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Bronson Commons

23332 Red Arrow Highway, Mattawan, MI 49071 · Non profit - Corporation · 100 certified beds · (269) 283-5200 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Jun 20251 immediate-jeopardy citation1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • about 21% of its spending goes to commonly-owned related companies

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 2 of 5

Worth a closer look. This home's staffing rating runs 3 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

Urgent care / clinic
24466 Red Arrow Hwy · (269) 668-4180 · Call to confirm hours
Pharmacy
52375 N Main St · (269) 324-8950 · Call to confirm hours
Grocery
24064 W McGillen Ave · (269) 668-2135 · Call to confirm hours
Park
24601 Front St · (269) 668-2128 · Typically dawn to dusk
Place of worship
57645 Murray St · (269) 762-5997

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 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 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 5 to 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased23.1%10.8%15.4%worse
Long-stay residents who lose too much weight8.6%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder2.5%0.8%0.9%worse
Long-stay residents with a urinary tract infection3.3%1.5%2.0%worse
Long-stay residents with depressive symptoms3.6%4.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.1%3.0%3.3%worse
Long-stay residents whose ability to walk worsened30.4%12.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication22.8%19.4%18.9%worse
Long-stay residents given the seasonal flu vaccine96.6%95.0%95.3%typical
Long-stay residents with pressure ulcers6.7%5.1%4.7%worse
Long-stay residents with worsening bladder/bowel control29.1%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table18.5%14.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.3%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine96.9%79.5%79.4%better
Short-stay residents rehospitalized after admission28.4%24.0%22.6%worse
Short-stay residents with an outpatient ER visit14.4%11.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.261.841.67better
Long-stay outpatient ER visits per 1,000 resident days1.141.641.80better

§ 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.

64.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 418 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

64.0%U.S. median 51.5%
Got home and stayed home
10.9%U.S. median 10.7%
Went back to hospital
42.9%U.S. median 56.6%
Met the expected recovery
0.62U.S. median 0.31
Therapy hours / resident / day
0.30hours / resident / day
Physical therapy
0.30hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 42.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 280 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 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.

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

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF64.0%CMS range 59.9–67.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 8.1–14.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge42.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge46.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge33.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting89.1%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge37.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.1%CMS range 3.2–7.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.541.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.45
RN hours/ resident / day
0.44
LPN hours/ resident / day
2.54
Aide hours/ resident / day
4.43
Total nurse hours/ resident / day
1.01
RN hoursweekends
40.3%
Total nursing turnover
10.7%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 90.9 residents a day — about 91% occupied, or roughly 9 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 4.43 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.45 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 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 3.94 hrs/resident/day on weekends vs 4.63 on weekdays — 15% thinner on weekends. RN hours go from 1.62 to 1.01 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% 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

11
deficiencies at the latest standard inspection (2025-06-12)
3
at the previous standard inspection (2024-05-16)

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.

