Medilodge of Milford
555 Highland Ave, Milford, MI 48381 · For profit - Limited Liability company · 111 certified beds · (248) 685-1460 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 3 actual-harm citations
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.1% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.9% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.8% | 1.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 1.1% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.9% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 8.3% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 32.2% | 19.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.7% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.5% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 12.0% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.8% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.1% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 79.1% | 79.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 25.3% | 24.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.4% | 11.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.14 | 1.84 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.69 | 1.64 | 1.80 | better |
§ 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.
55.6% 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 188 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 113 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 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 29% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.6%CMS range 48.2–63.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 7.9–14.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 58.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 46.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 52.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.1% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.9% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.6%CMS range 4.9–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.88 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 111 beds and averages 105.4 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 3.09 hrs/resident/day on weekends vs 4.01 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.82 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%. 1 administrator has left in the past year.
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.
25 citations, most serious first. The 13 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · Gcited before2025-09-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to properly use a Hoyer mechanical lift to transfer one resident (R51) of two residents reviewed for accidents, resulting in the mechanical lift falling on R51 causing a laceration to their head requiring a trip to the emergency room for imaging and treatment with staples to close the wound. Findings include: On 9/24/25 at 12:27 PM, a review of R51's progress notes was conducted and revealed the following: A nursing progress note entered into the record by Nurse 'I' dated 6/13/25 at 11:31 PM that read, Cena (nurse aide) informed me that lodger was being transferred to shower chair and hoyer tip <sic> and bumped her head. 1 inch laceration noted .New order to send to hospital noted . A nursing progress note entered into the record by Nurse 'J' dated 6/14/25 at 3:36 AM that read, (Ambulance Company) transported Lodger to (Hospital Name) for eval. (evaluation) due to head injury . A nursing progress note entered into the record by Nurse 'J' dated 6/14/25 at 4:45 AM that read, Lodger return with EMS (Emergency…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-09-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI 00133995 Based on observation, interview and record review, the facility failed to ensure timely interventions to reduce the risk of pressure ulcer development, perform accurate and timely skin assessments and ensure orders were clarified for one (R38) of four residents reviewed for pressure ulcers, resulting in R38 acquiring a device related pressure ulcer on the spine. Findings Include: R 38 On 9/12/23 at 9:50 AM, R38 was observed lying in bed on her back sleeping. Padded boots were observed in a wheelchair against the wall across from the bed. R38 was asked if they had any wounds or sores on their body. R38's Family Member present in the room explained R38 had a wound on her ankle and a wound on her back from a back brace. When asked about the wound on R38's ankle, R38's Family Member lifted up the bed covers and a flat pillow was observed under R38's lower legs, however her heels were in direct contact with the mattress. R38's Family Member was asked how she got the wound…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2023-09-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s MI00131500. Based on observation, interview, and record review, the facility failed to ensure adequate interventions to prevent weight loss for one resident (R90) of five residents reviewed for nutrition, resulting in a 15.69% weight loss from June 2023 to August 2023. Findings include: On 9/13/23 at 8:23 AM, R90's breakfast meal tray was observed on their bedside table in their room. The items on the meal tray were compared to the items on the meal ticket and it was noticed R90 had not been given their Health Shake supplement. It was further noted R90's tray had been set up