Norlite Nursing Center
701 Homestead Street, Marquette, MI 49855 · For profit - Corporation · 99 certified beds · (906) 228-9252 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 Jan 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $113,129 in federal fines (most recent 2023-12-14)
- its payroll- and facility-reported staffing and quality-measure scores sit 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 | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.8% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.0% | 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 | 2.1% | 1.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 1.1% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.8% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.6% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.2% | 19.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 8.3% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.1% | 14.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.5% | 1.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 15.9% | 24.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.4% | 11.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.13 | 1.84 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.70 | 1.64 | 1.80 | typical |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 53 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 21 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.07 therapist hours per resident per day in 2026Q1 — more than 3% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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 | 58.5%CMS range 46.3–70.5 | 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 | 9.9%CMS range 6.2–15.1 | 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 | 71.4% | 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 | 71.4% | 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 | 71.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.6–13.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 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 99 beds and averages 80.5 residents a day — about 81% occupied, or roughly 18 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.29 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.84 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.66 hrs/resident/day on weekends vs 4.54 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.50 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% 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.
28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2026-01-28 · tag F0675 — failed to support quality of life — isolatedHonor each resident's preferences, choices, values and beliefs.
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 the necessary equipment was readily available to provide care for two dependent Residents (#62 and #46) out of 18 residents reviewed for quality of life. This deficient practice resulted in emotional distress, feelings of frustration, social isolation, and physical discomfort.Findings include:Resident #62 (R62)Review of R62's Electronic Medical Record (EMR) revealed initial admission to the facility on 3/8/23 with diagnoses including hemiparesis (partial weakness, reduced strength, and/or impaired motor function on one side of the body) following cerebral infarction (stroke), multiple sclerosis (MS), muscle weakness, and need for assistance with personal care. Review of R62's most recent Minimum Data Set (MDS) assessment, dated 12/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.On 1/26/2026 at 4:03 PM, R62 was observed in bed lying in bed with greasy, unkempt hair.On 1/26/2026 at 4:06 PM, an interview was conducted with R62 regarding overall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-12-14 · 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 Based on observation, interview, and record review, the facility failed to prevent a Resident-to-Resident physical abuse, resulting in minimal harm for one Resident (R38) of two residents reviewed for abuse. This deficient practice resulted in numerous bruising sites and persistent fear of further abuse. Findings include: Intake Number: MI00139309 Review of the Facility Reported Incident (FRI) dated 9/10/23, revealed the following, .On 9/10/23 at 1556 (3:56 p.m.), (R50) exited his room on foot wearing socks, a shirt, and his brief. He glanced up the hall for a moment, and then proceeded to walk across the hall into (R38's) room. This had occurred 3 times prior in the past two weeks per (R38's) report. Upon seeing (R50) in her room again, (R38) removed her TB headphones and said to (R50), This isn't your room. Go back to your room. (R50) became agitated with (R38's) request, and began grabbing, slapping, and flailing at (R38), causing bruising to her R (right) thigh and pain in her upper arms and face. Certified…
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 · F2026-01-28 · tag F0725 — failed to have enough nursing staff — widespreadProvide 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 Based on observation, interview, and record review, the facility failed to provide sufficient staffing to address the care, needs, and safety of the entire facility population. This deficient practice resulted in unmet care needs and the potential for serious safety issues for all 82 residents of the facility.Findings include:On 1/27/26 at 2:05 PM, a confidential group interview was conducted regarding overall perception of nurse staffing levels. Six out of 14 confidential residents (CR's) expressed concerns with receiving timely assistance for care needs as well as the timely passing of meal trays. One CR stated, The place is understaffed, indicating Certified Nursing Assistants (CNAs) were often assigned to cover more than one hallway. CR10 stated the staffing shortage usually gets worse on the weekends.Review of the Resident Council Meeting Minutes revealed the following:1/6/26: .Old Business: . [Facility name] is looking to hire more CNAs to help with the shortage in nursing help concern.12/2/25: .Old…
