Medilodge of Ludington
1000 East Tinkham Avenue, Ludington, MI 49431 · For profit - Limited Liability company · 93 certified beds · (231) 845-6291 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 3 actual-harm citations
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $40,404 in federal fines (most recent 2025-08-29)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.4% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.3% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.6% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 8.6% | 4.3% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.0% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.5% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.3% | 19.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 74.0% | 95.0% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 4.9% | 5.1% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 21.7% | 20.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.9% | 14.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 68.2% | 79.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.5% | 24.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 20.1% | 11.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.08 | 1.84 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.48 | 1.64 | 1.80 | worse |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
60.2% 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 103 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 69.8% 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 63 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 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 44% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 60.2%CMS range 49.8–69.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 8.1–14.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 69.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 54.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 57.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 92.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.4%CMS range 5.1–13.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.75 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 93 beds and averages 82.3 residents a day — about 88% occupied, or roughly 11 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 3.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.54 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.19 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 3.13 hrs/resident/day on weekends vs 4.27 on weekdays — 27% thinner on weekends — a notable drop. RN hours go from 1.79 to 0.93 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
33 citations, most serious first. The 13 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · Gcited before2026-03-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2646749 Based on interview and record review the facility failed to appropriately stabilize 1 resident after a fall (R93), out of 2 residents reviewed for falls, resulting in increased pain, transfer to the hospital, and death. Findings:Resident #93 (R93)Review of an admission Record reflected R93 admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, osteoarthritis, spondylosis without myelopathy or radiculopathy (age-related degeneration of the spine involving disc wear and bone spurs without spinal cord compression), wedge compression fracture of T5-T6 (thoracic vertebra), and multiple fracture of ribs, bilateral. Review of a Nursing Evaluation Summary dated [DATE] reflected, (R93) was educated on call light use and the importance of using the call light system and the importance of calling for assistance, however, she has continuously been getting herself out of bed and into the bathroom on her own without calling for assistance.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-08-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess and treat two residents (Resident #1 and Resident #2) for acute changes, out of four residents reviewed, resulting in the need for emergency medical attention for both residents. Findings:Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old-female, originally admitted to the facility on [DATE], with pertinent diagnoses of presence of a cardiac pacemaker, a prosthetic heart valve, and implanted cardiac defibrillator, morbid obesity, high blood pressure, chronic kidney disease stage 3, atrial fibrillation, chronic obstructive pulmonary disease, and congestive heart failure. Review of a physician progress note for R1, dated 06/27/25, reflected .(R1s) multiple medical issues necessitate frequent clinical evaluations, placing (R1) at moderate risk for readmission to the hospital without frequent monitoring and skilled intervention .frequent monitoring and management by trained clinicians is essential to safeguard (R1'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.
- Actual harm · Gcited before2025-04-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes M100151387 and M100151421. Based on observation, interview and record review, the facility failed to prevent hospitalization, monitor, assess, intervene, document, and provide appropriate care of nephrostomy tubes for 2 (R1 and R2) of two residents reviewed for nephrostomy care, resulting in hospitalization and infection. Findings include: Resident #1 (R1) Review of a Face Sheet revealed R1 originally admitted to the facility on [DATE] and readmitted to the facility after a hospitalization on 3/31/25. Pertinent diagnoses include hydronephrosis (urine build up on kidney) with renal and ureteral calculous (kidney stones) obstruction (1/14/23), infection and inflammatory reaction due to nephrostomy catheter (3/31/25), acute pyelonephritis (kidney infection) (3/31/25), urinary tract infection (3/31/25), and Escherichia coli (E. coli, a bacterium that causes infection, 3/31/25). Review of the Minimum Data Set (MDS) dated [DATE] for R1 revealed she is cognitively intact had 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.