for them, but R90 was laying at less than a 30-degree angle (almost flat) in their bed attempting to feed themselves some pureed eggs. No staff were observed in the room at that time. On 9/13/23 at 12:21 PM, an observation of R90's lunch meal was conducted. The items on the tray were compared to the meal ticket and it was noted R90 was supposed to receive a Health Shake supplement, however; the Health…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement timely preventative interventions for pressure injury for one (R30) of one Resident reviewed for pressure injury prevention/management. Findings include:R30A review of R30's electronic medical record (EMR) revealed that they were admitted to the facility on [DATE] with diagnoses that included diabetes, heart failure, chronic kidney disease, depression and bladder dysfunction. Based on R30's Minimum Data Set (MDS) assessment dated [DATE], R30 needed substantial staff assistance for their mobility in bed. A Brief Interview of Mental Status (BIMS) completed on admission R30 had a score of 15/15 (indicative off intact cognition). A wound care provider note dated 6/17/25 revealed that R30 had a recommendation for a wheelchair cushion. An initial observation was completed on 9/23/25, at approximately 10:15 AM. R30 was observed sitting in their wheelchair on a Hoyer lift (total body lift) sling with no wheelchair cushion. An initial…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-25 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 social work services were implemented in a timely and efficient manner for one (R7) out of one resident reviewed for Social Service/Advanced Directives. Findings include:A review of R7's clinical record noted the resident was admitted to the facility on [DATE] with diagnoses that included: congestive heart failure, fatty liver and dementia with mood disorder. A review of the resident's Minimum Data Set Assessment (MDS) dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 6/15 (severely cognitively impaired).Continued review of R7's record noted, in part, the following:[DATE]: Nurse's Note: Pt (patient) educated, understood and signed psych medication consent form.Both forms given to social worker.XXX[DATE]: Consent of Psychoactive Medication Therapy: .Psychoactive Medication Order: Quetiapine/Seroquel 25 mg (an antipsychotic primarily used to treat bipolar and/or schizophrenia) .Specific Condition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to Intakes: MI00146265 and MI00148408. Based on observation, interview, and record review, the facility failed to ensure fall precautions were implemented for one resident (R904) with a history of falls out of three residents reviewed for falls resulting in the potential for recurrence of falls and injury. Findings include: On 12/4/24, a clinical record review revealed R904 was admitted to the facility for nursing care and rehabilitation on 11/15/24. R904 required surgical intervention for a fall sustained at home resulting in a right hip fracture. R904's medical history included chronic kidney disease, urinary retention, heart disease, and heart attack. A BIMS (Brief Interview for Mental Status) score was unobtainable when assessed due to acute delirium with hallucinations. Clinical record review revealed R904 sustained a fall at the facility on 11/17/24 and 11/26/24. Care plan initiated on 11/16/24 and revised on 11/27/24 documented Resident Focus: .at risk for falls/injury related to debility, right hip <sic> FX (fracture), encephalopathy and possible…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-14 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 observation, interview, and record review, the facility failed to provide nursing care and services according to professional standards of practice for one (R203) of one resident reviewed for tube feeding. Findings include: On 8/12/24 at 10:18 AM, R203 was observed lying in bed. R203 was receiving nutrition via a PEG (Percutaneous Endoscopic Gastrostomy) tube (a tube surgically placed into the stomach to deliver nutrition). The PEG tube pump was running at 45 milliliters per hour (ml/hr) and the bottle of formula was dated 8/12/24. On 8/13/24 at 9:01 AM, R203 was observed lying in bed. R203 was receiving nutrition via a PEG tube. The PEG tube pump was running at 45 ml/her and the bottle of formula was dated 8/13/24. A review of R203's clinical record revealed R203 was admitted into the facility on 7/22/24 and readmitted on [DATE] with diagnoses that included: prostate cancer, chronic kidney disease, and ST elevation myocardial infarction (STEMI), and gastrointestinal hemorrhage. A review of an Minimum…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess wounds, perform wound care treatments, coordinate with a comprehensive wound care team consisting of a wound care practitioner, document treatment plans, and implement physician's orders for wound care treatments for two residents, (R#'s 101 and 305) of three residents reviewed for skin impairments, resulting in verbalized complaints, fear of staff competency and infection, and R101 voluntarily leaving the facility for wound care at the hospital. Findings include: R101 On 8/13/24 at 2:09 PM, a review of R101's closed record revealed they admitted to the facility on [DATE] and discharged [DATE]. R101's diagnoses included: cutaneous abscess of buttock, and hidradenitis suppurativa, a chronic inflammatory skin disorder