ABCDEFGHIJKL

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

21 citations, most serious first. The 12 most serious are shown; the remaining 9 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2026-03-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes: #2790330, #2794131, #2798407Based on observation, interview and record review the facility failed to 1.) accurately assess and prevent an elopement of 1 (Resident #100) of 3 residents reviewed for elopement risk, resulting in an immediate jeopardy when Resident #100 left the premises on 2/14/26 at 5:04 AM, alone, unbeknownst to staff and was later located by staff at 5:55 AM approximately 100 yards from the facility; 2). Ensure safety during a mechanical lift transfer to 1(Resident #104) of 2 residents reviewed for safe transfers resulting in a fall with a head laceration.Findings include:The immediate jeopardy began on 2/13/26 and was identified on 3/11/26 when the facility failed to ensure the safety of and prevent an elopement for Resident #100 who was admitted to the facility on [DATE] and inaccurately assessed as not being an elopement risk. Resident #100 subsequently eloped from the building on 2/14/26 at 5:04 AM and was found by staff at 5:55 AM, the same day,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-06-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00151630 Based on observation, interview, and record review, the facility failed to ensure appropriate transfer techniques were implemented for 2 (Resident #172 and #65) of 4 residents reviewed for falls resulting in a fall with a hand laceration and a fracture for Resident #172 and an improper transfer with a slide board resulting in bruising on the bilateral (both) upper arms for Resident #65. Findings include: Resident #172 Review of an admission Record revealed Resident #172 was a female, originally admitted to the facility on [DATE]. Review of Resident #172's a Level of Assistance flowsheet revealed Resident #172 was limited assistance for transfer assistance with Therapy Recommendations including Front wheeled walker; Wheelchair-manual; Gait Belt; Verbal cues. Review of Resident #172's Radiology Report dated 3/16/25 revealed, .IMPRESSION: Suspected acute periprosthetic fracture (a break in the bone near an orthopedic implant) is along the distal femoral shaft (lower…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-03-12 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure a Registered Nurse (RN) served full time in the role of Director of Nursing potentially affecting all 89 residents that reside in the facility.Findings include:On 3/10/26 at 9:50 AM, surveyors entered the facility and were met by Staff Development/Registered Nurse (SD/RN) III. Surveyors requested to meet with either the Nursing Home Administrator and/or the Director of Nursing and SD/RN III reported the NHA and DON were the same person.On 3/10/26 at 9:55 AM, Director of Nursing (DON) B while meeting with survey team in the conference room, reported she was also the Executive Director/Nursing Home Administrator (NHA) A at this time.In an interview on 3/11/26 at 7:42 AM, DON B reported she had held the position of DON for about 5 years, and in August of 2025, the previous NHA vacated the position and she assumed the role. DON B reported she has been the only person in both roles since the previous NHA left until present. DON B reported here role as DON included auditing and education, new processes, policy updates,…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-12 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to inform residents and/or educate residents and effectively implement the grievance process for six of six residents from a confidential group meeting and all 85 residents that reside in the facility, resulting in the potential for residents to not meet their highest practicable level of wellbeing due to grievances not being documented, tracked, and the results of conclusions and/or resolutions not being recorded. Findings include: During a confidential group meeting on 06/11/25 at 10:34 AM, six of six residents reported that they talked about the same concerns month after month in resident council meetings. These residents also reported that they were not aware that they could have their private concerns documented on a form, that staff could assist them to complete the form, and/or that they could complete a concern form anonymously. The residents did not know that there were forms available and reported that they would utilize the concern forms if they had access to them. During an observation on 06/11/25 at 11:25 AM in…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-12 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #13 Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cancer, heart failure (chronic condition in which the heart does not pump blood as well as it should), anxiety and depression (persistent depressed mood or loss of interest in activities causing significant impairment in daily life). Review of a