Monroe Springs Skilled Nursing and Rehab
700 Stewart Rd, Monroe, MI 48161 · For profit - Individual · 89 certified beds · (734) 240-1820 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0602), cited Dec 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 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 | 11.1% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.8% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.3% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.3% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.1% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.4% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 4.1% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 19.7% | 12.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 26.8% | 19.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.5% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 5.1% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 20.0% | 20.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.6% | 14.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.6% | 1.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 92.6% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 29.6% | 24.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.1% | 11.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.45 | 1.84 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.94 | 1.64 | 1.80 | worse |
§ 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.
56.6% 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 138 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 70.2% 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 67 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 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 56.6%CMS range 48.1–62.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.6%CMS range 7.0–13.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 70.2% | 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 | 62.7% | 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 | 73.1% | 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 | 99.2% | 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 | 97.7% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.2% | 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 | 3.2% | 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 | 7.1%CMS range 4.4–10.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.02 | 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 89 beds and averages 82.4 residents a day — about 93% occupied, or roughly 7 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 3.84 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 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 3.53 hrs/resident/day on weekends vs 3.96 on weekdays — 11% thinner on weekends. RN hours go from 0.40 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
9 citations, most serious first — scroll within the box to see all.
- Actual harm · Gcited before2026-06-24 · 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 3037808.Based on interview and record review the facility failed to provide adequate supervision from two staff members during a transfer with a mechanical lift for one (R507) of five residents reviewed for accident hazards/safety resulting in R507 falling off the lift during transfer, hitting their head, and requiring five staples for wound closure.Findings include:The State Agency (SA) received a complaint that R507 fell from a mechanical lift and sustained injuries.According to the Electronic Health Record (EHR) R507 admitted to the facility in 2019 with multiple diagnoses that included Multiple Sclerosis, severe malnutrition, and dementia. The Minimum Data Set (MDS) indicated R507 had intact cognition and was totally dependent on staff for bed mobility and transfers from surface-to-surface. A care plan for Activities of Daily Living (ADL) initiated on 3/29/26 and the Kardex (a reference guide that summarizes the resident's care plan and daily needs), indicated that R507…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 3018035. Based on interview and record review the facility failed to notify the physician of missing medications for one (R506) of four residents reviewed for medication administration resulting in the physician being unaware that R506 missed two consecutive medication doses for a respiratory inhaler and an antibiotic. Findings include: The State Agency received a complaint that R506 missed several doses of medications.According to the Electronic Health Record (EHR) R506 admitted to the facility on [DATE]. The admission orders dated 4/8/26 for medication included the following: 1) Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/DOSE (respiratory inhaler)one (1) inhalation orally every 12 hours for copd (chromic obstructive pulmonary disease). 2) Cefadroxil Oral Capsule 500 MG (antibiotic) Give 1 capsule by mouth two times a day.A progress note on 4/8/26 at 6:40 PM indicated R506's Advair Diskus was not available.Review of R506's April 2026 Medication Administration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-24 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake 3037808. Based on interview and record review the facility failed to report an injury of unknown origin for one (R507) of four residents reviewed for abuse. Findings include:According to R507's the Electronic Health Record (EHR) R507 admitted to the facility in 2019 with multiple diagnoses that included Multiple Sclerosis, severe malnutrition, and dementia. The Minimum Data Set (MDS) indicated R507 had moderately impaired cognition and was totally dependent on staff for bed mobility and transfers from surface-to-surface. A progress note dated 6/18/26 at 8:39 AM indicated R507 complained of left knee pain. The physician was notified, pain medication was administered, and an X-ray ordered. The X-ray radiology report dated 6/18/26 indicated R507 had a slight comminuted fracture of the proximal left femur (comminuted fracture is when a bone splits or shatters into more than 3 pieces, usually caused by high impact trauma). R507 was transported to the emergency room for further evaluation and treatment. R507 was not present in the facility during the time…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-24 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 3018035.Based on observation, interview, and record review, the facility failed to make an ophthalmology appointment as ordered by the physician for one (R505) of three residents reviewed for the coordination of outside physician appointments resulting in the delay of ophthalmology services for R505.Findings include:On 6/23/26 at 3:40 PM, R505 was observed lying in bed with the TV on. During interview R505 reported that the facility had not scheduled an appointment for their cataract extraction. R505 said, The doctor said I would be able to see better if I got my cataracts removed. I was all set up to go and then something happened. I never went to the eye doctor again. I keep asking about it and no one can tell me anything. I want to know why I haven't got my cataracts out yet.Review of R505's Electronic Health Record (EHR) revealed R505 re-admitted to the facility on [DATE] with multiple diagnosis that included peripheral vascular disease and legal blindness. An Optometry Order…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-03 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to properly date-label stored food and remove expired food in resident refrigerators affecting all the residents who consumed food from the unit refrigerators resulting in unidentifiable resident food items, expired food items, and the potential for food-borne illness.Findings include:On 12/02/2025 at 10:30 AM unit refrigerators were observed with the Dietary Supervisor (DS) A. The following were noted:2nd floor unit fridge-Expired fruit, unlabeled.