West Hickory Haven

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.

40.3% 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 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 101 beds and averages 64.5 residents a day — about 64% occupied, or roughly 36 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 3.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.60 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.50 hrs/resident/day on weekends vs 4.16 on weekdays — 16% thinner on weekends. RN hours go from 0.64 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 68% is well above 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.

40 citations, most serious first. The 16 most serious are shown; the remaining 24 are one tap away and print in full.

• Actual harm · Gcited before2026-01-20 · 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 Complaint #2709480.Based on observation, interview, and record review, the facility failed to appropriately evaluate the placement of the bed to prevent accident hazards for one (R901) of one resident reviewed for accident hazards, resulting in R901 sustaining a thermal burn to their right great toe after it made contact with the baseboard heater which was directly next to the bed. Findings include: A review of complaints submitted to the State Agency revealed an allegation that R901's foot had direct and prolonged contact with an exposed Hydronic (water) baseboard heat. Due to R901 having neuropathy (damaged nerves), they were unaware they were being burned. When staff pulled their foot away from the metal heater, it resulted in skin tearing and severe bleeding, consistent with a significant burn injury. It was noted R901 had a diagnosis of Alzheimer's Disease.On 1/20/26 at 10:38 AM, R901 was observed lying in bed. R901 was pleasant, but when asked questions, was unable to clearly…

  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 · Past Non-Compliance
• Actual harm · G2025-10-29 · tag F0604 — failed to not use physical restraints improperly — isolated
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  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 #2649116 and Incident #2652020.Based on observation, interview, and record review, the facility failed to ensure physical restraints were not utilized for staff convenience to restrict movement of the resident's arms for one (R801) of three residents reviewed for abuse, resulting in a severely cognitively impaired resident's shirt sleeves being tied together to prevent them from grabbing onto staff causing psychosocial harm using the reasonable person concept. Findings include: A review of a complaint submitted to the State Agency (SA) revealed an allegation that R801, who had severe dementia and could not communicate, had her sleeves tied together by Certified Nursing Assistants (CNAs) 'C' and 'D' in order to treat her.A review of a second complaint submitted to the SA revealed an allegation that R801, who had Alzheimer's Disease and did not have the capacity to make decisions, had the hands of her sleeves tied together by staff on 10/15/25 because she was aggressive 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-08-26 · 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 has two deficient practices.Deficient Practice #1This citation pertains to intake #2581294Based on interview and record review the facility failed to prevent an avoidable accident for one resident (R203), of three residents reviewed for accident hazards, resulting in injury requiring transfer to the emergency room. Findings include:Based on interview and record review the facility failed to prevent an avoidable accident for one resident (R203), of three residents reviewed for accident hazards, resulting in injury requiring transfer to the emergency room. Findings include:A complaint received by the State Agency alleged R203 was not properly secured during a ride in the transport van and sustained a fall from their wheelchair that resulted in injury requiring a transfer to the emergency room. On 8/26/25 at 10:41 AM, a review of R203's closed clinical record revealed they admitted to the facility on [DATE] and discharged to the emergency room on 3/17/25. R203's diagnoses included: heart disease,…

  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 before2024-04-10 · 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 #MI00143690. Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for two (R905 & R906) of nine residents reviewed for abuse resulting in R906's right arm fracture when R906 was pushed to the floor by R905 as heard by (R909). Findings include: Review of a Facility Reported Incident (FRI) dated 3/21/24 revealed there was a resident to resident physical abuse incident which resulted in injury. On 4/10/24 at 11:35 AM, R906 was observed walking in their room with a sling on their right arm. R906 was asked about the sling. R906 explained it (right arm) was broken and it hurt a lot. When asked how their arm was broken, R906 explained they had been taking a puzzle to R905's spouse when R906 pushed them and R906 fell to the floor and broke their arm. R906 was asked if they ever had any interaction with R906 before that incident. R906 explained R905 had been their roommate, but they had 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-07 · 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 has two deficient practice statements Deficient Practice #1 Based on observation, interview and record review the facility failed to ensure effective interventions to reduce injury from falls were in place for one resident (R19) at risk of falling, of seven residents reviewed for accidents/hazards, resulting in R19 sustaining a non-displaced nasal fracture and diffuse bruising to bridge of nose and surrounding left eye. Findings include: On 2/05/24 at approximately 9:09 a.m., R19 was observed in their room, laying in their bed. R19 was observed to have dark bruising above their left eye. R19 was queried how they got the bruise above their eye and they indicated they fell out of the bed on the left side and hit their face on the tile floor and broke their nose. R19 was queried which side they fell out of the bed on and they indicated it was the left side of the bed where their bed remote, nightstand and call button were clipped. R19 was observed to have a mat next to their bed on the opposite side…