Minimum Data Set (MDS) assessment for Resident #13 with a reference date of 4/26/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #13 was cognitively intact. Section N of the MDS revealed Resident #13 received antianxiety, antidepressant, a diuretic (drug that causes the kidneys to make more urine) and opioid (class of drug used to reduce moderate to severe pain) medications. Review of a Care Plan for Resident #13 with a reference date of 5/14/24, revealed a problem/goal/interventions of: Problem: I use my medication to help me manage my diagnosis. I want to avoid any…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure activities of daily living (ADL) cares and assistance were provided per resident preference for 1 (Residents #17) of 2 residents reviewed for resident preferences, resulting in dissatisfaction with care and the potential for decline in sense of physical, mental, and psychosocial well-being. Findings include: Review of a Minimum Data Set (MDS) assessment for Resident #17, with a reference date of 4/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #17 was cognitively intact. Review of the Functional Abilities revealed that Resident #17 was dependent for toileting and transfers. In an interview on 06/10/25 at 10:57 AM, Resident #17 reported that she had moved rooms so that she could had access to a ceiling mechanical lift that would allow her to transfer easier. Resident #17 reported that staff tell her that she cannot use the commode every time she has to use the bathroom, because it takes too much of their time. Resident #17 reported…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #17 Review of Resident #17's Physician Orders revealed, Lorazepam (Ativan) tablet 0.5 mg .Frequency: Daily as needed for anxiety .Duration: 30 days Start Date/Time (after last modification): 5/19/25 .End Date/Time: 6/18/25 . The most recent dose was given on 6/6/25 at 7:36 AM. An attempt to interview Medical Director (MD) III on 06/12/25 at 12:18 PM was made, with no return phone call prior to survey exit. This surveyor requested physician rationale for Resident #17's order for PRN (as needed) Lorazepam written for greater than 14 days at a time. Review of Resident #17's Psychiatry Progress Note dated 5/14/25 revealed, .states that she has had some increased anxiety due to some issues she is working through with staff, but the extra Xanax (sic) during the day helped .Staff report no new or clinically significant changes or concerns with mood or behaviors at this time .Generalized anxiety disorder: moderately stable .Continue Lorazepam 0.5 mg 1 tablet at 4:35 PM PRN anxiety x 30 days. GDR (gradual dose…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 accurately assess 1 (Resident #70) of 1 resident reviewed for minimum data set (MDS) discharge encoding resulting in inaccurate discharge location data being submitted. Findings include: Review of a Facesheet revealed Resident #70 was a female who admitted to the facility on [DATE] with pertinent diagnoses which included: weakness and the need for personal assistance. Review of MDS for Resident #70 dated 3/19/25 revealed .A2000 discharge date [DATE], A2150 Discharge status, Code entered 04 indicating resident discharged to Short-Term General Hospital. Review of Resident #70's medical record revealed no noted documentation of a transfer from the facility to any hospital. In a telephone interview on 6/11/25 at 2:51 pm MDS Coordinator (MDSC) WW reported she was the nurse who had completed Resident #70's discharge MDS assessment. MDSC WW reviewed the MDS while on the phone and confirmed that she has coded Resident #70 as a short stay hospital discharge…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 follow professional standards of nursing practice for medication administration for 1 residents (Resident #3) of 18 reviewed for the provision of nursing services, resulting in medication not administered following physician ordered parameters, the lack of assessment, and the potential for medication adverse effects and complications Findings include: In an interview on 06/10/25 at 09:27 AM, Resident #3 reported that Registered Nurse (RN) E did not listen to her and/or follow the physician orders for her blood pressure medication. Resident #3 reported that the night before she had tried to tell RN E that her blood pressure was too low, and that she should not take her Apresoline (medication used to treat high blood pressure). Resident #3 reported that RN E still gave her the medication along with her other medications; Resident #3 felt dizzy and kept her eyes closed for a long time afterwards. In an interview on 06/10/25 at 09:17 AM, Unit Coordinator…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 meaningful activities to promote psychosocial well-being for 1 (Resident #42) of 1 resident reviewed for activities. This deficient practice resulted in decreased feelings of connectedness to the community, a lack of meaningful leisure involvement and increased boredom. Findings include: Review of an admission