-A chocolate cake unlabeled.-A half loaf of expired bread.3rd Floor unit fridge-A container of unlabeled, undated spinach dip.-An expired cake unlabeled.-A container of a leftover meal undated, unlabeled.On 12/2/2025 at 10:40 AM DS A was interviewed and said dietary staff were responsible to maintain the unit refrigerators. DS A further said all staff were aware that resident food items need to be labelled and dated to decrease the risk for food borne illness.On 12/03/2025 at 11:14 AM the Director of Nursing (DON) was interviewed regarding the kitchenette…
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 · D2025-12-03 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent the misappropriation of one resident's (R22) property from four residents reviewed for abuse resulting in 26 tablets of R22's narcotic pain medication (oxycodone 10-325 milligram (mg)) missing and unaccounted for.Findings include:On 3/11/2025 the State Agency (SA) received a Facility Reported Incident (FRI)indicating R22 had missing narcotic pain medications.According to the facility's investigation report, 26 tablets of R22's Oxycodone 10-325 mg could not be accounted for during the 3/11/25 A.M. shift change narcotic count. It was determined that the discrepancy began on 3/10/25 with Registered Nurse (RN) E. The facility terminated RN E and reported their license to the State Licensing Board and local police. R22 was interviewed and reported receiving pain medications as requested. The facility replaced R22's missing medications.On 12/1/25 at 3:03 PM, R22 was interviewed regarding the FRI and said, I knew my meds were missing…
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 · D2025-12-03 · 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
Based on observation, interview, and record review the facility failed to provide appropriate PEG tube care (a tube placed directly into the stomach through an abdominal wall incision for the administration of food, fluids, and medication) for one (R47) resident reviewed for tube feeding resulting in a compromised PEG tube with no cap, difficulty administering medications, and the potential for infection.Findings include: On 12/02/2025 at 9:33 AM, during observation of medication administration for R47, the resident's PEG tube was compromised and missing the attached cap. The PEG tube was clamped with a plastic clamp but not completely or securely capped off. The opening of the tube was covered with white tape. The white tape was soaked with beige colored liquid that was the same color and consistency of the resident's tube feeding formula. The tape easily slid off the port when LPN B touched it. The PEG tube was visibly worn with crushed medications observed inside the tube. Closer inspection revealed that the PEG tube port could not be securely connected to the feeding tube. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-12 · 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 MI00141226. Based on interview and record review the facility failed to properly secure a resident in a wheelchair before transportation for one resident (R901) out of three residents reviewed for safety, resulting in R901's wheelchair tipping backward and the potential for injury. Findings include: Record review of R901's face sheet revealed admission into the facility on 5/28/21 with a pertinent diagnosis of End Stage Renal Disease. According to the Minimum Data Set (MDS) dated [DATE], R901 had intact cognition and required assistance with Activities of Daily Living (ADLS). During an interview on 12/12/23 at 9:27 AM, R901 reported that on 11/19/23 when leaving the dialysis center and returning to the facility Transportation Aide A turned onto the road and the wheelchair then tipped backwards. During an interview on 12/12/23 at 10:05 AM with Transportation Aide (TA) A it was reported that on 11/19/23 she had picked up R901 at dialysis facility. When turning onto the road, R901…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-11-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 79 residents who receive meal services (1 nothing by mouth residents, or NPO) out of the facility's total census of 80 residents. Findings include: 1. On 11/14/23 at 3:04 PM, an accumulation of dust, ice, and food debris was observed on the floor of the walk-in freezer. At this time upon interview with the Dietary Manager, staff A, the surveyor inquired if the facility had any policies in place regarding cleaning related job duties for staff to follow to which they stated, Yes. We do a deep clean in here monthly. At this time the surveyor requested a copy of the walk-in-freezer's cleaning policy to review. On 11/15/23 at 9:14 AM, the exterior of the ovens, stove top, and its surrounding area were observed discolored with heavy staining in sections. At this time the surveyor inquired…
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 AVON HEALTHCARE — 9 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 | 2.2 | +1.8 vs chain |
| Health inspection | 4 of 5 | 2.0 | +2.0 vs chain |
| Staffing | 3 of 5 | 3.0 | ≈ chain avg |
| Quality measures | 2 of 5 | 3.7 | -1.7 vs chain |
The other 8 homes this chain runs (chain average 2.2★, per CMS)
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 |
|---|---|---|---|---|
| SPRINGS BAY OP HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/31/2023 |
| GOTTLIEB, MOSHE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 48% | since 07/31/2023 |
| FREUND, ELIYAHU | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; ADP OF THE SNF | — | since 07/31/2023 |
| BHURGRI, AAMER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/30/2025 |
| SABA, GAIL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/31/2023 |
| WOOD, KRYSTEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/31/2023 |
| AVON SPRINGS BAY MANAGEMENT LLC | Organization | ADP OF THE SNF | — | since 01/22/2025 |
| MONROE SPRINGS PROPERTY LLC | Organization | ADP OF THE SNF | — | since 01/22/2025 |
CMS files one row per role, so the 13 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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 $517K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
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 235520. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-03, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.