  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 before2023-08-29 · 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: MI00138956. Based on interview and record reviews the facility failed to consistently provide adequate supervision to prevent further falls for one (R707) of two residents reviewed for falls, resulting in the resident to have been transferred to the hospital and to have received four stitches to their lip for a through and through laceration, obtained multiple bruising, and a hematoma to left outer orbital area with slight bruising and pain using the reasonable person concept. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part, . It was discovered that (R707 name) had a through and through laceration that required four stitches . (R707 name) also had a prior laceration on her elbow that should have been repaired, but it was too late. (R707 name) is covered in bruises. The bruises could be from falling, but (R707 name) does have a bruise on her right wrist. The bruise looks almost like she was grabbed (thumbprint), but it is unknown for…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-06-03 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: On 06/01/2026 at 9:00 AM during a kitchen tour with dietary manager (DM) J observed the walk-in cooler gasket soiled with black build up. When queried, DM J indicated she concurred it was soiled and in need of cleaning and would ensure it was cleaned or possibly changed.According to the 2022 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.On 06/01/2026 at 9:03 AM Observed 2 in-use juice guns visibly soiled with dried red build up inside the nozzles. When queried, DM J said they should be cleaned daily and they currently needed to be thoroughly cleaned.On 06/01/2026 at 9:05 AM observed the only kitchen handwash sink was blocked by a cart. On 06/01/2026 at 9:10 AM observed interior top of microwave soiled 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-06-03 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish and maintain an effective infection prevention and control program that included a system for identifying, water management, hand hygiene and mapping. Findings include:A review of the facility's infection prevention and control program on 6/2/26 revealed that the facility was responsible for maintaining a structured surveillance system to monitor infections, identify trends, and support infection prevention interventions. The program required that infection data be consistently collected, analyzed, and mapped by resident location, infection type, and date of onset to support outbreak identification and prevention efforts. On 6/2/26 a record review showed the facility failed to demonstrate evidence of a systematic infection surveillance process. Infection logs were incomplete and did not consistently include resident identifiers, unit assignments, infection diagnoses, or dates of onset. The facility was unable to provide…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-06-03 · tag F0881 — failed to use antibiotics responsibly — widespread
  Implement a program that monitors antibiotic use.
  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 establish and maintain an effective infection prevention and control program that included a system for an ongoing antibiotic stewardship program Findings include:A review of the facility's Infection Prevention and Control Program on 6/2/26 revealed that the facility was required to maintain an ongoing infection surveillance system designed to analyze data, and implement interventions. The policy further indicated that the facility would maintain an antibiotic stewardship program that monitored antibiotic use, promoted appropriate prescribing practices, and evaluated treatment outcomes.On 6/2/26, a review of the facility's infection surveillance logs revealed incomplete documentation for two months. The logs failed to consistently identify residents with infections, track the type and location of infections, identify causative organisms, or document follow-up actions taken by the Infection Preventionist (IP). On 6/2/26 at 11:30 a.m., an interview was conducted with the IP. The IP stated that infections were…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-09 · tag F0627 — isolated
  Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
  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 2797202.Based on interview and record review, the facility failed to permit a resident to return to the facility following a transfer to hospital for one (R902) of four residents reviewed for discharge. Findings include:Review of a complaint reported to the State Agency included allegations that the facility sent R902 to the hospital on 3/5/26 and refused to allow them to return, and the family never received written discharge notices as required.Review of the clinical record revealed R902 was initially admitted into the facility on 2/19/26 and was discharged to hospital on 3/5/26 and had not returned. Diagnoses included: chronic kidney disease stage 3A, anxiety disorder, personal history of traumatic brain injury, vascular dementia severe with other behavioral disturbance, dementia in other diseases classified elsewhere, severe, with other behavioral disturbance, mild cognitive impairment of uncertain or unknown etiology, and age-related cognitive decline. The clinical record…