- Potential for harm · Ecited before2026-06-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 3042861 Based on interview and record review, the facility failed to ensure residents who required two people to assist with transfers, were transferred by two people at all times for 4 residents (R5, R6, R7, and R9) out of 10 residents reviewed for accidents and hazards. Findings include:During an interview on 6/23/2026 at 10:30 AM, Confidential Informant (CI) K reported that there are 6 people on the hall she is assigned to that require two people for assistance with transfers but there is not enough staff to get to everyone in time leading to making residents wait for help. CI K said that when one person goes on break, staff can't help everyone who needs it. During an interview on 6/24/2026 at 8:12 AM, CI K reported that they will often transfer residents who require a mechanical lift with only one person. According to CI K, there should always be two people assisting with transfers that require either a lift or a sit to stand, but that isn't possible due to not being able to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-06-24 · tag F0725 — failed to have enough nursing staff — patternProvide 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 pertains to intake 3042861 Based on observation, interview, and record review, the facility failed to ensure staff were deployed in sufficient numbers to meet the needs of 6 residents (R3, R10, R5, R6, R7 and R9) out of 10 residents reviewed for staffing. Findings include:R3Review of a Face Sheet reflected R3 admitted to the facility with diagnoses that included Parkinson's disease with dyskinesia, age related osteoporosis, orthostatic hypotension, repeated falls and depression. Review of a Care Plan initiated on 6/3/2025, reflected R3 had an Activities of Daily Living (ADL) self-care deficit related to her diagnoses and needed one person to assist with ambulation and toileting. The care plan also specified encourage use of visual prompts on beside table for reminder to use call light and walker. Further review of the entire care plan indicated R3 was at risk for falls and was on a toileting program to prevent falls and address R3's risk for incontinence. During an interview on 6/23/26 at 11:13 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.
- Potential for harm · Fcited before2026-03-11 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 interview and record review, the facility failed to implement an effective and current system of surveillance of staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak for 2 of 18 residents (Residents #35 and #59) and all residents residing in the facility, reviewed for infection prevention and control.Findings:Employee Line ListReview of the February Infection Surveillance Report revealed:A Registered Nurse called off of work for GI with an onset date of 2/2/26.An Activities Staff Member called off of work for GI with an onset date of 2/9/26.A Registered Nurse called off of work for GI with an onset date of 2/11/26.A Certified Nursing Assistant called off of work for Other with an onset date of 2/13/26.A Certified Nursing Assistant called off of work for GI with an onset date of 2/13/26.A Certified Nursing Assistant called off of work for Other with an onset date of 2/16/26.An office staff member called off of work for Other with an onset…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-11 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications were administered in accordance with physician orders for 2 of 8 residents (Resident #6 and #8) reviewed for nursing professional standards of practice.Findings:Resident #6 (R6) Review of an admission Record revealed R6 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: anxiety. Review of R6's Order Summary dated 8/13/26 revealed, LORazepam (Ativan) Tablet 0.5 MG Give 0.25 mg by mouth in the morning for anxiety Give 1/2 tab in the morning. Review of R6's Order Summary dated 8/12/26 revealed, LORazepam Tablet 0.5 MG Give 0.5 mg by mouth at bedtime for anxiety Give 1 tab PO at bedtime. Review of R6's Control Substance Record revealed that on 2/14/26 at 7:30 PM and 2/15/26 at 8:30 PM, R6 was dispensed Ativan 0.25 mg (1/2 tablet). Review of R6's February Medication Administration Record revealed that on 2/14/26 at 7:30 PM and 2/15/26 at 8:30 PM Ativan 0.5 mg (1 tablet) was documented…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-11 · tag F0741 — failed to have staff trained for behavioral health — patternEnsure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
