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McLaren Lapeer Region

1375 North Main Street, Lapeer, MI 48446 · For profit - Corporation · 19 certified beds · (810) 667-5588 Medicare & Medicaid certified

Call the home — (810) 667-5588 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 Jul 2023
Insights

On the public record, this home looks stronger than most — but visit before you decide.

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 (5/5)
  • 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
  • a high number of inspection citations overall (22) — 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) 5 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1257 N Main St · (810) 664-4526 · Call to confirm hours
Pharmacy
Grocery
328 W Nepessing St · (810) 577-1895 · Call to confirm hours
Park
1552 N Main St · 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
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 held steady at 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
Short-stay residents who newly got an antipsychotic medication1.4%1.1%1.4%typical
Short-stay residents given the seasonal flu vaccine90.8%79.5%79.4%better
Short-stay residents rehospitalized after admission18.1%24.0%22.6%better
Short-stay residents with an outpatient ER visit9.5%11.7%12.0%better

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.

74.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 187 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

74.4%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
52.6%U.S. median 56.6%
Met the expected recovery
1.96U.S. median 0.31
Therapy hours / resident / day
0.88hours / resident / day
Physical therapy
0.82hours / resident / day
Occupational therapy
0.25hours / resident / day
Speech therapy

Met the expected recovery: 52.6% 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 78 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 1.96 therapist hours per resident per day in 2026Q1 — more than 100% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF74.4%CMS range 67.7–80.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 8.2–15.910.7%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 discharge52.6%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 discharge50.0%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 discharge46.1%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay2.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.7%CMS range 3.1–9.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.751.02Oct 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

4.51
RN hours/ resident / day
0.26
LPN hours/ resident / day
2.04
Aide hours/ resident / day
6.81
Total nurse hours/ resident / day
3.39
RN hoursweekends
45.5%
Total nursing turnover
36.8%
RN turnover

How full it usually is: this home is certified for 19 beds and averages 17.1 residents a day — about 90% occupied, or roughly 2 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 6.81 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 4.51 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 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 5.81 hrs/resident/day on weekends vs 7.20 on weekdays — 19% thinner on weekends. RN hours go from 4.94 to 3.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% 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

2
deficiencies at the latest standard inspection (2025-09-04)
6
at the previous standard inspection (2024-09-09)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · Ecited before2025-09-04 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include:On 09/02/2025 at 9:35AM during the initial kitchen tour with the Certified Dietary Manager B, observed three separate spray nozzles downstream of atmospheric vacuum breakers located at the dishwasher station. On 09/02/2025 at 11:30am during lunch observation, observed Dietary Staff C reach in her pocket for a pen with gloves on, then proceed to don an additional pair of gloves without washing hands. On 09/02/2025 at 11:30am -12:00pm observed Dietary Staff C remove one pair of gloves after stepping away from the tray line and then proceeded to don an additional pair of gloves without washing hands. Dietary staff C was observed to be wearing two pairs of gloves at the same time. On 09/02/2025 at 11:30am -12:00pm…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-04 · 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 assess and change bandages for two residents Resident #9 and Resident #32) out of two residents reviewed for bandages, resulting in old or undated bandages going unchanged and assessed. Findings include: Resident #9 On 9/02/2025, at 1:26 PM, Resident #9 was sitting at their bedside. They had a large band aid to their right elbow. The band aid was undated and appeared old. Resident #9 offered that they had fallen at home prior and that was why they went to the hospital prior to the long-term care unit. On 9/03/2025, at 8:30 AM, a record review of Resident #9's electronic medical record revealed an admission on [DATE] with diagnoses that included generalized weakness, gastrointestinal bleeding and chronic kidney disease. Resident #9 required assistance with activities of daily living and had a slight cognitive deficit. A review of the skin care plan revealed Other: ST (skin tear) to R (right) Lower arm. A review of the physician orders…

