Martha T Berry MCF
43533 Elizabeth Road, Mount Clemems, MI 48043 · Government - County · 217 certified beds · (586) 469-5265 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
- 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 abuse, neglect, or exploitation citations (F0600, F0602) — most recent Sep 2024
- it has 1 actual-harm citation
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 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 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 | 12.5% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.1% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.2% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.6% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.2% | 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 | 4.0% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 12.7% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.2% | 19.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 97.2% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.5% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 19.3% | 20.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.5% | 14.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 86.8% | 79.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 16.3% | 24.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 14.0% | 11.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.93 | 1.84 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.03 | 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.
29.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 21 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 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | 29.2%CMS range 18.1–42.2 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.6%CMS range 6.0–13.5 | 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 | 42.9% | 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 | 61.9% | 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 | 33.3% | 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 | 96.3% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 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 | 3.7% | 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 | 6.8%CMS range 3.8–12.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.80 | 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 217 beds and averages 208.1 residents a day — about 96% occupied, or roughly 9 beds typically open. It runs essentially full — expect a waiting list. 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 5.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.30 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 4.00 hrs/resident/day on weekends vs 5.47 on weekdays — 27% thinner on weekends — a notable drop. RN hours go from 0.78 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Actual harm · Gcited before2025-11-10 · 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 Based on interview and record review the facility failed to ensure appropriate interventions were implemented to prevent a fall with injury for one resident (R901) of three reviewed for falls. Findings include:This citation pertains to Intake 2661503.A review of a progress note by Licensed Practical Nurse (LPN) A dated 10/05/25 at 12:38 PM, documented, Resident was observed lying in the hallway face down in a pile of blood. Writer (LPN A) assisted resident to (their) back then into wheelchair. Writer applied pressure to laceration on (right) R side of forehead and to bridge of nose . Writer asked resident what happened, and (they) began to cry stating that (their) head hurts. Writer applied pressure to bleeding areas until the ambulance arrived. Ambulance arrived and took resident to (hospital). Review of a post fall assessment by LPN A documented, .Post Fall Evaluation Late Entry: Fall Details: Date/Time of Fall: 10/05/2025 11:30 AM. Fall occurred in the hallway. Activity at the time of fall: Ambulating. Reason…
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 · E2026-04-02 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 Based on observation, interview, and record review, the facility failed to provide a homelike environment including the availability of warm/hot water, for nine residents (R36, R81, R82, R85, R87, R89, R123, R136, and R160). Findings include:R36 On 3/31/26 at 9:45 AM, R36 was observed lying in bed watching television. R36 pointed to the foot of the bed and stated, Those holes bother me. I don't like that and I wish it was fixed. The footboard at the end of the bed was noted to have two large open areas where the laminate on the footboard was missing and loose. Further observation revealed, in the wall behind the bed was a large hole about 6 inches long and 3 inches wide. A record review revealed R36 was admitted on [DATE] with the following medical diagnoses of Hypertension and Anxiety Disorder. R36's Brief Interview of Mental Status assessment score was 15/15 indicating intact cognition. On 4/01/26 at 10:30 AM, a tour of R36's room was conducted with the Housekeeping Director J and acknowledged the previously…
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 · D2026-04-02 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 the invitation and inclusion in care conferences (participation in planning their own care) of one resident (R103) of two reviewed for care planning. Findings include: On 3/31/26 at 10:27 AM, R103 was asked about their satisfaction with the care and services they were receiving at the facility. R103 stated, I want to get out of here. R103 was asked if they had discussed this issue in their care conference meetings. R103 indicated that they had never attended a care conference meeting and didn't know anything about them. R103 expressed a desire to attend their care conferences. A record review of R103's electronic medical record (EMR) revealed documentation of care conferences being conducted regarding R103 on 11/5/25 and 2/11/26. There was no documentation which indicated the residents' invitation to the conference, attendance, refusal, or a reason why the resident was not in attendance at either care conference. Further review of R103's EMR…