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 intakes #: 2652909 and 2646749Based on interview and record review, the facility failed to provide sufficient staff with the knowledge and skills sets to support and assist residents experiencing agitation and confusion and implement meaningful behavioral interventions for 5 of 18 residents (Residents #67, #19, #91, #57, and #85), reviewed for behavioral health needs.Findings:Review of a Complaint Investigation Report dated 10/17/25 the following anonymous complaint, Complainant states that there are quite a few residents with mental health issues on the floor that aren't safe, and they should not be in this facility Complainant states that management should be coming in to assist when there are not enough staff present, but they don't .Resident #67 (R67)Review of an admission Record revealed R67 was a [AGE] year-old male, admitted to the facility on [DATE].Review of a Minimum Data Set (MDS) assessment for R67, with a reference date of 2/8/26 revealed a Brief Interview for Mental Status…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # 2646749Based on observation, interview and record review, the facility failed to provide timely care to one (Resident #33) of three residents reviewed for dignity. Findings: Resident #33 (R33) Review of a Face Sheet revealed R33 was an [AGE] year-old male, last admitted to the facility on [DATE], with pertinent diagnoses of dementia and a stroke that caused weakness to the left side of his body. R33 was dependent on one staff person for all activities of daily living. During an observation on 3/09/26 at 10:02 AM, R33 laid in bed resting with his eyes closed, knees bent, and his heels resting on the mattress. The room smelled strongly of feces. R33 laid in a large, dried area of diarrhea. During an interview on 3/09/26 at 10:15 AM, Certified Nurse Aide (CNA) F reported not checking on R33 since arriving on the unit at 7:00 AM. CNA F stated that she had not yet gotten to R33 due to being the only CNA on the north-east hall this am and the high acuity levels. During an observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-11 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's right to designate a representative was supported and accurately recorded in the medical record for 1 of 8 residents (Resident #27) reviewed for resident rights.Findings:Resident #27 (R27)Review of an admission Record revealed R27 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure, type 2 diabetes, lymphedema, and severe morbid obesity.Review of a Minimum Data Set (MDS) assessment for R27, with a reference date of 3/9/26 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated R27 was cognitively intact. Review of R27's Care Plan dated 9/8/23 revealed, Resident plans to stay long-term in the Skilled Nursing Facility.Actively involve the resident/family in the resident's plan of care.Encourage on-going involvement with family and friend(s).Review of R27's admission Record on 3/10/26 at 2:24 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.
- Potential for harm · D2026-03-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #: 2646749Based on interview and record review, the facility failed to 1.) implement the facility policy for pressure injury prevention and management 2.) ensure pressure injury assessments were comprehensive and accurate, and 3.) ensure treatments were ordered and completed for 1 of 2 residents (Resident #27) reviewed for pressure injury prevention and management.Findings:Resident #27 (R27)Review of an admission Record revealed R27 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure, type 2 diabetes, lymphedema, and severe morbid obesity. Further review of R27's admission Record on 3/10/26 at 2:24 PM revealed that R27's niece (Family Member [FM] P) was documented as his Responsible Party-Clinical and Emergency Contact #1.Review of a Minimum Data Set (MDS) assessment for R27, with a reference date of 3/9/26 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform a comprehensive root cause analysis and implement meaningful interventions/preventative measures following a fall for 1 of 9 residents (Resident #27) reviewed for accidents and hazards.Findings:Resident #27 (R27)Review of an admission Record revealed R27 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure, type 2 diabetes, lymphedema, and severe morbid obesity. Further review of R27's admission Record on 3/10/26 at 2:24 PM revealed that R27's niece (Family Member [FM] P) was documented as his Responsible Party-Clinical and Emergency Contact #1.Review of a Minimum Data Set (MDS) assessment for R27, with a reference date of 3/9/26 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated R27 was cognitively intact. Review of R27's Witnessed Fall incident report dated 2/24/26 revealed: 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.