Record revealed Resident #42 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression (persistent depressed mood or loss of interest in activities causing significant impairment in daily life). Review of a Minimum Data Set (MDS) assessment for Resident #42 with a reference date of 10/8/24, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #42 was cognitively intact. Section F revealed it was very important for Resident #42 to choose her bedtime, be around pets, and to participate in her favorite activities. Review of a Care Plan 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one out of five residents (Resident #26) had water available at the bedside, resulting in the potential for dehydration. Findings include: Review of an admission Record revealed Resident #26 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (a progressive disease that primarily affects memory, thinking and behavior) and renal insufficiency (disease in which the kidneys lost the ability to remove waster and balance fluids). Review of a Minimum Data Set (MDS) assessment for Resident #26 with a reference date of 6/4/25, revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #26 was severely cognitively impaired. Review of a Care Plan for Resident #26 with a reference date of 9/25/19, revealed a problem/goal/interventions of: 1. Problem: Nutritional Status. Goal: My nutritional needs will be met through the next review. Interventions: Please…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that enhanced barrier precautions (EBP) were maintained during tube feeding administration for 1 (Resident #21) of 1 resident reviewed for tube feeding administration resulting in the potential for introduction of infection, cross-contamination, and disease transmission. Findings include: Review of a Facesheet revealed Resident #21 was a female who had admitted to the facility on [DATE] with pertinent diagnoses which included: cardiovascular accident (CVA/Stroke) and PEG (percutaneous gastrostomy tube/feeding tube). During an observation on 6/10/25 at 11:55 am, outside of Resident #21's room was a sign posted on the door frame indicating that the resident was in enhanced barrier precautions. Review of Physician Orders for Resident #21 revealed .diet order NPO (nothing by mouth) ordered 8/16/2024 .Isosource 1.5 bolus (single administration, all at one time) feed oral liquid 250mL (milliliters) via feeding tube four times a day…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 9 citations
  • Potential for harm · D2024-05-16 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 provide a written notice of transfer for 1 of 3 residents (Resident #65) reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the reason for transfer and their rights. Findings include: Resident #65(R65) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R65's admission date was 1/17/2024. Brief Interview for Mental Status (BIMS) score was a 12 which indicated her cognition was moderately impaired (8-12 moderately impaired). Resident had several discharges to the emergency room on 1/25/2024 and 2/18/2024 and a hospital admission from 1/28 to 2/6/2024. During an interview on 5/14/2024 at 10:30 AM, R65 said that she couldn't remember if she received a written transfer notice each time she went to the hospital. Review of R65's chart revealed no evidence that R65 received a written notice of transfer each time she went to the hospital and which included 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to provide oxygen services per the professional standards of practice when storing CPAP (continuous positive airway pressure) masks in 3 (Resident #8, Resident #13, Resident #59) of 3 residents reviewed for infection control practices when storing CPAP masks resulting in the potential for the development of a respiratory infection. Findings include: Resident #8 Review of a Facesheet revealed Resident #8 had pertinent diagnosis which included: obstructive sleep apnea (starting and stopping breathing while sleeping due to partial blockage of the airway). Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 3/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #8 was cognitively intact. During an observation on 5/14/24 at 11:08 PM., Resident #8's CPAP mask was laying uncovered, without a barrier, on top of the CPAP machine, on the nightstand beside the bed in Resident #8's room. Review of Resident #8 Physician Orders revealed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-16 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure that (1) pre and post dialysis treatment assessment and monitoring communication between themselves (the facility) and the dialysis provider (Name Omitted) was maintained and (2) that an agreement between themselves (the facility) and the dialysis provider (Name Omitted) was established and maintained in 1 (Resident #54) of 1 resident reviewed for dialysis services resulting in the potential for unrecognized adverse reactions, and/or resident decline related to dialysis treatments