    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 before2024-09-09 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure that the Quality Assessment and Process Improvement (QAPI) meetings were held quarterly, resulting in the lack of identification of concerns in the facility or corrective action being provided and no monitoring of issues, potentially affecting all residents living in the facility. Findings Include: FACILITY QAPI and QAA On 9/09/2024 at 3:54 PM, the Director of Nursing/DON was interviewed about the facility Quality Assurance Process Improvement/ QAPI program. When asked how often the QAPI committee met, the DON said the committee was supposed to meet quarterly and showed 2 meeting sign in sheets for a QAPI meeting in May 2024 and June 2024. She said she started at the facility in June 2024 and when she looked for the QAPI committee meeting minutes and sign in sheets, there were none. The DON said the interim DON had a meeting in May 2024 and she had a meeting in June 2024, but there were no meeting sign in sheets prior to that. The DON said she did not know if the committee met quarterly over the past year. A 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
  • Potential for harm · E2024-09-09 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 MI00141690. Based on observation, interview and record review, the facility failed to perform assessments and perform ongoing monitoring of all bed rails to identify potential areas of entrapment for all facility residents including the following residents: #'65, #70, #115, #116, and #120, resulting in the potential for zones of entrapment to remain unidentified, posing a risk to all 15 residents. Findings Include: Resident #65: A record review of the medical record, indicated Resident #65 was admitted to the facility on [DATE] with diagnoses: history of falls with left knee fracture, arthritis, neck pain, hypertension, atrial fibrillation and macular degeneration. On 9/03/2024 at 11:33 AM, Resident #65 was observed sitting in her wheelchair in the day room waiting for lunch. She said she had a history of falls at home, and her left knee cap had a fracture. She said she was at the facility for therapy. On 9/9/2024 at 11:37 AM, the Maintenance Technician L was interviewed…

    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 · D2024-09-09 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that needs were being accommodated for three residents [Resident # 70 (R70), Resident #116 (R116), and Resident #120 (R120)], including comfortable room temperatures for Resident #70 and Resident #120, a request for a room change for Resident #116 and a request for a wider bed for Resident #120 of a total sample of 15 residents, resulting in discomfort and being unable to get enough rest and sleep for Resident #116, feeling unsafe to move and afraid of falling out of a narrow bed for Resident #120 and feeling too cold in the room for Resident #70 and Resident #120. Findings include: FACILITY Resident #120 (R120): Environment R120, on 09/03/24 at 11:59 AM, complained about the room being so cold upon admission. R120 complained to staff about the room temperature since admission on [DATE], but nothing has been done. R120's roommate (in room [ROOM NUMBER]), Resident #121, was interviewed on 9/3/24 at 2:30 PM. R121 agreed that the room…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Numbers MI00141690 and MI00145384, Based on observation, interview, and record review, the facility failed to ensure a safe environment with adequate supervision and implement interventions to prevent a fall for two residents (Resident #14 and Resident #119) and failed to do a complete investigation for both residents resulting in Resident #14 sustaining multiple rib fractures after a fall and a potential for pain and a decline in medical condition and the likelihood of fall with injury to recur due to incomplete investigations for both Resident #14 and Resident #119. Findings include: Accidents Resident #14 (R14): According to the review of electronic medical records (EMR) on 9/4/24 at 1:00 PM, R14 was [AGE] years old and admitted to the skilled nursing facility on [DATE] with a diagnosis of Postoperative (Postop) ORIF (Open Reduction Internal Fixation) of the left trimalleolar fracture with general weakness in addition to other diagnosis. On 5/10/24, the facility assessment…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-09 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to appropriately store supplies in one Clean Utility/ Medication Storage Room of one room reviewed and ensure that one Medication/Treatment Cart of two carts reviewed was properly secured and that confidential resident information was secured, resulting in the potential for use of contaminated and outdated supplies and access to residents' medications and confidential information. Findings Include: FACILITY Medication Storage and Labeling A review of the facility medication carts with Nurse J, on 9/4/2024 at 2:00 PM, identified a medication cart unattended in the hallway outside of the day room with several medication drawers open; the medication cart was unlocked. In addition, resident information was on the computer screen: visible to anyone nearby. Nurse J shut the medication cart drawers, closed the computer screen and ensured the cart was locked. She said she thought Nurse D had stepped away from the cart and was in the medication room…