- Potential for harm · D2026-03-11 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure 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 Based on interview and record review the facility failed to include the Interdisciplinary Team (IDT) and psychiatric provider in the process of the gradual dose reduction of an antipsychotic medication for 1 of 5 residents (Resident #83) reviewed for psychotropic medication use.Findings:Resident #83 (R83)Review of an admission Record revealed R83 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with agitation with psychotic disturbances.During an observation on 03/09/2026 at 10:33 AM, R83 was observed in the hallway loudly yelling, I want to get out! She continued to yell in the hallway and self-propelled herself in her wheelchair across the hall and attempted to enter room [ROOM NUMBER]. The resident in room [ROOM NUMBER] stated R83 was always yelling and attempting to enter other rooms. The resident reported her behaviors were constant.Review of R83's Psychiatry Follow-up note dated 1/13/26 revealed, GDR quetiapine (seroquel) 25 mg tablet.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · D2026-03-11 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for 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 interview and record review, the facility failed to obtain dental services to replace a missing lower denture in a timely manner for 1 resident (R10) out of 1 resident reviewed for dental services.Resident #10 (R10)Review of an admission Record reflected R10 admitted to the facility on [DATE] with diagnoses that included osteoporosis without current pathological fracture, depression and anxiety.Review of a Care Plan Report initiated on 10/15/2024 R10 has a dental problem related to being edentulous, with a goal of reduced complications related to dental/oral issues. Interventions included in the Care Plan included Refer to dental services as needed.During an interview on 3/09/2026 at 10:12 AM, R10 states that she lost the lower denture when she accidentally put them on a meal tray and they got thrown away. R10 indicated the Nursing Home Administrator (NHA) is aware and told her he wanted to wait to see what Medicaid would cover. R10 reported it's been a long time since she lost her lower denture, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-09 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 Intake 1268402Based on observations, interview, and record review, the facility failed to ensure 1 resident (Resident#1) of 3 was free from verbal abuse when a staff member swore about the resident's behavior. Findings include:Review of Policy Abuse, Neglect and Exploitation last revised 1/10/24 revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy defined Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-18 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes M100151387 and M100151421. Based on observation, interview and record review, the facility failed to ensure staff were competent to manage care for two (R1 and R2) of two residents reviewed for nephrostomy care, resulting in hospitalization and repeated incompetent care. Findings include: Review of the State Operations Manual (SOM) 483.35(a)(3) reflected, The facility must ensure that licensed nurses have specific competencies and skill set necessary to care for residents' needs, as identified through .assessments and .in the plan of care. Resident #1 (R1) Review of a Face Sheet revealed R1 originally admitted to the facility on [DATE] and readmitted to the facility after a hospitalization on 3/31/25. Pertinent diagnoses include hydronephrosis (urine build up on kidney) with renal and ureteral calculous (kidney stones) obstruction (1/14/23), infection and inflammatory reaction due to nephrostomy catheter (3/31/25), acute pyelonephritis (kidney infection) (3/31/25), urinary tract…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-13 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide needed services to ensure the dignified well-being of three residents (R47, R5, and R71) and the potential for all dependent residents to have unmet needs. Findings include: R47 The medical record reflected R47 admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease and Protein Calorie Malnutrition. The Minimum Data Set (MDS) dated [DATE] reflected R47 was moderately cognitively intact, had a urinary catheter, was frequently incontinent of stool, and was receiving end-of-life care. On 2/11/25 at 10:20 AM an observation and interview were conducted with R47 in his room. A soft-touch call light was observed at his side and urinary catheter tubing and a collection bag were noted. R47 reported several instances when he had soiled himself and had to wait for over an hour for staff to help him. When asked about using his call light R47 reported If I can find it (the call light) that the response wait times…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-13 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 follow their policy for transfers for one (R61) of one resident reviewed for hospital transfers. Findings Include: Review of a policy titled Transfer and Discharge (including AMA (Against Medical Advice)) last reviewed/revised 10/30/23 revealed: Emergency Transfers/Discharges- . a. obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. d. Complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents: Review of a Face Sheet for R61 revealed she originally admitted to the facility on [DATE]. Review of the SBAR (Situation-Background-Assessment-Recommendation) dated 2/6/25 for R61 revealed she had a change of condition and was sent to the hospital. This form is to be sent with the resident to the hospital. Review of the Electronic Medical Record (EMR) for R61 revealed there were no physician orders to transfer to 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.