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 before2026-01-28 · 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 treat five Residents (#10, #30, #35, #37, & #56) with a dignified dining experience out of 18 residents reviewed for dignity. This deficient practice resulted in a lack of personal dignity and feelings of embarrassment based on the reasonable person. Findings include: During dining observation on 1/27/26 the following was observed: Resident #37 (R37) At approximately 12:17 p.m., Licensed Practical Nurse (LPN) Z was observed assisting R37 with a lunch meal in their room. LPN Z was seated next to R37 and was noted to have blue gloves on during the meal service. Resident #10 (R10) At approximately 12:23 p.m., Dining Assistant/Staff BB was observed assisting R10 with a lunch meal in their room. Staff BB was seated next to R10 and was noted to have blue gloves on during the meal service. Resident #56 (R56) At approximately 1:09 p.m., Dietary Aide/Staff AA was observed assisting R56 with a lunch meal in the hallway. Staff AA was seated next 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 · E2026-01-28 · tag F0559 — patternHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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 advanced written notification of a room change for 3 Confidential Residents (CR's) of 14 residents during the resident group interview and one Resident (#6) of one resident reviewed for room changes.Findings include:Resident #6 (R6)Review of R6's Electronic Medical Record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including Alzheimer's disease, panic disorder, generalized anxiety disorder, and obsessive compulsive disorder.Review of Section C: Cognitive Patterns in the most recent Minimum Data Set (MDS) assessment for R6, dated 11/10/25, ranked Cognitive Skills for Daily Decision Making as, Moderately impaired-decisions poor; cues/supervision required.On 1/27/2026 at 9:56 AM, an interview was conducted with the Durable Power of Attorney (DPOA) FF for R6 regarding any care concerns at the facility. DPOA FF indicated the facility had changed R6's room, awhile back without any explanation or written notification.…
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 · E2026-01-28 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain a homelike environment by ensuring resident room temperatures were maintained within the acceptable parameters for two Confidential Residents (CR's) out of 14 residents from a resident group interview and 2 Residents (#39 & #62) of 18 residents reviewed for environmental concerns.Findings include:Resident #62 (R62)Review of R62's Electronic Medical Record (EMR) revealed initial admission to the facility on 3/8/23 with diagnoses including hemiparesis (partial weakness, reduced strength, and/or impaired motor function on one side of the body) following cerebral infarction (stroke), multiple sclerosis, muscle weakness, and need for assistance with personal care. Review of R62's most recent Minimum Data Set (MDS) assessment, dated 12/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.On 1/26/2026 at 4:06 PM, an interview was conducted with R62 regarding overall satisfaction with care at 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 · E2026-01-28 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 appropriate food temperatures and palatability for nine Confidential Residents (CR) of fourteen residents reviewed for food satisfaction.Findings include:On 1/27/26 at 2:05 PM, food palatability, food choices, and mealtimes were discussed at a confidential group interview. 9 out of 14 residents stated their food is almost always cold. One CR stated, [Food] temperature is a problem. Another CR said, Last night's dinner was inedible it was so cold. 6 out of 14 residents stated meals were served at inconsistent times. Yet another CR stated, You have to guess [what time meals will be served]. During the lunch meal, which was specified to hallway trays only due to an infectious outbreak, the following was observed: Hallway trays began on the 500 hall at approximately 12:04 p.m. and ended at 12:14 p.m. It was observed that all meal trays were passed out to resident rooms, even when a resident was not in their room or hallway. Hallway trays began on the 300 hall at approximately 12:23 p.m. and ended at 12:30…
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 before2026-01-28 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 1/27/2026 at 3:30 PM, three boxes of single serve items, including cups and lids, were observed sitting on the storage room floor. The boxes were opened with some of the contents used. When asked about deliveries, Dietary Manager (DM) T stated that the last delivery came in the day before.According to the 2022 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In 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.