characterized by painful nodules, abscesses, and scarring. R101's post-operative records from the hospital revealed they underwent incision and drainage of multiple buttock, back, thigh, and perianal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to timely assess pressure ulcers present on admission into the facility in a timely manner, and implement preventative measures to maintain skin integrity for one (R203) of two residents reviewed for pressure ulcers. Findings include: On 8/12/24 at 10:18 AM, R203 was observed lying on his back in bed. Two pairs of heel protector boots were observed in the room, on a chair and on the floor, not applied to R203's feet. R203's feet were pressed against the foot board of the bed. A low air loss mattress was observed. R203 reported he had sores on his feet. A review of R203's clinical record revealed R203 was admitted into the facility on 7/22/24 and readmitted on [DATE] with diagnoses that included: prostate cancer, chronic kidney disease, and ST elevation myocardial infarction (STEMI). A review of an Minimum Data Set (MDS) assessment dated [DATE] revealed R203 had intact cognition, required substantial/maximum assistance for bed mobility and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a thorough and accurate assessment was done upon admission, physician's orders for an indwelling urinary catheter were in place, and the catheter was securely anchored for one (R204) of three residents reviewed for urinary catheters. Findings include: On 8/12/24 at 10:25 AM, R204 was observed sleeping in a chair in the room where his wife resided. R204's was observed with tubing from a urinary catheter exiting the bottom of his long pajama pants. The urinary catheter drainage bag was observed hung on R204's walker which was next to the resident and therefore the tubing was stretched from the pant leg to the walker. On 8/13/24 at 10:25 AM, R204 was observed ambulating with a walker. Tubing from the urinary catheter was observed coming out of the bottom of R204's pant leg and attached to the drainage bag that was attached to the bottom of the walker making contact with the floor. The tubing was observed dragging on the floor as R204…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-14 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate care was provided to prevent dislodgement of a PEG (Percutaneous Endoscopic Gastrostomy) tube (a tube surgically placed into the stomach to deliver nutrition), physicians orders for nutrition and hydration were in place, and care to the PEG tube site was provided according to physician's orders for one (R203) of one resident reviewed for tube feeding, resulting in the PEG tube being torn from R203's stomach requiring a hospital transfer, the potential for poor nutritional and hydration status, pain, infection and skin breakdown. Findings include: On 8/12/24 at 10:18 AM, R203 was observed lying in bed. R203 was receiving nutrition via a PEG tube. The PEG tube pump was running at 45 milliliters per hour (ml/hr) and the bottle of formula was dated 8/12/24. On 8/13/24 at 9:01 AM, R203 was observed lying in bed. R203 was receiving nutrition via a PEG tube. The PEG tube pump was running at 45 ml/her and the bottle of formula…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-14 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a physician and/or physician extender evaluated and assessed a new/worsened pressure ulcer for one (R85) of two residents reviewed for pressure ulcers, resulting in the lack of pressure ulcer assessment by the physician, and the potential for inconsistent and timely documentation of wound status, and/or decline of the wound. Findings include: On 8/12/24 at 12:21 PM, R85 was observed in room appeared to be resting. When R85 was asked how they were doing and stated that their bottom was hurting and could not get comfortable due to the pain, other than that R85 was content. A record review revealed that R85 was admitted to the facility on [DATE] with diagnoses of Parkinson's diseases, pressure ulcers of sacral region and muscle weakness. R85 had a brief interview for mental status score of 15, indicating an intact cognition. A further review of the chart revealed that R85's wound care orders had been updated that morning 8/12/24. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-14 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
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 labs were obtained timely for one resident (R40) of one resident reviewed for labs, resulting in the potential for unmet medical care needs. Findings include: On 8/12/24 at 1:20 PM, a review of R40's clinical record revealed a note entered into the record on 7/8/24 by Nurse Practitioner (NP) 'G' that read, .Check a CMP (comprehensive metabolic panel, a routine blood test that measures 14 different substances in a blood sample) and CBC (complete blood count, a blood test to look at a wide range of conditions) to monitor fluid volume status . A note entered into R40's record by Nurse 'I' on 7/19/24 at 10:48 AM was reviewed and read, .Resident asked nurse why his blood work from 7/8/24 still hadn't been completed yet, Dr. ('H') in the building at the time and resident asked her about it. Dr. ('H') ordered for blood work to be reordered STAT today . Continued review of R40's record revealed a note entered into R40's record by Nurse 'I' on 7/23/24 at 12:00 PM that read, .Resident stated