  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 · D2026-03-09 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  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 2797202.Based on interview and record review, the facility failed to provide the legal representative a written notice of transfer/discharge and send a copy to the Ombudsman for one (R902) of four residents reviewed for discharge. Findings include:Review of a complaint reported to the State Agency included allegations that the facility sent R902 to the hospital on 3/5/26 and refused to allow them to return, and the family never received written discharge notices as required.Review of the clinical record revealed R902 was initially admitted into the facility on 2/19/26 and was discharged to hospital on 3/5/26 and had not returned. Diagnoses included: chronic kidney disease stage 3A, anxiety disorder, personal history of traumatic brain injury, vascular dementia severe with other behavioral disturbance, dementia in other diseases classified elsewhere, severe, with other behavioral disturbance, mild cognitive impairment of uncertain or unknown etiology, and age-related cognitive…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-20 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2615411Based on record review and interview, the facility failed to secure medication storage in an unlocked medication cart (Sapphire Cart) allowing one resident (R904) to gain access to another resident's medications resulting in one medication, Namenda (medication to treat moderate to severe dementia) never recovered.Findings Included:A Facility Reported Incident (FRI) received by the State Agency revealed on 9/1/25 at 9:30 AM, R904 was observed with three pill packets and several loose pills in their left pant pocket. All medications were reconciled apart from the Namenda.Clinical record review revealed R904 was admitted to the facility on [DATE] for long term care and had a medical history of diabetes, urinary retention, and falls related to muscle weakness. R904 was independent in a wheelchair for short distances, alert and orientated to person and place and was their own responsible party. R904 had a documented Brief Interview mental Status (BIMS) score of 8/15 indicating…

  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.

  Pharmacy Service Deficiencies · Past Non-Compliance
• Potential for harm · D2025-10-29 · 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 #2649116 and Incident #2652020.Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the Abuse Coordinator and State Survey Agency within the required timeframe for one (R801) of three residents reviewed for abuse, resulting in a delay in investigation and the alleged perpetrators continuing to work with the victim. Findings include:A review of a complaint submitted to the State Agency (SA) revealed an allegation that R801, who had severe dementia and could not communicate, had her sleeves tied together by Certified Nursing Assistants (CNAs) 'C' and 'D' in order to treat her.A review of a second complaint submitted to the SA revealed an allegation that R801, who had Alzheimer's Disease and did not have the capacity to make decisions, had the hands of her sleeves tied together by staff on 10/15/25 because she was aggressive and agitated. It was alleged staff left the room for at least an hour and left R801 in restraints,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-26 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #2581294Based on interview and record review the facility failed to notify the resident's responsible parties of an elopement for two residents (R#'s 201 and 202) of three residents reviewed for changes of condition. Findings include:A complaint received by the State Agency alleged two resident's eloped from the facility and their responsible parties were not notified.On 8/26/25 at 9:30 AM, a review of R201's progress notes revealed an Interdisciplinary Team Note entered into the record on 5/16/25 by Nurse 'B' that read, (R201) is alert to self and often ambulates throughout the facility.On 5/3/25 and 5/10/25 he did exit the facility through the front doors and staff saw him and redirected him into the facility. He was visualized by staff the entire time.A review of R201's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, adjustment disorder, mood disorder, and delirium. R201's Minimum Data Set (MDS) assessment…

  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 · E2025-07-24 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation relates to Intake: 1195243. Based on observation, interview, and record review, the facility failed to provide a safe, comfortable homelike environment for six Residents (R400, R401, R402, R403, R404, R405) of six residents reviewed for resident rights. Findings include: A complaint was received by the State Agency on 6/30/25, which alleged the air conditioning was not working in the residents' rooms on the Emerald Hall, causing it difficult for staff to complete resident care and excessively hot resident room temperatures. On 7/24/25 at 11:11 a.m., a digital thermostat encased in plastic was observed on Emerald Hall with the two temperatures, 70 degrees Fahrenheit and 75 degrees Fahrenheit. It was unclear which was the one the time was set to, and which one was the temperature in the hallway, as there was no designation observed. On 7/24/25 at 11:16 a.m., an orange large air mover unit was observed on Emerald Hall, circulating the hallway air as staff entered the hall. R400 On 7/24/25 at 11:15…

  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 · Ecited before2025-03-13 · tag F0557 — pattern
  Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
  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 residents personnel clothing was routinely returned to them from laundry for three residents (R39, R57 and R56) and multiple residents who asked to remain anonymous at the resident council meeting. This had the potential to affect all residents who relied on the facility to care for their laundry. Findings include: Resident Council On 3/12/25 at 10:00 AM, a Resident Council meeting was conducted with 10 residents who asked to remain anonymous. The residents were asked about life in the facility and any concerns they might have. Multiple residents expressed issues pertaining to their clothing not being returned to them. One resident reported that laundry is sent out of the facility and many times it does not come back to their room. They noted that the person in charge of laundry had been out for over two months, and they believed that added to the confusion. Another resident reported that they had a special [NAME] football shirt that…

  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

$135,784 in federal fines across 3 penalties.

• $81,480 — penalty dated 2025-10-29
• $15,593 — penalty dated 2024-04-10
• $38,711 — penalty dated 2024-02-07

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to THE PEPLINSKI GROUP — 10 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 38 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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