- Potential for harm · Dcited before2026-01-28 · 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 #2687526.Based on interviews and record review the facility failed to protect the resident's right to be free from physical abuse by a resident for one Resident (#90) of two residents reviewed for abuse resulting in R82 grabbing R90's head, and based on the reasonable person concept would cause feelings of pain, fear and intimidation for Resident #90.Findings include:Review of an Anonymous Complaint to the State Agency dated 12/8/2025 at 1:58 PM read in part: (R82) grabbed (R90's) head aggressively, (facility staff name omitted) and (facility staff name omitted) intervened between the two. Both nurses called (the Director of Nursing [DON]) immediately after reporting the incident. (The Nursing Home Administrator [NHA]) told (staff name omitted) that he watched the video and (R82) was 'petting' (R90's) head when that was not the case. This was a resident to resident not being reported by the facility .Resident #82 (R82)Review of an admission Record revealed R82, was originally…
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 · D2026-01-28 · 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 This citation pertains to intake# 2687526Based on interviews and record review, the facility failed to fully implement its Abuse Program Policy and Procedure and immediately identify and thoroughly investigate incidents of resident to resident abuse for 2 Residents (Residents #82 & #90) from 18 residents reviewed for abuse and based on the reasonable person concept would cause feelings of pain, fear and intimidation for Residents #90, and the potential for continued resident abuse to go unreported and/or undetected.Findings include:Review of an Anonymous Complaint to the State Agency dated 12/8/2025 at 1:58 PM read in part: (R82) grabbed (R90's) head aggressively, (facility staff name omitted) and (facility staff name omitted) intervened between the two. Both nurses called (the Director of Nursing [DON]) immediately after reporting the incident. (The Nursing Home Administrator [NHA]) told (staff name omitted) that he watched the video and (R82) was 'petting' (R90's) head when that was not the case. This was 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.
- Potential for harm · D2026-01-28 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 #2687526.Based on interviews and record review the facility failed to implement their policy and procedure for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act and as a result of the facility's failure to implement the facility Abuse Policy and ensure resident safety, resulted in R82's physical abuse to continue and placed all residents at risk for serious injury, physical and psychosocial harm, and impairment.Review of an Anonymous Complaint to the State Agency dated 12/08/2025 1:58 PM read in part: (R82) grabbed (R90's) head aggressively, (facility staff name omitted) and (facility staff name omitted) intervened between the two. Both nurses called (Director of Nursing-DON) immediately after reporting the incident. (Nursing Home Administrator-NHA) told (staff name omitted) that he watched the video and (R82) was petting (R90's) head when that was not the case. This was a resident to resident not being reported by 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 · D2026-01-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary supervision to prevent wandering residents entering private resident rooms resulting in feelings of frustration for five Confidential Residents (CR's) out of 14 residents in a confidential group interview and one Resident (#10) out of 18 residents reviewed for quality of care.Findings include:On 1/27/26 at 2:05 PM, a confidential group interview was conducted where several residents voiced their frustration regarding wandering residents entering their personal living quarters. One CR stated, wandering residents came into their room so often, I can't keep my door open. When asked if it takes staff a long time for staff to redirect the resident out of their room, the CR stated, I redirect her because I don't want her near me. She follows me around all day. Another CR added, Yes, there's a problem with wanderers. She [the same resident mentioned above] stares at me and watches what I'm doing. I usually have to redirect…
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 16 citations
- Potential for harm · Dcited before2026-01-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to maintain appropriate standards of infection control practices to prevent the spread of pneumonia for one Resident (R36) of one Resident reviewed for infection control practices. This deficient practice resulted in the potential for continued spread of pneumonia to other residents residing within the facility. Findings include:Review of R36's Progress Notes, read, in part, 1/27/26 at 9:24 a.m., This RN (Registered Nurse) notified by wing change nurse that resident appears to have had a change in condition.droplet precautions initiated, RN supervisor notified and to speak with emergency contact. Wing staff updated on precautions.On 1/27/26 at approximately 1:30 p.m., Hospitality Aide/Staff Y was observed assisting hallway meal trays. To the right of R36's door, a sign was observed which stated R36 was on precautions. Staff Y proceeded to enter R36's room without Personal Protective Equipment (PPE) to drop off her lunch tray. When exiting, Staff Y stated that she should have worn PPE into R36's room.An interview…