    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 · D2024-09-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Infection Prevention and Control standards of practice were followed for 1). Hand Hygiene and Personal Protective Equipment/PPE use for one resident (Resident #120), 2.) a Water Management program specific to the facility, and 3.) Pneumonia and COVID Vaccination consent was not obtained and administered for one resident (Resident #71), resulting in the potential for the spread of infection, which could cause serious illness. Findings Include: FACILITY Infection Control: On 9/05/2024 at 9:38 AM, during an interview with the Infection Preventionist/IP A she was asked about the facilities Water Management Program. The IP A said the maintenance department in the hospital handled the Legionella water testing for the facility and it was last performed in the summer. She said she had seen the results and had communication with the Maintenance Director. IP A was asked for a copy of the Water Management Plan and she said the hospital…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-13 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement baseline care plans to guide the care provided to 8 residents (Resident #7, Resident #58, Resident #59, Resident #60, Resident #62, Resident #108, Resident #110, and Resident #112) of 12 residents reviewed for care plans, resulting in the failure to provide instructions to the staff for effective and person -centered care to promote well-being and manage care needs. Findings Include: Resident #7: Death: A record review of the Face sheet and progress notes indicated Resident #7 was admitted to the facility on [DATE] and died on 6/28/2023 with diagnoses: Myopathy, diabetes, heart failure, thrombocytopenia, candidal esophagitis, gastritis, dysphagia, hypertension, arthritis, and weakness. The Minimum Data Set assessment was not completed, as the resident was only in the facility for a few days. A record review of a Nursing note dated 6/26/2023 at 5:26 PM, revealed Resident #7 spoke with her family and physician and requested Hospice…

    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 · Ecited before2023-07-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that food products were properly labeled with an Opened on and Use by dates and dispose of expired food items, resulting in the potential for bacterial harborage and food borne illness. This deficient practice had the potential to affect all residents that consume food prepared in the kitchen for a census of 11 Residents. Findings include: On 7/11/23 at 7:55 AM, an initial tour of the kitchen was conducted with Dietary Retail Manager (DRM) T. The walk-in refrigerated unit was reviewed with the DRM. An open container of mushrooms were observed with a received date on 6/26/23 and a use by date on 7/3/23. The container had been opened and past the use by date. The DRM removed the mushrooms from the refrigerated unit. Sliced jalapeno peppers had been placed into a plastic container. The container had no open date or use by date on the container. The DRM was questioned about the kitchen policy of labeling food items. The DRM reported…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2023-07-13 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide documentation of adequate notice of Medicare Part A benefits of non-coverage for 1 resident (Resident # 63) of 3 Residents that were reviewed for notice of non-coverage of Medicare Part A benefits, resulting in the resident's inability to exercise the right to file an appeal in a timely manner. Findings include: During a review of the notice on of non-coverage for Medicare Part A benefits on 7/12/2023 at 10:30 AM, the following was revealed: Resident #63's last covered day of Medicare A benefits was documented on the SNF Beneficiary Protection Notification Review, form as 2/23/2023. The document said it was a facility initiated discharge from Medicare Part A Services when benefit days were not exhausted. There was no Notice of Medicare Non-Coverage form received from the facility. There was no documentation to indicate when Resident #63 was notified that the Medicare Part A Services were going to end. On 7/12/2023 at 11:30 AM, during an interview with Admissions Nurse B related to the lack of a Notice of Medicare…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-13 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Number MI00137064. Based on interview and record review, the facility failed to ensure an allegation of abuse was reported timely to the State Agency for one resident (Resident #4) of one resident reviewed for Abuse, resulting in the facility reporting an allegation of abuse 5 days after it occurred and the nurse reported the allegation to her supervisor. Findings Include: Resident #4: Abuse: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #4 was admitted to the facility on [DATE] and discharged [DATE] with diagnoses: Anoxic brain damage, history of a pulmonary embolism, dysphagia, anemia, thrombocytopenia, schizoaffective disorder, severe intellectual disabilities, conduct disorder, and weakness. The MDS assessment dated [DATE] revealed the resident had cognitive decline and was not able to participate in the Brief Interview for Mental Status assessment. Section E (Behavioral Symptoms) of the MDS indicated Resident #4 had demonstrated…

    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 · D2023-07-13 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Number MI00137064. Based on interview and record review, the facility failed to investigate an allegation of abuse upon notification of the incident for one resident (Resident #4) of one resident reviewed for abuse, resulting in the potential for ongoing resident abuse. Findings Include: Resident #4: Abuse: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #4 was admitted to the facility on [DATE] and discharged [DATE] with diagnoses: Anoxic brain damage, history of a pulmonary embolism, dysphagia, anemia, thrombocytopenia, schizoaffective disorder, severe intellectual disabilities, conduct disorder, and weakness. The MDS assessment dated [DATE] revealed the resident had cognitive decline and was not able to participate in the Brief Interview for Mental Status assessment. Section E (Behavioral Symptoms) of the MDS indicated Resident #4 had demonstrated behaviors of hitting, scratching, kicking, etc. A review of a Facility Reported Incident…