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 before2026-04-02 · 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 provide timely repositioning and transfer assistance for two dependent residents (R85, R160) of three observed for quality of care. Findings include: R85On 03/31/2026 at 12:10 PM, 12:31 PM, 12:40 PM, and 1:17 PM, R85 was observed in the alcove dining area along with eight other residents. R85 was in a 'Broda' style wheelchair (designed for safer positioning and fall prevention). R85 was leaning toward the left side of the chair with the left shoulder lower toward the armrest. At 1:17 PM, R85's head was on the left side bolster, and the torso was leaned over to the left and scrunched down slightly. R85 did not respond to queries. At 1:36 PM, the left elbow was sticking out the back side of the wheelchair between the back support and side of the wheelchair. R85 moved their left leg up and down as it hung over the left arm of the wheelchair. At 2:08 PM, the chair had been leaned back to around 30-45 degrees. At 2:53 PM, R85 was observed in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-02 · 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 apply protective heel boots (footwear used to relieve pressure on the heel) for one resident (R147) out of five reviewed for skin conditions. Findings include:A review of the Electronic Medical Record (EMR) for R147 revealed a physician's order last revised 8/28/2024 for R147 to have protective boots while in bed.Further review of the EMR revealed R147 was admitted to the facility 5/24/2022 with diagnoses of peripheral vascular disease, contracture of right and left knees, chronic pain syndrome, and type two diabetes. Review of R147's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out 15, indicating fully intact cognition. Section M (Skin Conditions) revealed that the resident is at risk of developing pressure ulcers/injuries.On 03/31/2026 at 10:30 AM and 1:15 PM, R147 was observed lying in bed with no protective heel boots in place.On 04/01/2026 at 11:29 AM and 2:08 PM, R147 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 · D2025-01-29 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 an update for a preadmission screening (PAS) and resident review (ARR) /Hospital Exempted Discharge for a Level II evaluation was completed for one resident (R187) of three residents reviewed for PASARR. Findings include: A review of the medical record revealed that R187 admitted into the facility on 9/18/24 with the following diagnoses of paranoid schizophrenia, post traumatic stress diorder and dissociative identity disorder. A review of the most recent Minimum Data Set assessment dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. A review of the medical record revealed a Preadmission Screening with a hospital exemption dated on 9/18/24. There was no change in condition for hospital discharge within 30 days and the PASSAR had not been updated. There was no additional PASARR forms nor was a Level II screening requested due to R187 having mental illness diagnoses. On 01/28/2025 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 · D2025-01-29 · 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
This citation pertains to Intakes MI00149363 and MI00149481. Based on observation, interview, and record review, the facility failed to implement a dental care plan for one resident (R110) out of one reviewed for comprehensive care plans. Findings include: On 01/27/25 at 10:00 AM R110 was observed laying in bed watching television. R110 was asked about dental care and stated they wanted teeth pulled at a dentist office, not the facility. A review of the medical record revealed R110 admitted into the facility on 1/05/2024 with the following diagnoses, Dysphagia, Malnutrition, Adult Personality Disorders, and Adjusment Disorder. A review of the Minimum Data Set (MDS) assessment on 1/9/25 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 indicating moderately impaired cognition. Further review of of R110's medical record revealed dental consultions and issues with they're teeth. There was no comprehensive dental care plan with interventions noted in the medical record. On 01/29/2025 at 1:00 PM, an interview was conducted with Social Worker A regarding R110's dental care…
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 before2025-01-29 · 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 implement skin interventions and date skin care treatments, for one sampled resident (R153) of three reviewed for skin. Findings include: On 1/27/25 at 1:34 PM, R153 was observed in their room sitting in a wheelchair. R153 was asked about the care at the facility and mentioned they need a new bandage strip. R153's right elbow was observed with a brown bandage on it without a date and intial, R153's right upper thigh was observed with a brown bandage on it without a date, and R153's right leg was observed with a discolored area that was not covered. R153 explained the facility has not followed up and changed the bandages for a few days. On 1/29/25 at 9:42 AM, R153's skin on the left leg was observed with a large red area that had a large blister that was not covered. R153 reported it was not covered on 1/28/25 and