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 before2024-11-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 76 residents of the facility. Findings include: On 11/19/24 at approximately 7:20 AM, during morning meal service, a stainless steel pan of the pureed meal was observed on the steam table. [NAME] B was asked to identify the pureed food, to which she stated was, eggs, sausage and hashbrown potatoes. The temperature was measured with a metal stem probe thermometer and found to be 115°F. An interview with [NAME] B was conducted at this time and learned the food was put through a blender process and placed in the steam table. When the measured temperature was shared with [NAME] B, she stated that's not good. [NAME] B then placed the pan into the steamer to reheat. At 7:50 AM an interview was conducted with [NAME] B who was asked what temperature she had re-heated the food to. [NAME] B stated it had been reheated 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 · Ecited before2024-11-21 · 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
Based on observation, interview, and record review, the facility failed to provide a dignified dining experience in their Dining Room (DR) by standing over seated residents while assisting with feeding and failing to serve all residents at the same table together. This deficient practice had the potential to affect all residents dining in the main dining room. Findings include: During the lunch meal service on 11/19/24 at 12:30 PM, approximately 30 residents were observed in the DR. Six of the seven tables with multiple residents seated at them each were partially served. Some residents at each of the six tables were eating while other residents sitting at the tables did not have their meals. One table had one resident eating while three residents and several visitors at the same table were waiting. Approximately 20 minutes later at 12:50 PM, two of the three residents waiting at this table were served while one resident continued to wait. At 1:05 PM, the last resident at this table was served. During an interview on 11/19/24 at approximately 1:10 PM, the visitors at this table who…
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 · E2024-11-21 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one medication cart remained locked when unattended of four medication carts reviewed, and failed to discard two expired glucose meter control solutions of six control solutions reviewed. This deficient practice resulted in the potential for misappropriation of medications for the nine residents on the 500 unit, and the potential for inaccurate blood glucose readings for six residents receiving blood glucose testing. Findings include: On [DATE] at 3:42 p.m. and [DATE] at 1:53 p.m., the medication cart on the 500 unit was unlocked and unattended. The Director of Nursing (DON) was questioned on [DATE] at 8:05 a.m. regarding the expectation for securing the medication carts. The DON said the expectation is for medication carts to be kept locked when not in use and for nurses to lock the medication carts when walking away from them. On [DATE] at 2:44 p.m., the medication storage room was inspected with Licensed Practical Nurse D (LPN…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure adequate nutritional assessment, and interventions for one Resident (#63) of one resident reviewed for significant weight loss. Findings include: Resident #63 (R63): On 11/19/24 at 8:03 AM, R63 said they had been losing weight. R63 denied issues with their teeth or swallowing difficulties that could affect their eating habits. R63 stated they had spoken with the Certified Dietary Manager (CDM) to discuss food preferences, but did not have much hope that the food wood change to R63's liking. Review of R63 Electronic Medical Record (EMR) indicated R63 was admitted to the facility on [DATE]. On 10/24/24, a Brief Interview for Mental Status (BIMS) assessment was completed for R63, resulting in a score of 13 out of 15, indicating R63 was cognitively intact. Review of a progress note dated 11/15/24 at 1:13 PM, CDM note read in part [R63] has experienced an 11# or 9% weight loss over the course of one month . [R63] told the writer she didn't know how…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a change in condition was assessed and monitored by the attending physician for one Resident (#22) of 19 sampled residents. Findings include: Resident #22 (R22) Review of R22's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including acute kidney failure and retention of urine. Review of R22's most recent Minimum Data Set (MDS) assessment, dated 9/26/24, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicative of intact cognition. On 11/21/24 at 8:02 AM, R22 was observed sitting in a wheelchair at a dining room table, slowly propelling forward and backward with his legs. When asked why R22 preferred the continued rocking motion, he stated, My leg still aches . I had a blood clot not too long ago. Review of R22's EMR revealed the following progress notes: 1. 