- Potential for harm · D2025-02-13 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a bed hold policy to one (R61) of one resident reviewed for hospitalization. Findings include: Review of a Face Sheet for R61 revealed she originally admitted to the facility on [DATE]. Review of the SBAR (Situation-Background-Assessment-Recommendation) dated 2/6/25 for R61 revealed she had a change of condition and was sent to the hospital. Review of the EMR (Electronic Medical Records) for R61 revealed no Bed Hold Policy was provided for her transfer to the hospital on 2/6/25. In an interview on 2/13/25 at 3:11 PM, the Director of Nursing (DON) reviewed R61's EMR and could not find documentation indicating that the resident received a Bed Hold Policy when she transferred to the hospital on 2/6/25, noting that she should have received one. Review of a policy titled Transfer and Discharge (including AMA (Against Medical Advice)) last reviewed/revised 10/30/23 revealed: Emergency Transfers/Discharges- . a. obtain physicians' orders for emergency…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-24 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably 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 This citation pertains to intake #MI00147480 Based on observation, interview, and record review, the facility filed to provide care to accommodate the needs of 5 of 5 residents reviewed. Findings: During an observation on 10/23/24 at 8:10 AM, the resident in bed 48-1 laid in bed resting with eyes closed. The call light was clipped to the privacy curtain out of sight and out of reach of the resident. During an observation on 10/23/24 at 8:20 AM, the following were noted for the resident in bed 2-1: (a) the touch pad call light laid on the residents lower right quadrant of his torso. The resident stated he could not reach the touch pad to call for assistance because he is a quadriplegic, (b) an empty cup with a straw sat on the over the bed table and the resident stated he was very thirsty but was not able to alert staff that he needed more water, (c) the resident's lips were dry and cracked, (d) both legs had contractures and there was not a pillow between his legs to reduce pressure, and (d) there were no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-24 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake # MI00-147480 Based on observation, interview, and record review, the facility failed to secure 1 of 4 medication carts and failed to follow guidelines for preparing, storing, and dating medications. Findings: During an observation on 10/23/24 at 8:25 AM, the northeast medication cart was unlocked and not attended by nursing staff. During the same observation the following additional observations were made: (a) a small plastic and unlabeled medication cup sat in the top drawer of the unlocked med cart and contained 4 unidentified pills, (b) a novolin 70/30 insulin flex pen prescribed to the resident in bed 26-1 did not have a date identifying when it was opened, (c) a levemir insulin flex pen prescribed to the resident in bed 9-2 did not have a date identifying when it was opened, (d) a toujeo solostar insulin pen prescribed to the resident in bed 29-1 did not have a date identifying when it was opened, (e) a humalog insulin kwik pen prescribed to the resident in bed 22-2 did not have a date identifying when it was opened, (f) a basaglar insulin pen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-24 · tag F0880 — failed to prevent and control infections — patternProvide 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 This citation pertains to intake #MI00147635 Based on observation, interview, and record review, the facility failed to follow standards of practice for enhanced barrier precautions for 3 of 3 resident's reviewed and failed to follow infection control practices for oxygen storage for 1 of 3 resident's, and for laundry services. Findings: Enhanced Barrier Precautions: During an observation on 10/23/24 at 8:05 AM, the resident residing in bed 2-1 was found to have a urostomy (an indwelling medical device that evacuates urine directly from the kidneys to a bag outside the body) and a wound. There were no gowns or gloves readily available to the staff when performing high contact care activities for this resident. There were no signs near the room to alert staff that the resident in bed 2-1 was on enhanced barrier precautions (EBP). During an observation on 10/23/24 at 8:20 AM, the resident residing in bed 64-1 was found to have a PICC (peripherally inserted central catheter) and had returned to the facility last…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-25 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s: MI00146057 and MI00145975 Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 5 of 11 residents (Resident #3, #7, #11, #13, and #2), reviewed for the provision of nursing services, resulting in medication errors and medications being administered outside of the physician ordered parameters. Findings: Resident #3 (R3) Review of an admission Record revealed R3 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: hypotension. Review of R3's Order Summary dated 9/3/24 revealed, Midodrine HCl Oral Tablet 10 MG (Midodrine HCl) Give 1 tablet by mouth with meals for hypotension Hold for systolic >120 (top number of blood pressure greater than 120). To be administered at 8:00 AM, 12:00 PM, and 6:00 PM (a blood pressure assessment was to be completed prior to each dose of Midodrine to ensure parameters were followed). Review of R3's September…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-25 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement their abuse and neglect policy and procedure for 1 resident (R8) of 4 residents reviewed for abuse and neglect from a total sample of 13 residents, resulting in allegations of neglect not being reported to the state survey agency, allegations of neglect not being thoroughly investigated, the potential for abuse and neglect to