    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 · D2023-07-13 · 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

    Based on interview and record review, the facility failed to develop and implement comprehensive resident-centered care plans for three residents (Resident #108, Resident #110, and Resident #112) of 12 residents reviewed for care planning, resulting in the potential for unmet care needs and decline in overall health and wellbeing. Findings include: Resident #108: A review of Resident #108's medical record revealed an admission into the facility on 6/26/23 with diagnoses that included multiple fractures of ribs on the right and left sides, depression, contusion of right thigh, atrial fibrillation, weakness, chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. A review of the Minimum Data Set assessment, dated 6/29/23, revealed the Resident had mild cognitive impairment and needed limited assistance with activities of daily living. Further review of the medical record revealed the Resident was receiving oxygen therapy and aerosol treatments. A review of Resident #108's progress notes revealed a note dated 6/26/23 at 7:42 PM, Resident with a wound vac to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-13 · 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

    Based on observation, interview and record review, the facility failed to 1) incorporate the standards of care into the fall policy and operationalize the fall policy for Resident #110, who had a fall and hit their head and 2) maintain an environment free of safety hazards for Resident #112, of six residents reviewed for safety and falls, resulting in the failure of communication of a fall for Resident #110 with the potential for continued safety concerns and injury, and the potential of neurological changes to go unidentified and untreated, and Resident #112 obtaining a skin tear on their arm and the potential for further injury with sharp edges of tiles in the bathroom and infection. Findings include: Resident #110: A review of Resident #110's medical record revealed an admission into the facility on 6/29/23 with diagnoses that included liver disease, coagulation defect, atrial fibrillation, anxiety disorder, and venous insufficiency. A review of the Minimum Data Set assessment, revealed the Resident had intact cognition and needed limited assistance with transfers, walk in room,…

    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 · D2023-07-13 · 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

    Based on observation, interview and record review, the facility failed to ensure that nebulizer equipment was maintained in a clean and sanitary manner for one resident (Resident #108) of one resident reviewed for respiratory care and oxygen needs, resulting in the potential for respiratory infections. Findings include: Resident #108: A review of Resident #108's medical record revealed an admission into the facility on 6/26/23 with diagnoses that included multiple fractures of ribs on the right and left sides, depression, contusion of right thigh, atrial fibrillation, weakness, chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. A review of the Minimum Data Set assessment, dated 6/29/23, revealed the Resident had mild cognitive impairment and needed limited assistance with activities of daily living. A review of Resident #108's orders revealed the Resident was prescribed Ipratropium-albuterol (DuoNeb 0.5 mg(milligram)-2.5 mg/3 mL (milliliters) inhalation solution) three times a day. The nebulizer treatment was scheduled to be given at 7:00 AM, 2:00 PM…

    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 · D2023-07-13 · tag F0710 — isolated
    Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one resident ( Resident #60) of one resident reviewed for physician services, had physician's orders for care and treatment upon admission, resulting in the lack of necessary medications, including medication to treat the resident's pain. Findings Include: Resident #60: Pain Management: On 7/11/23 at 11:49 AM, Resident #60 was observed lying in bed in her room with a visitor sitting in a chair beside her. She said she was admitted to the facility from the hospital the day prior 7/10/2023 about 5:00 PM. The resident said she came to the hospital after falling and obtaining a right hip fracture. She said she was having pain, but the nurse told her the physician had not provided orders and the resident could not have any medications including pain medication. Resident #60 said the nurse provided an ice pack to apply to her right hip and it did help some with the pain. The resident said she did not receive pain medication until the next day…