2/27/24 at 14:00 [2:00 PM] written by Licensed Practical Nurse (LPN) G: Resident has 3+ [moderate] pitting edema to BLE…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-21 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure a correct therapeutic diet was prescribed for 2 Residents (#25 and #41) of 5 Residents reviewed for nutritional issues. This deficient practice resulted in the potential for unmet nutritional needs and the potential for health complications. Findings include: Resident #25 (R25) R25 was admitted to the facility 8/19/2020 with diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, dysphagia (difficulty swallowing) and diabetes mellitus. The Minimum Data Set (MDS) assessment dated [DATE] revealed R25 was totally dependent for eating meaning the helper does ALL of the effort. R25 was also coded as dependent for dressing, bathing, toileting and personal hygiene. The Brief Interview for Mental Status (BIMS) assessment was not attempted and was coded No (resident is rarely/never understood). The physician orders included a Diet order: CCD NAS, Pureed (carbohydrate controlled diet, no added salt, pureed). On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and/or prevent or a significant weight loss for one Resident (R2), of three residents reviewed for nutrition. This deficient practice resulted in a significant weight loss of 12.9% within three weeks of admission to the facility for R2. Findings include: Review of R2's Face Sheet revealed the Resident was admitted on [DATE] from an acute care hospital with the following diagnoses, in part: fracture of lower end of right femur, orthopedic aftercare, cellulitis of right lower limb, fall on same level from slipping, tripping, and stumbling without subsequent striking against object, and pressure ulcer of unspecified buttock, Stage 2 . Review of R2's Minimum Data Set (MDS) admission assessment, dated 7/18/24, revealed R2 had one Stage II pressure injury present upon admission, as well as a surgical wound. R2 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. The Resident's height and weight were…
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 · D2024-08-20 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such 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 provide pain management as prescribed by the physician consistent with professional standards of practice for one Resident (R2), of three residents reviewed for pain management. This deficient practice resulted in the consistent late administration of prescribed pain medication and non-administration of available PRN (as needed) pain medication to address R2's pain. Findings include: Review of R2's Face Sheet revealed the Resident was admitted on [DATE] from an acute care hospital with the following diagnoses, in part: fracture of lower end of right femur, orthopedic aftercare, cellulitis of right lower limb, fall on same level from slipping, tripping, and stumbling without subsequent striking against object, and pressure ulcer of unspecified buttock, Stage 2 . Review of R2's Minimum Data Set (MDS) assessment, dated 7/18/24, revealed R2 had one Stage II pressure injury that was present upon admission, as well as a surgical wound. R2 scored 14 of 15 on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-12-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure food contact surfaces were maintained in a clean and sanitary condition. 2. Failing to ensure expired food was discarded. 3. Failing to demonstrate proper testing of the sanitizing solution 4. Failing to maintain non-food contact surfaces in a clean manner. 5. Failing to label food in the walk in freezer which had been removed from its original packaging. 6. Failing to ensure the drain from the ice machine was not subject to back siphonage of contaminated water. 7. Failing to maintain two hand sinks in good repair 8. Failing to maintain walls and floors in a clean condition. These deficient practices have the potential to result in food borne illness among any and all 76 residents of the facility. Findings include: 1. On 12/12/23 at approximately 4:20 PM, the counter mounted slicer, located in the kitchen next to the bread rack and covered with a plastic bag. This…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement interventions to address care needs for three Residents (R39 & R50) of 18 residents reviewed for care planning. This deficient practice resulted in lack of adequate care plans to ensure appropriate care was provided. Findings include: Intake: MI00139309 R50 Review of R50's Electronic Medical Record (EMR) revealed admission to the facility on 2/28/22 with diagnoses including dementia with behavioral disturbance, visual hallucinations, and insomnia. R50's 8/17/23 MDS assessment revealed he scored a 7/15 on the BIMS, indicating moderate cognitive impairment. Review of the Facility Reported Incident (FRI) dated 9/10/23, revealed the following, .On 9/10/23 at 1556 (3:56 p.m.), (R50) exited his room on foot wearing socks, a shirt, and his brief. He glanced up the hall for a moment, and then proceeded to walk across the hall into (R38's) room. This had occurred 3 times prior in the past two weeks per (R38's) report. Upon…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update or revise care plan interventions in a timely manner for two Resident (#48 & #56) of eighteen residents reviewed for care plans. This deficient practice resulted in the potential for unmet care needs. Findings Include: Resident #56 (R56) Review of R56's electronic medical record (EMR) revealed initial admission to the facility on 3/3/22 with diagnoses including dementia and cognitive communication deficit. Review of R56's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicative of moderate cognitive impairment. Review of R56's EMR revealed nine falls occurred between the dates of 9/20/23 - 11/16/23 (9/20/23, 9/22/23, 9/27/23, 9/30/23, 10/1/23, 10/18/23, 10/19/23, 10/20/23, 11/16/23). One fall (which occurred on 10/1/23) resulted in R56's transfer to the emergency department for further evaluation secondary to a head injury including facial bruising. Review of Event…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing 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 observation, interview, and record review, the facility failed to ensure one resident (R32) with missing hearing aids of two residents reviewed for assistive devices was assisted in making an appointment with a professional specializing in the provision of hearing assistive devices. This deficient practice resulted in the potential for impaired communication in social interactions and voiced frustration due to inability to adequately hear others when they are speaking. Findings include: During an interview on 12/12/23 at 1:10 p.m., Resident 32 (R32) was observed having difficulty hearing the questions that were being asked during a resident interview with the surveyor. A loud volume of voice had to be utilized and questions had to be repeated several times for R32 to understand what was being asked. R32 said she used to wear hearing aids in both ears but hasn't had them in a couple of months. R32 said it's frustrating to talk with others without her hearing aids. She said she wished she had her hearing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · 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
