Helen Newberry Joy HLTCU Golden Leaves Living Cent

Location & what’s nearby

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

Quality measures — how residents actually fare

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

Staffing

How full it usually is: this home is certified for 39 beds and averages 26.8 residents a day — about 69% occupied, or roughly 12 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Weekend coverage: total nurse staffing is 3.87 hrs/resident/day on weekends vs 4.82 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.40 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% 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 unchanged from the previous inspection. 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.

35 citations, most serious first. The 15 most serious are shown; the remaining 20 are one tap away and print in full.

• Actual harm · Gcited before2026-01-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficiency pertains to Intake #2694753Based on observation, interview, and record review, the facility failed to implement interventions consistent with recognized standards of practice to promote the healing of a pressure injury for one Resident (R1) of three residents reviewed for pressure injury. This deficient practice resulted in the worsening of stage 3 pressure injury on the right heel of R1. Findings include:Intake #2694753 was submitted to the state agency on 12/10/25. The intake alleged the facility failed to prevent worsening of a pressure injury (PI) to the heel of Resident #1 (R1).On 1/2/26 at 10:32 AM, 11:17 AM, and 12:19 PM, R1 was observed in her room sitting in her wheelchair at bedside with both feet placed directly on the floor without a support surface or pressure-reducing device.R1 was interviewed on 1/2/26 at 12:19 PM. A wound dressing was observed on her right lateral posterior calf. R1 said she had a wound on her calf but could not recall how long the wound on the calf had been…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-06-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficiency pertains to Intakes #MI00153229 and #MI00152446 Based on observation, interview, and record review, the facility failed to prevent one Resident (#3) of eight residents reviewed for homelike environment related to personal property from entering the rooms and taking personal possessions of other residents. This deficient practice resulted in Residents #2, #4, & #5 experiencing fear of continued resident to resident abuse, frustration, and emotional distress and items being taken from #7 and #8. Findings include: On 6/4/25 at 10:15 AM, the doorways to residents' room were observed with mesh-type barriers with stop sign notifications on the barriers. The barriers extended across the doorways and were secured with Velcro on each end to the doorframes. The Director of Nursing (DON) said the barriers were utilized to prevent Resident #3 (R3) from entering the rooms of other residents. Resident #2 (R2) On 6/4/25 and 6/5/25, the door to R2's room was observed with a sign indicating Do Not Enter. The door…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-06-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficiency pertains to Intakes #MI00152446 and #MI00153229 Based on interview and record review, the facility failed to ensure three Residents (#2, #4, and #7) of five residents reviewed for abuse were free from physical abuse by another Resident (#3) with a documented history of physical abuse of others. This deficient practice resulted in R2 and R4 experiencing fearfulness, frustration, and emotional distress, and R7 experiencing fear, pain and sustaining reddened areas on the neck after a choking event. Findings include: Two facility-reported incidents (FRI) regarding resident-to-resident altercations were reported to the state agency. #MI00152446 was reported on 4/14/25 and #MI00153229 was reported on 5/18/25. Both FRI listed Resident #3 (R3) as being involved in physical altercations with other residents. Intake #MI00152446 reported, in part: . DON [Director of Nursing] received call from RN [Registered Nurse] Supervisor that there was a resident-to-resident altercation. [Resident #2 (R2)] was sitting…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-06-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide 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 assess and monitor pressure injuries, develop and implement a plan of care for pressure injuries, and maintain infection control practices during dressing changes for One Resident (R14) of One resident reviewed for pressure injuries. This deficient practice resulted in harm when R14 experienced worsening of wounds and the development of three stage 3 pressure injuries. Findings include: Resident #14 (R14) was interviewed on 6/24/24 at 12:56 p.m. R14 was noted to be lying on his back in bed with the sides of his body pressed against the side rails on the bed. R14 said, they ordered me a new bed - it should have been here by now. R14 said a new bed had been ordered due to wounds on his buttocks. On 6/24/24 at approximately 2:00 p.m., the Director of Nursing (DON) said there were no pressure injuries in the facility. When asked for clarification, the DON reiterated the facility did not have any residents who had pressure injuries. When asked…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-06-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess, develop and revise care plan interventions, provide adequate supervision, and investigate falls for root cause, to minimize the risk of fall recurrence for one Resident (R23) of two residents reviewed for falls. This deficient practice resulted in R23 experiencing multiple falls with numerous injuries including transfer to the emergency department for facial suturing. Findings include: Resident #23 (R23) was admitted to the facility on [DATE] with a diagnosis of severe Dementia with agitation. An admission Minimum Data Set (MDS) assessment dated [DATE] documented R23 as having a history of falls prior to admission to the facility. Section J1700 of the MDS documented R23 had a fall within the month prior to admission to the facility and had falls within 2-6 months prior to admission to the facility. On 6/24/24 at 2:10 p.m., a position change alarm box was observed on the head of R23's bed. R23 was observed ambulating 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-08-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by:- Failing to ensure labeling of food.- Failing to ensure expired food was discarded.- Failing to ensure proper hand sanitization when serving food.This deficient practice had the potential to result in food borne illness among any or all 29 residents in the facility who receive meals.Findings include:During an observation on 8/26/25 at 10:12 a.m., the #9 walk in refrigerator contained:1. 