the bandage on their right elbow needed to be replaced because it fell off. On 1/29/25 at 9:45 AM, Unit Manager A was asked to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-29 · 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 interventions to prevent the development of a deep tissue injury and subsequent stage 3 pressure ulcer ( full-thickness skin loss) for one resident (R49), of three residents reviewed for pressure ulcers. Findings include: On 1/28/25 at 8:21 AM, R49 was observed in bed eating breakfast, heels flat on the bed. Attempts to interview the resident were to no avail as the resident was pleasantly confused. A review of R49's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Dementia, Muscle Weakness, and Psychotic Disorder. Further review of R49's medical record revealed they were significantly cognitively impaired, and was dependent for bed mobility per their care plan initiated on 12/13/23. Further review of R49's medical record revealed they sustained a fall on 8/6/24 resulting in a left hip fracture. Further review of R49's medical record revealed the following progress notes:…
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 before2025-01-29 · 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 implement adequate supervision, and effective fall interventions for one sampled resident (R117) of four residents reviewed for falls, resulting in multiple falls, and a hospitalization. Findings include: On 1/28/25 at 8:28 AM, R117 was observed in bed on their back, floor mats observed on both sides of the bed. Attempts to interview the resident was to no avail due to their cognition. A review of R117's medical record revealed they were admitted into the facility on 4/6/23 with diagnoses that included Dementia, Hypertension, and Muscle Weakness. Further review revealed the resident was severely cognitively impaired with a brief interview for mental status score of 3/15, had a language barrier, and was dependent on staff for all activities of daily living. Further review of the resident's medical record revealed the following progress notes related to unwitnessed falls: 9/17/2024 13:22 (1:22pm) Incident Note .Resident observed kneeling on [their] knees next to the bed on the floor mat by the activities lady.…
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 · D2025-01-29 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such 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 Based on observation, interview, and record review, the facility failed to administer a pain patch for one sampled resident (R28) of one review for medication administration. Findings include: On 1/27/25 at 1:36 PM, R28 was asked about the care at the facility and stated, Yesterday they didn't give me my pain patch. R28 reported this happens often. A review of R28's medical record revealed, R28 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A review of R28's Minimum Data Set (MDS) assessment dated [DATE], noted R28 with an intact cognition and requires staff assistance to complete activities of daily living (ADLs). A review of the Medication Administration Record (MAR) for December 2024 revealed, Lidocaine Patch 4 % Apply to the painful area topically one time a day for Musculoskeletal pain. Apply to the affected areas/painful region -Start Date 06/17/2023. On December 20th the MAR was marked with a 9 indicated see nurses notes (for reason why 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.
Show the remaining 6 citations
- Potential for harm · D2025-01-29 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 ensure a medication error rate not greater than 5%, for one resident (R181) out of four residents observed during medication pass, resulting in a medication error rate of 7.4%. Findings include: On 1/28/25 at 8:16 AM, Licensed Practical Nurse (LPN) B prepared medications for R181 which included Diltiazem (to treat high blood pressure) ER (extended release) and Methenamine Hippurate (to prevent urinary tract infections). After placing all medication tablets in a medication cup, LPN B stated oh the other nurse told me that they need to be crushed. LPN B explained there is a standing order that states medications can be crushed if needed. LPN B explained they had a reference book indicating medications could and could not be crushed. LPN B was then observed to reference the medication book and stated, I don't see them in here. LPN 'B then crushed all the medications, mixed them with pudding, and administered them to R181. LPN B was asked if…
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 · D2024-09-17 · 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 This citation pertains to Intake: MI00146692 Based on interview, and record review, the facility failed to ensure protection from misappropriation of property for one resident (R700) out of one resident reviewed for abuse . Findings include: Reviewof a facility reported incident documented, A resident's (R700) debit card ws obtained and used by an employee without the permissionof the resident or their responsible party. The suspected employee was brought in for interviewing and confessed to using the card without permission . On 9/17/24 at 10:45 AM, R700 was observed in they're room laying in bed. R700 unable to recall the incident. A review of R700's clinical record revealed R700 was admitted into the facility on 8/02/23 with diagnoses that included: chronic Obstructive Pulmonary Disease, Psychotic disorder with Hallucinations. A review of R700's Minimum Data Set (MDS) assessment dated [DATE] revealed R700 had a Brief Interview of Mental Status (BIMS) assessment score of 6 indicating severe 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.