that he still had not gotten…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · D2024-08-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow infection control guidance for one resident (R306) of three residents reviewed for urinary catheters. Findings include: On 8/12/24 at approximately 10:43 a.m., R306 was observed in their room, lying in their bed. R306's catheter draining bag was observed located not below the bladder (indicating a risk for urine to backflow up into the bladder causing infection). R306 was noted not to have any signage on their door that indicated staff were to apply enhanced barrier precautions (EBP) when providing direct care to them. R306 was queired if staff were wearing any protective gowns when caring for them and they indicated nobody had. On 8/12/24 at approximately 3:32 p.m., R306 was observed in their room, lying in their bed. R306's catheter draining bag was still observed high and located not below bladder. R306's door was still noted to not contain any information that staff were to apply EBP. On 8/13/24 at approximately 8:54 a.m., R306…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a legally authorized resident representative signed a DNR (do not resuscitate) form (part of an advance directive) for one resident (R72) of one resident reviewed for advance directives. Findings include: On [DATE] the medical record for R72 was reviewed and revealed the following: R72 was initially admitted to the facility on [DATE] and had diagnoses including Adult Failure to Thrive and Congestive heart failure. A review of R72's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] revealed R72 needed extensive assistance with most of their activities of daily living. R72's BIMS score (brief interview for mental status) was five indicating severely impaired cognition. A DNR form titled Do Not Resuscitate Order dated [DATE] was reviewed and revealed that it was signed by R72's daughter as a patient advocate A competency evaluation titled Decision Making Determination Form signed on [DATE] by attending Physician and [DATE] by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake #'s MI00131529 and MI00138838. Based on interview, and record review, the facility failed to ensure family notification was made for a change of condition for one resident (R104), of two residents reviewed for notification of changes. Findings include: A complaint was received by the State Agency that alleged the family was not made aware of R104's fall. A review of R104's clinical record was conducted and revealed a progress note entered into the record on 7/26/23 at 11:36 PM by Nurse 'M' that read, .Lodger (R104) fell around 9:45 in their room, a CNA (Certified Nurse Aide) saw Lodger on the floor and notified nurse . It was noted the progress note did not indicate the resident's family had been made aware of the fall. A review of an assessment titled, Fall - Initial - V 2 dated 7/27/23 was conducted and also did not indicate family had been made aware of the fall. On 9/14/23 at 10:59 AM, an interview was conducted with the facility's Director of Nursing (DON) regarding R104's fall. The DON indicated the nurse should have notified the family and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0585 — failed to handle grievances — isolatedHonor 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
This citation pertains to intake #MI00138838 Based on interview and record review, the facility failed to document and follow up on family grievances for one resident (R#104) of one resident reviewed for grievances, resulting in feelings of frustration. Findings include: A complaint was received by the State Agency that alleged the facility failed to follow up on grievances after speaking with facility staff regarding multiple concerns. A review of R104's clinical record was conducted and revealed a progress note entered into the record on 7/26/23 at 11:36 PM by Nurse 'M' that read, .Lodger (R104) fell around 9:45 in their room, a CNA (Certified Nurse Aide) saw Lodger on the floor and notified nurse . On 9/14/23 at 11:34 AM, an interview was conducted with Unit Manager 'L' regarding whether they had spoken with R104's family. They said they did, and the family had voiced concerns about not being notified of the fall and R104 experiencing intermittent left and right leg pain. They were asked if they documented any of the family's concerns on a grievance form and said they did not,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for one (R95), of one residents reviewed for dialysis care plans. Findings include: On 9/12/23 at 10:05 AM, R95 was observed sitting in a wheelchair in her room. R95 was asked if she received hemodialysis. R95 explained she went to the hemodialysis center three times a week, on Monday, Wednesday and Fridays. Review of the clinical record revealed R95 was admitted into the facility on 8/10/23 with diagnoses that included: end stage renal disease, dependence on renal dialysis and anemia in chronic kidney disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R95 was cognitively intact and required the assistance of staff for activities of daily living (ADL's). The MDS assessment also indicated R95 was on dialysis. Review of R95's care plan revealed no dialysis care plan, or interventions to ensure R95's specialized needs were met. On 9/14/23 at 2:27 PM, the Director of Nursing (DON) 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.