Based on observation, interview, and record review, consistently monitor and assess effectiveness of behavioral interventions and provide behavioral health services for 1 resident (R10) of 2 residents reviewed for behaviors. This deficient practice resulted in continued severe outbursts of anger and mental distress and the potential for harm to self or others due to exhibited untreated behaviors. Findings include: Resident 10 (R10) was admitted to the facility 12/18/19 with diagnoses that included but were not limited to: generalized anxiety disorder, major depressive disorder, and Alzheimer's disease. R10's most recent Minimum Data Set (MDS) assessment was a quarterly assessment on 9/27/23. Section C1310(A) of the MDS coded R10 with inattention and disorganized thinking, documenting the behavior was present and fluctuated (comes and goes, changes in severity). Section E0200 assessed R10 as displaying behavioral symptoms directed toward others and verbal behavioral symptoms directed toward others. On 12/12/23 at 1:00 p.m., R10 was observed in her room. R10 was very agitated 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 · D2023-12-14 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and record review, the facility failed to maintain a medication administration error rate of less than 5% based on two medication errors of 26 medication administration opportunities. This deficient practice resulted in a medication administration error rate of 7.7% and the potential for inaccurate dosage of medications. Findings include: On 12/13/23 at approximately 8:00 a.m., Resident #27 (R27) was observed receiving two ophthalmic drops in each eye from LPN D. LPN D instructed R27 to hold open his eyelids. LPN D then placed two drops of ophthalmic solution directly onto the cornea of each eye instead of in the conjunctival sac per standards of practice and facility policy. LPN D Provided R27 with 2 tissues and instructed R27 to hold the tissues against his closed eyelids for at least 60 seconds instead of instructing R27 to hold the tissues against the inner canthus (corner of eye) per standards of practice and facility policy. According to the physician's orders, R27 was prescribed Artificial Tears ophthalmic solution 1% with directions to instill 1-2 drops…
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 before2023-09-07 · 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
Based on interview and record review, the facility failed to consistently monitor resident infections, as evidenced by, lack of a real-time resident surveillance log of all residents with symptoms of infections, lack of employee/resident infection comparisons, and lack of timely identification and analysis of infectious organism clusters. This deficient practice resulted in the potential for the spread of infectious organisms in the entire susceptible population of 74 residents. Findings include: Record review of the Infection Control program documentation on 9/7/23 at 8:36 a.m., in the presence of Licensed Practical Nurse (LPN)/Infection Preventionist (IP) A revealed the following, in part: 1) Documentation of monthly Resident Surveillance Logs, January 2023 through July 2023 delineated only diagnosed infections that were treated by physician prescribed antibiotics. No residents were identified with signs/symptoms of potentially communicable/infectious diseases, including fever, nausea, vomiting, diarrhea, cough, congestion, etc., nor were they documented on the infection control…
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
$113,129 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $113,129 — penalty dated 2023-12-14
- Medicare payment denial — starting 2026-02-26 for 48 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BUCK, LINDA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER | 22% | since 01/01/2003 |
| EISELE, BARBARA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 14% | since 08/31/2005 |
| HOLLIDAY, VICTOR | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER | 6% | since 01/01/1988 |
| JAEDECKE, ROBERT | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 14% | since 08/31/2005 |
| JOHNSON, ERIC | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER | 22% | since 01/01/2003 |
| JOHNSON, LEE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER | 22% | since 01/01/2003 |
| UP REHAB SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2005 |
| CARLSON, WAYNE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2013 |
| JOHNSON, WAYNE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/09/2025 |
CMS files one row per role, so the 20 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
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 $334K 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 235367. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-28, 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.