Lake Orion Nursing Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

47.9% 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 132 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 56.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 91 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 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 120 beds and averages 95.0 residents a day — about 79% occupied, or roughly 25 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 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.15 hrs/resident/day on weekends vs 3.76 on weekdays — 16% thinner on weekends. RN hours go from 0.66 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

22 citations, most serious first. The 13 most serious are shown; the remaining 9 are one tap away and print in full.

• Actual harm · G2025-09-10 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Complaint #1337621.Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for one (R801) of three residents reviewed for accidents and supervision, resulting in the resident being hospitalized for alcoholic ketosis due to alcohol ingestion and lactic acidosis due to walking in 94 degree Fahrenheit (F) temperatures after staff allowed him to go on a leave of absence (LOA) with an unknown individual without consent from the legal guardian and did not identify he had not returned for approximately 30 hours. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that noted the following, .two days ago a male resident left the facility and no one knew where he was at for 1.5 days .Someone signed him out but they can't read who it was. The police were contacted. The resident was found at (hospital name) and is still there at this time .On 9/9/25 to 9/10/25, an unannounced onsite…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-06-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00153580. Based on interview and record review, the facility failed to provide supervision according to the individualized plan of care for one (R801) of three residents reviewed for falls, resulting in an acute intertrochanteric fracture of the left femur (hip) and an acute subdural hematoma (bleeding between the brain and the skull that ultimately resulted in the resident's death after R801 was left unsupervised on the toilet and sustained a fall. Findings include: A review of R801's hospital records revealed the following: A Discharge summary dated [DATE] documented, Discharge Final Diagnosis: Subdural hematoma .(R801) .presented to hospital on [DATE] s/p (status post) unwitnessed fall at her assisted living facility (nursing home). Pt (patient) unresponsive on arrival and not protecting her airway. Pt intubated in the ED (Emergency Department) and taken for CT (Computed Tomography) imaging. Imaging showed acute subdural hematoma measuring 3.6 cm (centimeters)…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00150810, MI00150926, MI00151349 Based on interview and record review, the facility failed to ensure one (R801) of three residents reviewed for accidents, was transferred in a safe manner with fully functioning equipment and with the proper level of assistance, resulting in the resident falling out of the mechanical lift sling and sustaining an acute impacted fracture (fracture typically caused by force or trauma) of the right hip, a distal intertrochanteric fracture (fracture between the bony protrusion of the thighbone) of the right hip, an acute intertrochanteric fracture of the left hip, and Focal round hyperdensity (spot brighter than the surrounding brain indicating an abnormality) within the right sylvian fissure (part of the brain) measuring approximately 5 mm (millimeters) .potentially representing aneurysm (bulging blood vessel) or hemorrhage (bleeding). Findings include: A review of a complaint submitted to the State Agency revealed an allegation that on…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2026-05-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: 2984138.Based on observations, interviews, and record reviews, the facility failed to ensure care plans and/or fall interventions were timely implemented, reviewed, and/or revised. The facility also failed to follow its fall management policy by ensuring all falls were reviewed by the interdisciplinary team and that fall risk assessments were completed in accordance with the facility policy. Findings include:A review of a complaint submitted to the SA (State Agency) reported the facility neglected to address issues regarding resident falls.On 5/13/26 an onsite investigation was conducted.R202A review of the R202's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease and chronic obstructive pulmonary disease (COPD) and history of falls. A Minimum Data Set (MDS) assessment dated [DATE], noted a Brief Interview for Mental Status (BIMS) score of 10 (which indicated moderately impaired cognition).On 5/13/26 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-12-23 · tag F0725 — failed to have enough nursing staff — widespread
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  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 relates to Intake 2645567. Based on observation, interview, and record review, the facility failed to provide adequate staffing for two residents, R403 and R404, which had the potential to affect all facility residents. Findings include: Review of an anonymous complaint received by the State Agency on 10/01/25 revealed an allegation when R403 was not assisted with timely toileting on 9/29/25 from 11:00 p.m. to 7:00 a.m. due to short staffing. The complainant alleged, I was speaking with a coherent resident (R403) who stated she sat on the toilet for one hour and 45 minutes and she turned the call light on and no one came to assist for an hour. She (R403) had to use her cell phone to call the facility downstairs and have them send help. After using her own cell phone to call for help it was another 45 minutes before someone came to help her off the toilet, in which she told me she had to scream, 'help, help'. The building is always short staffed . The complainant alleged nursing management 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-23 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake 2546912Based on observation, interview and record review, the facility failed to provide an environment that promoted and enhanced residents' dignity for three (R402, R404 and R405) of three residents reviewed for dignity. Findings include: R404 On 12/23/25 at 11:58 a.m., R404 was observed in their room dressed and seated on the edge of their bed. R404 stated two to three days prior an aide (Certified Nurse Aide S) rushed them off the toilet when they were trying to have a bowel movement. R404 reported they typically needed one-person assistance to get off their commode. R404 explained CNA S was mean to them when they kept telling them to get off the toilet over and over in a raised voice and then made them get off the commode. R404 further described CNA S and said they were going to report them to their supervisor to come down and see what they caused (which was unclear to them). R404 said this made them feel terrible, belittled.I am scared of (CNA S) now. R404 clarified CNA S…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-10 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  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 Complaint #1337621.Based on interview and record review, the facility failed to ensure a resident with a substance abuse disorder was assessed and interventions put in place for one (R801) of one resident reviewed for behavioral health services, after it was discovered he went on a leave of absence (LOA), consumed alcohol, and was treated for alcoholic ketosis and withdrawal in the hospital. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that noted the following, .two days ago a male resident left the facility and no one knew where he was at for 1.5 days .The resident was found at (hospital name) .On 9/9/25 to 9/10/25, an unannounced onsite investigation was conducted.A review of R801's clinical record revealed R801 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: alcohol dependence with withdrawal (as of 6/30/25). It was indicated on R801's face sheet that he had a legal guardian. A 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 · D2025-05-01 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop comprehensive care plans per residents' assessed needs for two (R72 and R31) of 18 residents reviewed for care planning. Findings include: R72: On 4/29/25 at 10:18 AM, a housekeeper was observed talking to R72 about the bathroom towel bar being ripped off the bathroom wall from a fall the resident had the night before. On 4/29/25 at 10:31 AM, R72 was observed lying in bed with their feet propped up on a wheelchair placed next to the bed. There was a large, white, undated bandage to their left elbow. When asked how they were doing, R72 reported they were doing good and was almost ready to go home but had a bad fall in the bathroom and hit their left elbow and cut it and hit their head. They reported their head was not too bad, but their elbow was the worst. The resident further reported they should've been wearing their grippy socks, they were barefoot and knew better. When asked about the bar if that was broken from the fall, they…