go undetected, and the potential for residents not being protected from ongoing abuse and neglect. Findings: Review of an admission Record reflected R8 admitted to the facility on [DATE] from a private home. Pertinent diagnoses included hemiplegia (complete paralysis) and hemiparesis (weakness or partial paralysis) on one side of the body due to a stroke; vascular dementia without behavioral disturbance, oropharyngeal dysphagia (swallowing problems), type 2 diabetes, and required the use of a suprapubic catheter to empty her bladder. Review of an admission Minimum Data Set (MDS) assessment dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-25 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide appropriate treatment and services and carry out Activities of Daily Living (ADL) assistance for 1 resident (R8) of 2 residents reviewed for ADLs from a total sample for 13 residents. Findings: Review of an admission Record reflected R8 admitted to the facility on [DATE] from a private home. Pertinent diagnoses included hemiplegia (complete paralysis) and hemiparesis (weakness or partial paralysis) on one side of the body due to a stroke; vascular dementia without behavioral disturbance, oropharyngeal dysphagia (swallowing problems), type 2 diabetes, and required the use of a suprapubic catheter to empty her bladder. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] indicated R8 required setup or clean-up assistance with eating, was totally dependent on staff for oral hygiene, toileting, dressing, personal hygiene, bed mobility including rolling, sitting up, lying down from sitting and transfers. R8 required the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate treatment for the care of a suprapubic catheter was carried out for 1 resident (R8) out of 13 residents reviewed for quality care, resulting in the potential for complications from infection and/or skin breakdown. Findings: Review of an admission Record reflected R8 admitted to the facility on [DATE] from a private home. Pertinent diagnoses included hemiplegia (complete paralysis) and hemiparesis (weakness or partial paralysis) on one side of the body due to a stroke; vascular dementia without behavioral disturbance, oropharyngeal dysphagia (swallowing problems), type 2 diabetes, and required the use of a suprapubic catheter to empty her bladder. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] indicated R8 required setup or clean-up assistance with eating, was totally dependent on staff for oral hygiene, toileting, dressing, personal hygiene, bed mobility including rolling, sitting up, lying down…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-09 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
This Citation pertains to Intake Number MI00145415. Based on observation, interview, and record review, the facility failed to safeguard the confidentiality of medical records for 12 of 73 residents (R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17), resulting in the potential for unauthorized access to residents' medical records and the potential for the loss of resident privacy and the confidentiality of their personal health information. Findings include: During an observation on 7/8/24 at 11:20 AM, the computer screen on top of the Northeast Wing Medication Cart (for Rooms 17 to 23- as identified by facility staff) was observed open to multiple residents' (R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17) electronic Medication Administration Records (e-MAR), which included personal and health identifying information (i.e., residents' names, room numbers, and medical record numbers). This information was visible to anyone walking by the medication cart. In addition, anyone walking by the medication cart could have stopped and accessed any of the residents'…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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
This Citation pertains to Intake Number MI00145415. Based on observation, interview, and record review, the facility failed to secure 1 of 5 medication carts (Southwest Medication Cart), resulting in narcotics/controlled substances not being under double lock, resident medications not being secured, the potential for unauthorized individuals gaining access to the medication cart, and the potential for medication theft. Findings include: During an observation on 7/8/24 at 3:25 PM, the Southwest Medication Cart was observed in the hallway unlocked (the red dot on the locking mechanism was visible) and unattended. Staff were not within visual range of the medication cart at the time it was observed unlocked. Therefore, surveyor was able to open the drawers on the medication cart that contained individual residents' medications and floor stock medications (i.e., bottles that contained medications that could be used by multiple residents- e.g., Tylenol, general use multivitamins, antacids) unobserved by facility staff. The nurse assigned to the medication cart (Registered Nurse (RN) C)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-24 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 Based on observation, interview, and record review, the facility failed to ensure 3 residents (Residents #29, #57, and #60 ) were cared for in a manner that enhanced their quality of life, promoted resident dignity, and assured equal access to quality care and services regardless of the level of staff support required when requests for assistance were not met in a timely manner. Findings: Resident #29 (R29) Review of a Progress Notes in the Electronic Medical Record (EMR) revealed R29 admitted to the facility on [DATE] after a hospitalization for exacerbation of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF) with diagnosis that included coronary artery disease (CAD), a history of a heart attack, high blood pressure, high cholesterol, chronic pain with a history of a compression fracture in her back, restless leg syndrome and was dependent on oxygen. Review of an admission Minimum Data Ser (MDS) assessment dated [DATE] reflected R29 was cognitively intact as evidenced by a BIMS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-24 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to implement adequate Infection Surveillance that included consistent tracking of employee, volunteer, and contract employee infections, as appropriate, to monitor for trends, mitigate the potential for Outbreaks of infectious disease and aide in conducting outbreak investigations. Findings: Review of a policy Infection Surveillance last reviewed/revised 10/26/2023 reflected A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections, monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. 