and the potential for a disruption in the continuity of care. Findings include: Review of a Face sheet revealed Resident #54 had pertinent diagnoses which included: renal failure (failure of the kidneys) and dependence on renal dialysis (treatment to remove waste and excess water from the body when the kidneys are no longer able to do it). Review of a Minimum Data Set (MDS) assessment for Resident #54, with a reference date of 2/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #54 was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-04-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to: 1. Ensure cleanliness of food and non-food contact surfaces; 2. Securely store food product after opened; 3. Properly label/date opened food products; and 4. Discard expired food items. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected all residents who consume food/supplement from the kitchen and all residents who consume food from the pantry refrigerators/freezers. Findings include: During an observation/interview with Culinary Associate (CA) L during the initial kitchen tour on 4/17/23 beginning at 8:50 AM in the Dry Storage area, noted an opened case of granulated sugar wherein the inner product bag was fully opened and unsealed such that the product was exposed. There were two bags of blueberry muffin mix with a use by date of 4/12/23 on the back shelving rack. One of the bags was opened, but not labeled or dated. On a separate shelving rack, there was a piece of plastic on top of the bottom shelf where cases of artificial…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-19 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was clinically approriate for self-administration of medications in 1of 17 residents (R40) reviewed for medication administration, resulting in the potential for missed medications. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R40 scored 12/15 (moderately cognitively intact), on her BIMS (Brief Interview Mental Status) with diagnoses that included Alzheimer's disease, anxiety, and depression. During an observation on 4/17/23 at 9:26 AM, R40 was sitting at her bedside eating breakfast. Next to her breakfast tray was a medicine cup with 7 pills. R40 stated, I take my pills with food. The nurse leaves it here every morning. They can trust me to take them. Later in the day they leave a cup with 2 pills in it. It may be aspirin. I don't know. I take that by myself as well. During an interview on 4/17/2023 at 10:48 AM, Nursing Home Administrator (NHA) A stated, There are currently no residents 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement comprehensive person-centered care plans for 2 of 17 residents (R8 and R45) reviewed for care plans, resulting in the potential for additional falls for Resident #8 and unmet psychosocial care needs for Resident #45. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R8 scored 10/15 (moderately cognitively intact) on his BIMS (Brief Interview Mental Status), required extensive assistance of two-persons physical assistance for transfers with diagnoses that included heart failure, dementia, and anxiety. Review of R8's Incident Report dated 3/18/2023 at 12:45 PM reported the resident had a fall during a transfer using the Arjo mechanical lift when he began to slide from the harness. Recommendation to prevent further falls was to use the green sit-to-stand for transfers. Therapy recommendation was not to use the Arjo for transfers. During an observation and interview on 4/18/2023 at 7:25 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-19 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 identify Post Traumatic Stress Disorder (PTSD) triggers and implement interventions to mitigate these triggers for 1 of 24 Residents (Resident #45) reviewed for trauma informed care, resulting in the potential risk for re-traumatization and unmet care needs. Findings include: A review of a Face Sheet for Resident #45, dated 10/06/22, revealed a pertinent diagnosis of bipolar disorder (mental condition that causes changes in a person's mood, energy, and ability to function). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Inventory of Mental Status (BIMS) assessment score of 15 indicating Resident #45 was cognitively intact. Section I of the MDS revealed active diagnoses of Anxiety Disorder, Bipolar Disorder, and Post Traumatic Stress Disorder. A review of a Behavioral Health progress note for Resident #45, dated 3/6/23, the section labeled Social History: Past Trauma stated: sexually abused by brother starting…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This citation pertains to intake MI00128560. Based on observation, interview, and record review, the facility failed to take appropriate measures to prevent the possible spread of COVID-19 by failing to: 1.) ensure that accurate isolation precaution signage was posted outside the room of a resident diagnosed with COVID-19 and 2.) ensure staff donned appropriate PPE (personal protective equipment) prior to entering a COVID-19 