- Potential for harm · Dcited before2023-09-14 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 observation, interview and record review, the facility failed to ensure medications were available for administration for one residents (R59) of one residents reviewed for Nursing standards of practice. Findings include: On 9/12/23 the medical record for R59 was reviewed and revealed the following: R59 was initially admitted to the facility on [DATE] and had diagnoses including Polyosteoarthritis, Dementia and Repeated Falls. A review of R59's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/11/23 revealed R59 needed extensive assistance with most of their activities of daily living. R59's BIMS score (Brief interview for mental status) was five indicating severely impaired cognition. A review of R59's careplan revealed the following: Focus-The resident has/is at risk for acute & chronic pain related to Left Humerus fracture (healing), arthritis, chronic low back pain, Osteoporosis, Hx (history) of Left Femur fracture .Interventions-Administer pain medications as ordered. Give 1/2 hour…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to implement interventions to maintain or prevent further decline in range of motion for one (R14) of one Resident reviewed for range of motion and positioning resulting in a potential for further decline in range of motion or worsening of contractures. Findings include: R14 R14 was originally admitted to the facility on [DATE]. R14's admitting diagnoses included poly-osteoarthritis, stroke, joint contractures (limited movement in joints), and loss of vision. R14 was confined to bed and needed extensive staff assistance with their Activities of Daily Living (ADL - mobility in bed, dressing, eating etc.). Based on a Minimum Data Set (MDS) assessment with an assessment reference date of 6/8/23, R14 had a Brief interview for Mental Status (BIMS) score of 8/15, indicative of moderate cognitive deficits. An initial observation was completed on 9/12/23 at approximately 10:30 AM. R14 was observed in their bed. R14 was observed on their back with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00131529 Based on observation, interview and record review the facility failed to ensure interventions to reduce falls were implemented for one resident (R59) of eight residents reviewed for accidents/hazards. Findings include: On 9/12/23 at approximately 10:16 a.m., R59 was observed in their room, laying in their bed, bilateral floor mats were observed next to R59's bed. R59's walker and wheelchair were observed on the other side of room far away from R59's bed. R59 was queried if they had any falls and they indicated they have fallen. On 9/12/23 at approximately 11:01 a.m., and 4:04 p.m., R59 was observed in their room, laying in their bed. R59's bathroom was observed to not contain a commode over the toilet. On 9/13/23 at approximately 8:52 a.m., R59 was observed in their room, laying in their bed. R59 was still observed to have their walker out of reach from the bed. R59 was also not observed to have a commode over their toilet in their bathroom. On 9/13/23 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake #'s MI00131500 and MI00131529. Based on observation, interview, and record review, the facility failed to ensure resident food preferences for two residents, (R62 and R41) and three residents from the group meeting who wished to remain anonymous, of 17 residents reviewed for dining, resulting in verbalized complaints and disappointment with meals. Findings include: R62 and R41 On 9/12/23 at approximately 10:40 AM, R62 was observed sitting in their wheelchair. The resident was alert and able to answer questions asked. R62 reported some concerns regarding the food received at the facility. The resident stated that they were a vegetarian and the facility was not able to accommodate their meal choices and often had to bring in their own food. R62 stated that despite requests and grievance, they still received food with meat in it and noted that on a few occasions they would provide what they were told was vegetable soup, it would have pieces of sausage in it. On 9/12/23 at approximately 12:33 PM, R62 was observed eating lunch in their room. The resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to complete a timely rehabilitation screening and/or evaluation and initiate interventions for a one resident (R14) of