'Infection Surveillance' refers to an ongoing systematic collection, analysis, interpretation, and dissemination of infection-related data. The policy specified that the surveillance would include infection site, pathogen (if available), signs and symptoms, location within the facility of the illness and a summary and analysis of the number of residents and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-24 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to recognize and implement a Durable Power of Attorney, in a timely manner for 1 resident (Resident #56) from a total sample of 18 residents reviewed for Advanced Directives, who demonstrated impaired decision making capacity and defer to the established Attorney-in-fact who could act in the best interest of the resident based on their wishes. Findings: Resident #56 (R56) Review of an admission Record reflected R56 admitted to the facility from home on [DATE] with diagnosis that included schizophrenia, bipolar disorder, drug induced parkinsonism, high blood pressure, muscle weakness, difficulty in walking, need for assistance with personal care, urine retention, presence of urogenital implants, and a personal history of breast cancer. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] reflected R56 admitted from a Short-Term General Hospital. R56 was assessed as being severely cognitively impaired as evidenced by a Brief Interview for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-24 · tag F0847 — isolatedInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain appropriate witness to certify 1 of 4 residents reviewed for Binding Arbitration (Resident #56) from a total sample of 18 residents was of sound mind and competent to make informed consent for a facility staff member to initial and sign an Alternative Dispute Resolution Agreement (binding arbitration) on their behalf; failed to document the resident understood the terms of the binding arbitration agreement and waive their right to a trial by judge or jury to have some or all dispute claims heard in a court proceeding. Findings: Resident #56 (R56) Review of an admission Record reflected R56 admitted to the facility from home on [DATE] with diagnosis that included schizophrenia, bipolar disorder, drug induced parkinsonism, high blood pressure, muscle weakness, difficulty in walking, need for assistance with personal care, urine retention, presence of urogenital implants, and a personal history of breast cancer. Review of an admission Minimum Data…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake MI-000138952 Based on interview and record review, the facility failed to completely transcribe admission orders and obtain clarification orders from a surgeon for one resident (Resident #7), resulting in the potential for postoperative complications including wound infection and anemia. Findings: Resident #7 (R7) Review of an admission Record reflected R7 admitted to the facility from a hospital on 7/24/23 with pertinent diagnosis that included nondisplaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, encounter for other orthopedic aftercare, acute posthemorrhagic anemia and other specified abnormal findings of blood chemistry. Review of a Care Plan initiated on 7/26/2023 reflected R7 had impaired skin integrity as evidenced by/related to a surgical incision. The goal of the care plan was that R7 would show signs of healing and/or improvement. Interventions included Labs as ordered; Notify Nurse of any new areas of skin impairment noted during bathing or daily care; Notify physician/NP…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$40,404 in federal fines across 1 penalty.
- $40,404 — penalty dated 2025-08-29
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to MEDILODGE — 53 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.1 | -1.1 vs chain |
| Health inspection | 2 of 5 | 2.7 | -0.7 vs chain |
| Staffing | 4 of 5 | 3.7 | +0.3 vs chain |
| Quality measures | 3 of 5 | 4.0 | -1.0 vs chain |
The other 52 homes this chain runs (chain average 3.1★, per CMS)
Showing 40 of 52; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EVEREST OPCO GROUP LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/01/2018 |
| B&Y HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| B&Y TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| CODY HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| CRAIG FLASHNER 2007 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| NORCROSS, ROBERT | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 02/01/2018 |
| ROGERS, STACEY | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 02/01/2018 |
| KIRK, KRISTINE | Individual | W-2 MANAGING EMPLOYEE | — | since 02/01/2018 |
| FLASHNER, CRAIG | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
| PERLSTEIN, YITZCHOK | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
| BLOSSOM HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
| PRESTIGE ADMINISTRATIVE SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
CMS files one row per role, so the 14 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
7 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.
This home reported $485K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235358. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.