- Potential for harm · D2023-11-15 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a privacy bag for a urinary drainage bag for one resident (R79) out of two reviewed for catheters, resulting in loss of privacy and dignity. Findings Include: On 11/13/2023 at 11:05 AM, R79 was observed in the dining area sitting in their wheelchair. R79 was observed to have a catheter, with no privacy bag on the urinary drainage bag. R79 was queried as to if they prefer not to have a privacy bag. R79 stated that they prefer to have a privacy bag on, and that they thought they had the drainage bag with the blue cover on it. A review of the medical record revealed that R79 admitted into the facility on [DATE] with the following diagnoses, Obstructive and Reflux Uropathy, Dysphagia, and Major Depressive Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. R79 also required extensive two person assist with transfers and bed mobility. On…
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 · D2023-11-15 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each 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 M100139900. Based on observation, interview and record review, the facility failed to ensure that call lights remained within reach for six (R30, R62, R83, R110, R131, R136) of 13 sampled residents, resulting in resident and family member dissatisfaction with care and the potential for delayed or unmet care needs. Findings include: R83 Review of the medical record facesheet for R83 revealed an admission date of 01/31/20 with diagnoses that included Dementia, Anxiety Disorder and Muscle Weakness. The Minimum Data Set (MDS) assessment dated [DATE] indicated R83 required primarily total (Dependent) assistance for activities of daily living (ADLs). The Brief Interview for Mental Status (BIMS) score of 10/15 indicated moderate cognitive impairment. On 11/13/23 at 2:56 PM, R83 was observed laying in bed. R83's call light was observed on top of the tall wardrobe storage cabinet adjacent to the head of the bed out of the resident's reach. Review of R83's Care Plan dated 08/09/23 revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-15 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 MI00139058. Based on interview and record review, the facility failed to protect a vulnerable resident (R84) from unconsentual inappropriate touching by a resident (R166) who had documented sexual behaviors of out of seven residents reviewed for abuse, resulting in emotional distress. Findings include: Review of the facility Five Day Investigation Report submitted to the State Agency revealed that R84 reported to a staff member on 07/09/23 that while in a common activity area they had been touched in a sexually inappropriate manner by R166 and that they found it upsetting. This report indicated that a second staff member reported observing R84 being tearful and expressing emotional distress shortly following the alleged incident. The report indicated that during follow-up facility interviews, R84's responses fluctuated between acknowledging that the incident occurred and either denying or not recalling that the incident occurred. Facility interviews with R166 indicated that they…
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 · D2023-11-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00139900. Based on observation, interview and record review the facility failed to ensure staff cleaned rooms daily for two room areas 2131 and 3133, resulting in the potential for dissatisfaction with room conditions and the accumulation of debris. Findings include: On 11/13/23 at 10:32 AM, 12:42 PM and 4:45 PM, in room [ROOM NUMBER]: The resident was observed to be in bed. A tube feed pump was active and attached to a pole with four legs/feet. On the flat surface of two of the four feet were two [NAME] size areas of what looked like dried tube feeding. Observed under the head of the bed on the floor were: a small wedge (ankle/foot orthotic boot), a call light cord clip and two caps for the tube feeding line (these are removed when the tube feeding is connected to the resident). In room [ROOM NUMBER]: a tube feed pump was active and attached to a pole with four legs/feet. On the flat surface of one of the four feet was a dime size and smaller areas of what looked like dried…
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BROWN, RALPH | Individual | MANAGING CONTROL - GOVERNING BODY | since 11/01/2017 |
| EVANS, KEVIN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2016 |
| FLYNN, COURTNEY | Individual | MANAGING CONTROL - GOVERNING BODY | since 04/25/2024 |
| THOMPSON, PATRICK | Individual | MANAGING CONTROL - GOVERNING BODY | since 11/01/2016 |
| MACOMB COUNTY HUMAN SERVICES BOARD-AN AGENCY OF MACOMB COUNTY | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2010 |
| MORRISON MANAGEMENT SPECIALISTS INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2016 |
| BEG, MIRZA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/10/2025 |
| LUYEHO, CHRISTINE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/31/2024 |
| CONCEPT REHAB, INC. | Organization | ADP OF THE SNF | since 09/20/2016 |
CMS files one row per role, so the 14 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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 $378K 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 235155. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-02, 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.