one reviewed for impaired mobility, resulting in the likelihood for further decline in range of motion, impairment with skin integrity, and increase in pain during Activities of Daily Living (ADL). Findings include: R14 A record review revealed R14 was originally admitted to the facility on [DATE]. R14's admitting diagnoses included poly-osteoarthritis, stroke, joint contractures (limited movement in joints), and loss of vision. R14 was confined to bed and needed extensive staff assistance with their Activities of Daily Living (ADL - mobility in bed, dressing, eating etc.). Based on a Minimum Data Set (MDS) assessment with an assessment reference date of 6/8/23, R14 had a Brief interview for Mental Status (BIMS) score of 8/15, indicative of moderate cognitive deficits. An initial observation was completed on 9/12/23 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0847 — isolatedInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that two (R4 and R51) residents/legal responsible representatives received a clear understanding of the facility's Binding Arbitration agreement prior to signing the document and ensured that the representative had the legal ability to sign the document. Findings include: During the entrance conference the facility reported that the Binding Arbitration was offered to all residents entering into the building. The facility provided a list of residents that had agreed to Binding Arbitration. The facility policy titled, Binding Arbitration Agreements was reviewed and documented, in part: This facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, this facility .Binding Arbitration is a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake #MI00131529 Based on observation, interview and record review the facility failed to ensure a clean/comfortable and homelike environment for two residents (R30 and R72) of two residents reviewed for the Physical environment. Findings include: On 9/12/23 at approximately 10:20 a.m. R30 was observed in their room up in their bed. R30 was observed to have a large hole in their drywall behind them. R30 was queried regarding the hold and reported Look at my room. It's a disaster. The carpet is up back there. Staff are tripping over it. Then I got this hole next to my head. On 9/13/23 at approximately 8:54 a.m. R72 was observed in their room, laying in their bed. R72 was observed to have a large hole in their drywall next to their bed. On 9/14/23 at approximately 8:52 a.m., R72 was observed in their room, laying in their bed. R72 was still observed to have the same large hole in in their drywall next to their bed. On 9/14/23 at approximately 9:09 a.m., R30 was observed in their room, laying in their bed. R30 was still observed to have a large hole in their…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to MEDILODGE — 53 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.1 | +0.9 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 4 of 5 | 3.7 | +0.3 vs chain |
| Quality measures | 5 of 5 | 4.0 | +1.0 vs chain |
The other 52 homes this chain runs (chain average 3.1★, per CMS)
Showing 40 of 52; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FIFTEENINONE OPCO GROUP LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/24/2013 |
| B&Y HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/24/2013 |
| B&Y TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/24/2013 |
| CODY HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/24/2013 |
| CRAIG FLASHNER 2007 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/24/2013 |
| NORCROSS, ROBERT | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 06/24/2013 |
| ROGERS, STACEY | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 10/20/2014 |
| KIRK, KRISTINE | Individual | W-2 MANAGING EMPLOYEE | — | since 11/01/2013 |
| GENERATIONS HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/24/2013 |
| PRESTIGE ADMINISTRATIVE SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2016 |
| FLASHNER, CRAIG | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/24/2013 |
| PERLSTEIN, YITZCHOK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/24/2013 |
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.4M 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235650. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-25, 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 →
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