isolation room for 1 (Resident #65) of 1 resident reviewed for transmission based infection control practices, resulting in the potential for spread of infection to a vulnerable population. Findings include: Review of a COVID Antigen test result document revealed Resident #65 had a positive result (for COVID-19) on 4/14/23. Review of a COVID-19 PCR test result document revealed Resident #65 had a positive result (for COVID-19) on 4/14/23. Review of an Order Summary for Resident #65 revealed a physician order for Isolation Update Required: Contact, Droplet Plus .Reasons for Isolation .COVID-19 Coronavirus .COVID-19 Coronavirus Infection Instructions Place…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-06-12 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to ensure the results of the most recent federal surveys and corresponding plans of correction were readily accessible to all residents in the facility, with a census of 85 residents, resulting in the residents not being informed of identified deficiencies and solutions as written in the plan of correction. Findings include: During a confidential group meeting on 06/11/25 at 10:34 AM, six of six residents reported that they were not aware they could read the survey reports; they did not know who to ask or where to find them. During an observation on 06/11/25 at 11:25 AM in the sitting area next to the main lobby there was a shelf hanging approximately 4-5 feet up on the wall containing a binder that housed survey reports. In an interview on 06/11/25 at 12:02 PM, Licensed Practical Nurse (LPN) JJ reported that she did not know where to find the survey reports; and was not sure how residents were expected to get access to those. In an interview on 06/12/25 at 11:19 AM, Nursing Home Administrator (NHA) A reported that the survey…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2025-07-08 for 21 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 / managerTypeRoleShareSince
BRONSON HEALTH CARE GROUP INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 07/01/2011
ALLEN, RICHARDIndividualCORPORATE DIRECTORsince 01/01/2017
CHEN-ZHANG, LYNNIndividualCORPORATE DIRECTORsince 11/01/2022
COLEMAN, GENEVIEVEIndividualCORPORATE DIRECTORsince 01/01/2025
GIBSON, SCOTTIndividualCORPORATE DIRECTORsince 09/28/2012
GONZALEZ, JORGEIndividualCORPORATE DIRECTORsince 01/01/2018
HERMSEN, KATHARINEIndividualCORPORATE DIRECTORsince 01/01/2025
HOFFMAN, KELLIEIndividualCORPORATE DIRECTORsince 01/01/2025
HUNT, BRENDAIndividualCORPORATE DIRECTORsince 07/01/2011
KARRE, NELSONIndividualCORPORATE DIRECTORsince 07/01/2011
LIGGINS, JAMESIndividualCORPORATE DIRECTORsince 01/01/2016
LINS, STEVENIndividualCORPORATE DIRECTORsince 07/01/2011
LUBWAMA, GRACEIndividualCORPORATE DIRECTORsince 01/01/2025
NICHOLSON, ROBERTIndividualCORPORATE DIRECTORsince 07/01/2024
NYBERG, NEILIndividualCORPORATE DIRECTORsince 07/01/2011
ODAR, MICHAELIndividualCORPORATE DIRECTORsince 07/01/2016
PARFET, DONALDIndividualCORPORATE DIRECTORsince 01/01/2008
SHARMA, NAMITAIndividualCORPORATE DIRECTORsince 11/01/2022
STEWART, ERICKIndividualCORPORATE DIRECTORsince 11/01/2022
WASHINGTON, LUTHER MARSHALLIndividualCORPORATE DIRECTORsince 11/01/2022
WORGESS, RACHELIndividualCORPORATE DIRECTORsince 01/01/2025
WORKMAN, WILLIAMIndividualCORPORATE DIRECTORsince 01/01/2022
ARNAN, MARTINSONIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/2019
EAST, REBECCAIndividualCORPORATE OFFICER; ADP OF THE SNFsince 02/01/2015
FALAHEE, JAMESIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/1987
JOHNSON, CHERYLIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/2021
MANNS, BILLIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/2020
WAY, MIKEIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/1986
COLEGROVE, LEIGHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/11/2021
GOEL, ASHUTOSHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/21/2025
PATRICK, TIFFANYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/06/2026
SANCHEZ, HUGHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/21/2025
SANGALI, CHRISTINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/21/2025

CMS files one row per role, so the 45 rows in the source record cover these 33 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.

$11.5M
Net patient revenuemost recent cost report
-46.8%
Operating marginrevenue minus expenses
$3.6M
Related-party expense21% of expenses
Who pays — share of resident-days
Medicaid 48%Medicare 11%Other / private 41%

This home reported $3.6M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$522per resident / day
operating cost
$15,884per month
≈ monthly operating cost
$356per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MI

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.

Typical monthly cost in Michigan
$11,254/mo
Nursing home (semi-private)
$11,969/mo
Nursing home (private)
$5,818/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235434. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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