Brittany Manor

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

53.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 162 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 64.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 91 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.45 therapist hours per resident per day in 2026Q1 — more than 76% of the 13,892 homes that report any therapy hours at all.

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

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

Staffing

How full it usually is: this home is certified for 138 beds and averages 91.2 residents a day — about 66% occupied, or roughly 47 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.92 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.63 hrs/resident/day on weekends vs 4.23 on weekdays — 14% thinner on weekends. RN hours go from 1.12 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

22 citations, most serious first. The 15 most serious are shown; the remaining 7 are one tap away and print in full.

• Actual harm · Gcited before2026-04-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes #: 2808141, 2749047, and 2977070Based on interview and record review, the facility failed to 1.) ensure comprehensive nursing assessments were completed and 2.) identify and notify the provider of a change in condition for 2 residents (Resident #7 and #8) out of 3 residents reviewed for quality of care resulting in a delay in treatment, the worsening of symptoms, and hospitalization.Findings:Resident #7 (R7)Review of an admission Record revealed R7 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure and chronic obstructive pulmonary disease. Further review of the record revealed R7 did not receive hospice services.During an interview on 04/13/2026 at 10:37 AM, Responsible Party (RP) J reported that at 5:00 AM on 3/22/2026 a facility nurse informed her R7's oxygen level had dropped down into the 80's and R7 was diaphoretic (sweaty) and was given supplemental oxygen. Wen RP J called to check on R7 an…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-11-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # 2656241 and #2658212.Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a staff person, for two of three residents (Resident #100 and Resident #101) reviewed for abuse, resulting in the need for emergency medical attention and admission to the hospital for R100. Findings: Resident #100 (R100)Review of an admission Record revealed R100 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnosis of dementia. Review of R100's Plan of Care reflected that R100 was independent with walking, bed mobility, feeding herself with set-up assistance, and transferring between surfaces. During an interview on 11/06/25 at 9:37 AM, R100 stated that in the past, staff shoved her and that it made her mad. Review of an admission Record revealed R101 was a [AGE] year-old male, admitted to the facility on [DATE] with pertinent diagnoses of dementia. Review of video and audio footage,…

  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 · Past Non-Compliance
• Actual harm · Gcited before2025-01-23 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promptly identify a change in condition and act upon those changes for 1 resident (R4) out of 4 residents reviewed for quality of care, resulting in R4 experiencing unnecessary pain, a delay in evaluation and surgical intervention for a femur fracture. Findings: Resident #4 (R4) Review of an admission Record revealed R4 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: difficulty in walking, muscle wasting and atrophy, need for assistance with personal care, weakness, history of falls prior to admission, and dementia. Review of R4's Brief Interview for Mental Status (BIMS) dated 11/26/24 revealed a score of 11, out of a total possible score of 15, indicating R4 was moderately cognitively impaired. (Last assessment obtained prior to his fall on 1/12/25.). R4's BIMS dated 1/17/25 revealed a score of 15, indicating R4 was cognitively intact. During an interview on 01/23/2025 at 11:15 AM, R4 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-01-23 · 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 # MI00149549 Based on observation, interview, and record review, the facility failed to ensure a resident was transferred following care planned interventions and standards of practice for 1 resident (Resident #1) out of 4 residents reviewed for accidents and safety, resulting in R1 sustaining a preventable fall with facial bruising and lacerations requiring hospital treatment. Findings: Resident #1 (R1) Review of an admission Record revealed R1 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: difficulty in walking, muscle wasting and atrophy, and need for assistance with personal care. Review of R1's Brief Interview for Mental Status (BIMS) dated 12/17/24 revealed a score of 12, out of a total possible score of 15, indicating R1 was moderately cognitively impaired. R1 had a fall at the facility on 11/7/24 and 12/30/24 confirming she was a high risk for falls. During an observation on 01/22/2025 at 11:48 AM, R1 was sitting…