  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 · D2025-05-01 · 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 ensure a resident's physician ordered treatment was dated and timely provided for one (R23) of two residents reviewed for skin care management. Findings include: On 4/28/25 at approximately 11:25 AM, R23 was observed lying in bed, their right ankle/foot was wrapped with what appeared to be white gauze. There was no date on the wrapped gauze on their ankle. The resident, who was alert and able to answer all questions was asked as to why their left ankle was wrapped and when was the last time nursing staff wrapped it. The resident reported that they had a very deep pressure ulcer on their heel/ankle that was mostly resolved however, they still suffered from what they believed was caused by nerve issues from their wound, and having their heel wrapped helped to lessen the pain. R23 was asked when the last time it was wrapped and their ankle was observed, the resident responded it was several days ago and was believed it should have been…

  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 · D2025-05-01 · 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 observations, interviews and record reviews, the facility failed to monitor bowel movement and initiated facilities bowel protocol for one (R19) resident reviewed for bowel and bladder. Findings include: On 4/29/25 at 1:34 PM, R19 was observed in room sitting in a wheelchair. R19 was asked how their stay was at the facility, R19 replied that they enjoyed the facility, but they needed to have a bowel movement, and the facility was refusing to give them prune juice. R19 was asked when their last bowel movement was. R19 reported, two or three days ago, and that their stomach had started to experience abdominal discomfort. A record review revealed that R19 was admitted to the facility on [DATE] with medical diagnoses of hemiplegia, cognitive communication deficit and constipation. Review of the minimum data set(MDS) for brief interview for mental status score (BIMs) revealed a 13, which indicated intact cognition. On 4/30/25 at 11:22 AM, a review of the medical record revealed that on 4/26/25 at 11:08 AM,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide 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 continuous oxygen therapy was accurately documented and administered per physician orders for two (R31 and R4) of two residents reviewed for respiratory care. Findings include: R31 On 4/29/25 at 10:36 AM, R31 was observed sitting in a wheelchair in his room with no oxygen on. An oxygen tank was attached to the back of R31's wheelchair and the oxygen tubing was coiled up and in a canvas bag hanging from the handle of the wheelchair. The pressure gauge on the oxygen tank showed the needle between the 1000 and 2000 PSI (pounds per square inch) markings. An oxygen concentrator was observed in R31's room with the oxygen tubing coiled around it. R31 was asked if he usually wore oxygen. R31 explained he had been told he only needed oxygen at night and did not wear it during the day. Review of the clinical record revealed R31 was admitted into the facility on 9/8/23 and readmitted on [DATE] with diagnoses that included: acute respiratory…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00148758. Based on observation, interview and record review, the facility failed to safely serve a hot beverage for one Resident (R908) of one reviewed for hot beverages, resulting in first-degree burns (superficial burn or wound that affects the first layer of the skin) on their abdomen and chest. Findings include: A review of a Facility Reported Incident (FRI) Intake MI00148758 revealed on 11/27/24 at 6:43 AM, The facility provided R908 a cup of hot coffee without proper containment to prevent spilling and R908 sustained a liquid burn to their chest and abdomen. Clinical record review revealed R908 was admitted to the facility on [DATE] with a history of heart disease, and TIA (Transient Ischemic Attack also known as a mini stroke caused by brief blockage of blood flow to the brain) with intracranial injury which resulted in R908 having functional decline with fine motor skills and weakness. R908's most recent BIMS (Brief Interview for Mental Status) scored 15/15 indicating…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · Fcited before2024-03-26 · 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 interview and record review the facility failed to ensure a comprehensive infection control program that consistently identified infections based on symptoms and justified the use of antibiotics, (Using McGeer's Criteria for the definition of infections), as well as calculated infection rates, demonstrated on-going tracking, trending, in-services, education, and environmental rounding. Findings include: On 3/25/24 at 3:18 PM a review of the facility's infection control program data was reviewed and revealed the following: August 2023: A document titled Antibiotic Usage Log revealed resident infections both facility acquired and community acquired, however; the data did not include any identification of symptoms or consistent usage of labs or imaging to justify the use of antibiotic therapies. September 2023: There was no monthly summary included with the data, nor did the monthly data contain a calculated infection rate. A review of the Antibiotic Usage Log revealed resident infections both facility acquired and community acquired, however; the data did not include any…

  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

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$89,466 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $89,466 — penalty dated 2025-09-10
• Medicare payment denial — starting 2025-10-02 for 39 days

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

Who owns this facility

CMS files one row per role, so the 32 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

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

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