    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 · D2023-07-13 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure staff competence and education for abuse for two of five staff members, resulting in the staff lacking necessary qualifications to provide safe resident care. Findings Include: FACILITY Sufficient and Competent Nurse Staffing: On 7/13/23 at 3:43 PM, staff education was reviewed with Staff Educator A and the Director of Nursing/DON. The facility is connected to a hospital and staff from the hospital float to the facility from the hospital to work as needed. The staff from the hospital did not all receive Long Term Care required education. A review of the yearly training and competencies revealed some of the competencies did not have a year on them: Staff D and F. Staff H's Yearly competency was dated 10/1/2019; it was her new hire competency. There was no more recent competency received. Staff D, F and G did not have yearly Abuse training. During the interview on 7/13/2023 at 3:45 PM, the DON and Staff Educator were asked about the lack of required staff education, and both said the facility was working to develop 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-13 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1) Properly store/secure medications for Resident #109 and a cart that stored skin/wound treatments and prescribed skin applications and 2) Label intravenous (IV) fluids and IV tubing for Resident #112, of two medication carts, one medication room and one treatment cart reviewed for proper storage and expired medications and one resident with IV infusion, resulting in the potential for drug diversion, ingestion of medicated substances, and phlebitis/infections. Findings include: Resident #109: A review of Resident #109's medical record revealed an admission into the facility on 2/20/23 and re-admission on [DATE] with diagnoses that included acute kidney failure, chronic kidney disease, diabetes, heart disease and glaucoma. A review of the Minimum Data Set assessment revealed the Resident had a Brief Interview of Mental Status score of 11/13 that indicated mild cognitive impairment and needed assistance with activities of daily living. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-13 · tag F0809 — failed to serve meals on a reasonable schedule — isolated
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide Resident #112, who had signs/symptoms of hypoglycemia and diagnoses of diabetes, with a bedtime (HS) snack and offer HS snacks to a Confidential Group of residents, of three residents reviewed for food services, resulting in the potential for uncontrolled blood glucose levels, signs and symptoms of hypoglycemia, feelings of frustration and hunger. Findings include: Confidential Group: On 7/13/23 at 10:15 AM, a group of two Residents were interviewed for a confidential group of Residents. The Residents were asked if they receive a snack at nighttime or if they request them. Both Residents reported they were not offered a nighttime snack and did not know they could ask for a snack at nighttime or at any time. One Resident reported she would order one but that there was not an option on the menu. A Resident stated, a snack has never been mentioned, and I didn't know it was an option. A Resident reported it was a long time between dinner and breakfast the next day and both Residents reported they wanted to…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-13 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure that the required composition of the Quality Assurance Process Improvement (QAPI) committee members were in attendance for 2 of 4 quarterly meetings, resulting in the potential for impaired resolution of services, unidentified issues or decreased quality of care with the potential to effect all 11 residents in the facility. Findings Include: FACILITY QAPI and QAA: On 7/13/23 at 3:55 PM, during a review of the Quality Assessment Process Improvement/QAPI meetings with the Director of Nursing/DON she said she was new to the facility and had been there since May 1, 2023. She said the committee met quarterly and the next meeting would be the 3rd week in July. During the review, it was noted that the March 2023 and September 2022 meetings lacked the required attendees. Only 5 staff attended the March 28, 2022 meeting. The Administrator did not attend. The September 30, 2022 meeting again had five attendees: the DON, Hospital Chief Nursing Officer filling in for the Administrator, the Medical Director, Social Worker and an…

    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 · D2023-07-13 · tag F0947 — failed to train nurse aides adequately — isolated
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure that 1 of 3 nurse aides, reviewed for mandatory 12 hours of yearly training,, had the required training, resulting in the potential for the nurse aides to not be able to safely provide the necessary care and services for the residents of the facility. Findings Include: FACILITY Sufficient and Competent Nurse Staffing: During a review of education documents for CNA's working in the facility, it was identified that 1 Certified Nursing Assistant D did not have the mandatory 12 hours of yearly CNA training for Long Term Care. On 7/13/23 at 3:43 PM, staff education was reviewed with Staff Educator A and the Director of Nursing/DON. The facility is connected to a hospital and staff from the hospital float to the facility to work as needed. The DON and Staff Educator were asked if the staff from the hospital receive Long Term Care specific education, they said they did not all have the training. A review of CNA training revealed 1 of 3 CNA's did not have the required 12 hours of CNA training as required. Certified Nursing…

    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

“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.

Who owns this facility

Owner / managerTypeRoleSince
MCLAREN HEALTH CARE CORPORATIONOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/1992
BURKE, MICHAELIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 03/30/2020
BURROUGH, ERICIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 01/01/2016
GRANT, CHADIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 07/29/2019
INCARNATI, PHILIPIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 10/01/1992
NOUNOU, MAJEDIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 02/19/2025
RIEHL, ROBERTIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 02/19/2025
SCOTT, JUSTUSIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 01/01/2003
SHARMA, VISHNUIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/19/2025
SMITH, D. WESLEYIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 02/19/2025
DAVIS, TIFFANYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNFsince 02/19/2025
VARGAS, TIMOTHYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNFsince 02/19/2025

CMS files one row per role, so the 29 rows in the source record cover these 12 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.

1 organizational owner 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.

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 235577. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-04, 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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