  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 before2023-08-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision and assistance for 2 Residents (R2 and R4) to prevent falls, resulting in R2 sustaining multiple falls with injuries and loss of use of her arms and R4 remaining at high risk of falls with injuries. Findings include: Review of R2's face sheet, dated 8/25/23 revealed R2 was an [AGE] year old female admitted to the facility on [DATE] and had diagnoses that included: dementia, wedge compression fracture of sacrum (2/15/23), wedge compression fracture of 5th lumbar vertebra (2/14/23), fracture of the 1st lumbar vertebra (12/28/23, fracture of 4th lumbar vertebra (12/28/23), difficulty walking, muscle wasting, need for assistance with personal care, and fracture of T11-12 vertebra (11/5/21). R2 was not her own responsible party. Review of R2's care plan dated 3/10/23 revealed R2 had a laceration to her right brow r/t (related to) a fall. Review of R2's care plan dated 3/10/23 revealed R2 had a skin tear to her right-hand r/t…

  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 before2026-04-15 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation refers to Intake 2748888. Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 8 sampled residents (R4). Findings include:A review of R3's admission Record, dated 4/14/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's admission Record revealed they had multiple diagnoses that included encephalopathy, anxiety, dementia, and repeated falls. A review of R3's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/3/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 6 which revealed R3 was severely cognitively impaired. A review of R4's admission Record, dated 4/13/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R4's admission Record revealed they had multiple diagnoses that included dementia and anxiety. A review of R4's MDS, dated [DATE],…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-10-08 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to complaint #2626994. Based on interview and record review, the facility failed to implement policies and procedures for ensuring reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Social Securities Act regarding reportable incidents for 2 residents (R101 and R102) of 3 residents reviewed for abuse. Findings include:Review of an admission Record revealed R101 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and parkinson's disease. Review of an admission Record revealed R102 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and encephalopathy. Review of MI-FRI #61781 Facility Investigation Report revealed on 9/14/2025 at 3:30 PM R101 struck R102 on the mouth in the activity room. This event was witnessed by facility staff and reported to the Director of Nursing (DON) on 9/14/2025 at 4:00 PM. Further review revealed the Nursing Home Administrator (NHA) submitted the 2-hour 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · Ecited before2025-03-27 · tag F0658 — failed to meet professional standards of care — pattern
  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 1.) accurately document administration of controlled substances and 2.) ensure narcotic medications were administered following the physician order for 4 residents (Residents #23, #74, #84, and #10), reviewed for controlled substances, resulting in medication errors. Findings: Resident #23 (R23) Review of an admission Record revealed R23 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: generalized anxiety disorder. Review of R23's Order Summary dated 3/5/25 revealed, diazePAM (Valium) Oral Solution 5 MG/5ML .Give 4 ml via PEG-Tube two times a day for ANTIANXIETY AGENTS. To be administered at 8:00 AM and 9:00 PM. Review of R23's Controlled Substance Proof of Use form revealed 1 dose of diazepam was administered on 3/7/25 at 9:45 AM. R23's 9:00 PM dose of diazepam was not documented as dispensed. Review of R23's March Medication Administration Record revealed both doses of R23's diazepam 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-27 · tag F0842 — failed to keep accurate, complete medical records — pattern
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain a complete and accurate medical record for 5 residents (R2, R69, R73, R76 & R88) out of 19 residents reviewed. Findings: Resident #88 (R88) Review of a closed clinical record for a Death investigation during the annual recertification survey revealed R88 originally admitted to the facility on [DATE] with a cognitive communication deficit, aphasia (inability to speak), a history of aspiration (inhalation of particulate into the lungs), and received nutrition through a feeding tube. Review of a Nurses Note dated 1/28/2025 at 2:20 AM reflected (R88) passed away at 1:51 AM 1/28/2025. Daughter (name), PA (physician assistant), DON (Director of Nursing), & Funeral home notified per daughter's request. Progress notes leading up to R88's death were reviewed and revealed the following: Review of a Change in Condition note dated 1/22/2025 at 10:10 AM revealed (R88) moaning on and off all night, per CNA (Certified Nurse Aide). (R88) moaning a few times…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-27 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to proved dignified care and services for two facility residents (R10 and R34). Findings: Resident #10 (R10) Review of an admission Record revealed R10 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: tracheostomy, diabetes mellitus with diabetic neuropathy, kidney disease, and heart disease. Review of a Minimum Data Set (MDS) assessment for R10, with a reference date of 2/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated R10 was moderately cognitively impaired. Review of R10's Care Plan revealed R10 required the use of a mechanical lift and the assistance of 2 staff members to transfer from his bed to his wheelchair. During an observation and interview on 03/26/25 at 08:48 AM, R10 pressed his call light and reported that he was ready to get up and into his wheelchair for the day. R10 reported that it frequently…

