 06/01/2023
LEADERSTAT LTDOrganizationADP OF THE SNFsince 01/01/2025
OCS REAL ESTATE HOLDINGS LLCOrganizationADP OF THE SNFsince 01/01/2021
OMNICARE LLCOrganizationADP OF THE SNFsince 01/01/2025
PLANTE & MORAN PLLCOrganizationADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 26 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.

11 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.

$3.7M
Net patient revenuemost recent cost report
-7.0%
Operating marginrevenue minus expenses
$622K
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 43%Medicare 14%Other / private 43%

This home reported $622K paid to related parties — landlords or management companies under common ownership — equal to about 16% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$363per resident / day
operating cost
$11,022per month
≈ monthly operating cost
$339per 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 235612. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, 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.

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