  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 · D2025-03-27 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
  Ensure 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food and beverages were enjoyable for three facility Residents (R34, R59, and R41) out of 19 residents reviewed. Findings: R34 Review of the Electronic Medical Record (EMR) admission Record reflected R34 originally admitted to the facility 2/25/25 and has current pertinent diagnoses of Feeding Difficulties and Need for Assistance with Personal Care. The Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the Resident was mildly cognitively impair. Section GG (titled Functional Abilities and Goals) of this MDS revealed R34 required Substantial /maximal assistance with eating and that a Helper does more than half the effort. On 3/25/25 at 11:53 AM lunch service was observed to be in progress in the North Hall Dining Room. Initially present were three residents at one table, two residents at another, and two residents sitting at tables by themselves. All…

  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 · E2024-04-04 · 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 observation, interview, and record review the facility failed to record, track, and respond to resident concerns/grievances for two residents (#1, #232) and two residents in confidential resident council meeting resulting in the potential of resident concerns not being addressed and the potential for care needs unmeet. Findings Included: Resident #232 (R232) Review of the medical record revealed R232 was admitted to the facility 03/11/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD), nicotine dependence, hypokalemia (low potassium) hypocalcemia (low calcium), muscle weakness, morbid obesity, gastro-esophageal reflux, ischemic cardiomyopathy (heart damage), hyperlipidemia (high fat content in blood), atherosclerotic heart disease (damage to major blood vessels in the heart), type 2 diabetes, hypertension, and congestive heart failure (CHF). During observation and interview on 04/02/2024 R232 was observed sitting on the side of his bed. R232 explained that he had placed his call light on Thursday or Friday night, because he need assistance. He…

  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 · D2024-04-04 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — the official record, unedited, may be distressing

  During record review and interview the facility failed to ensure the advanced directives, Do Not Resuscitate documentation was completed with two signatures for one (R#48) of one resident reviewed for completed advanced directives. Findings Include. Resident #48 (R48) Record review revealed R48's Do Not Resuscitate (DNR) was signed on 03/07/24 but did not have 2 witness signatures as required. During an interview on 04/03/24 at 12:17 PM, Social Worker (SW) S stated they usually have 2 signatures, his does not. Writer asked if she would expect to see two signatures for witnesses? SW S stated yes.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-04 · 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 observation, interview, and record review, the facility failed to ensure that written notification required for facility-initiated transfers were provided to residents or resident representatives for 2 (Resident #24 and #38) of 2 residents reviewed for hospitalization, resulting in the potential of residents and/or representatives being un-informed of the reason for transfer and their appeal rights. Findings include: Resident #38 (R38) Review of the medical record revealed that Resident #38 (R38) was readmitted to facility 2/21/24 with diagnoses including sepsis, difficulty in walking, weakness, congestive heart failure, peripheral vascular disease, and chronic kidney disease. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/24 reflected that R38 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). Review of two separate Discharge MDSs with ARDs of 10/5/23 and 2/13/24 reflected that R38 had unplanned discharges to…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-04 · tag F0625 — isolated
  Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the bed hold policy was provided for 2 (Resident #24 and #38) of 2 residents reviewed for hospital transfer, resulting in the potential for resident's and/or representatives to be uninformed of the facility's bed hold policy. Findings include: Resident #38 (R38) Review of the medical record revealed that Resident #38 (R38) was readmitted to facility 2/21/24 with diagnoses including sepsis, difficulty in walking, weakness, congestive heart failure, peripheral vascular disease, and chronic kidney disease. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/24 reflected that R38 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). Review of two separate Discharge MDSs with ARDs of 10/5/23 and 2/13/24 reflected that R38 had unplanned discharges to an acute care hospital, on each date, and that her return to the facility was anticipated. In an…

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

  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.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CIENA HEALTHCARE/LAUREL HEALTH CARE — 81 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 13 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

This home reported $3.6M paid to related parties — landlords or management companies under common ownership — equal to about 25% 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

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