1 bag of opened celery with a use by date of 8/23/25.2. 1 large bag of sliced green peppers that appeared to be mushy and slimy with no had no use by date.3. 1 opened bag of diced onions with a use by date of 8/24/25.4. 1 opened bag of sliced onions with a use by date of 8/25/25.During an observation on 8/26/25 at 10:25 a.m., the #3 refrigerator had a small plastic container of cultured buttermilk with an open date of 8/19.During an observation on 8/26/25 at approximately 10:27 a.m., the #7 walk in freezer…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-28 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to provide a comfortable temperature level in the dining room, and maintain the wheelchairs of three Residents (R5, R19, and R24) in clean and sanitary conditions.Findings include:Findings include: Resident #19 (R19) On 8/27/2025 at 8:45 AM, an observation was made of an unoccupied wheelchair belonging to R19 in the hallway leading to the main dining room. The wheelchair was observed with a large amount of food particles of various shapes, colors, and sizes underneath the cushion and along the sides of the seat. On 8/27/25 at 8:50 AM, an observation was made of a second wheelchair in R19's room. The wheelchair was identified as R19's unoccupied and had food crumbs on the seat of the wheelchair. On 8/27/25 at 9:00 AM, an observation was of Resident #5 and Resident #24's unoccupied wheelchairs in the hallway. They were observed with multiple old food crumbs and drink stains on them and debris of food on the seats. On 8/27/25 at 9:15 AM, an interview was conducted with The Director of Nursing (DON), who was asked…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-28 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide information to formulate an advance directive for two Residents (#4 and #21) of two residents reviewed for advanced directives.Findings include:Resident #4 (R4)Review of the Minimum Data Set (MDS) assessment, dated 6/11/25, revealed admission to the facility on [DATE].Review of the Electronic Medical Record (EMR) did not reveal that the resident/responsible party had received advanced directive information or formulated an advanced directive.Resident #21 (R21)Review of the MDS assessment, dated 6/5/25, revealed admission to the facility on 2/22/25.Review of the EMR did not reveal that the resident/responsible party had received advance directive information or formulated and advanced directive.During an interview on 8/27/25 at 11:45 a.m., Licensed Practical Nurse (LPN) D reported she had been providing information for residents/responsible parties for advanced directives. LPN D reviewed the EMR for #4 and #21 and acknowledged the residents were…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-28 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  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 investigate resident-to-resident altercations for two Residents (R12 and R6) of two residents reviewed for abuse. Findings include: Resident #12 (R12) was admitted to the facility on [DATE] with a primary medical diagnosis of chronic obstructive pulmonary disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R12 had no functional limitations in range of motion, was independent for activities of daily living, and was independently ambulatory utilizing a walker. Further review of the MDS disclosed R12 had fully intact cognition. During an interview on 8/26/25 at 1:22 PM, R12 said another resident had recently struck her in the head and grabbed her by the wrist and twisted it resulting in a sore wrist. R12 indicated it was the same resident with whom she had previous altercations – Resident #4 (R4). A progress note in the electronic medical record (EMR) of R12 dated 8/6/25 at 9:47 AM read, in part: Spoke with resident…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to obtain physician orders for the use of a catheter for one Resident (#21) of three residents reviewed for catheters.Findings include:Resident #21 (R21)Review of the Minimum Data Set (MDS) assessment, dated 6/5/25, revealed admission to the facility on 2/22/25 with active diagnoses that included depression and multiple sclerosis. R21 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition.During an observation on 8/26/25 at 12:25 p.m., R21 had a catheter bag that was located in a privacy bag.During an interview on 8/26/25 at 12:28 a.m., R21 stated, I was going to the bathroom a lot and they needed to help me.I was getting up at night and they put the catheter in me.I drink a lot of fluids as I have had urinary tract infections in the past and I don't want to get another one.Review of the Electronic Medical Record (EMR) revealed there was no physician order for an indwelling catheter for R21.During an interview on 8/27/25 at 1:24 p.m., Registered Nurse (RN)/Nursing…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  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 supplemental oxygen according to physician orders, change and date respiratory tubing, and maintain clean respiratory equipment for one Resident (R19) of three residents reviewed for respiratory services. Findings include: Resident #19 (R19) was admitted to the facility 3/16/22. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed R19 had moderately impaired cognition and received supplemental oxygen for a primary medical diagnosis of congestive heart failure.On 8/26/25 at 11:31 AM, R19 was observed sitting in a recliner in her room wearing an unlabeled/undated nasal cannula (a tube used to deliver supplemental oxygen). The undated tubing was attached to an oxygen concentrator set to a flow rate of 3 LPM (liters per minute). The oxygen concentrator was observed to be visibly soiled with dust and visual debris was evident on and around the concentrator. A note was taped to the oxygen concentrator that…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-28 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  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 ensure a medication error rate less than 5 percent, with 12 errors identified, out of 41 medication administration opportunities observed. This deficient practice resulted in a medication error rate of 29.27 percent.Findings include: Errors 1 - 12. Resident #7 (R7) - During observation of preparation of oral and inhalation medications for R7 on 8/27/25 at 10:24 AM, Licensed Practical Nurse (LPN) D dispensed aspirin 81 milligrams (mg) one chewable tab, ferrous sulfate 325 mg one tab, ascorbic acid 500 mg one tab, sennosides-docusate sodium 8.6 mg / 50 mg one tab, guaifenesin extended release (ER) 600 mg one tab, topiramate 50 mg one tab, oxcarbazepine 600 mg one tab, desvenlafaxine ER 100 mg one tab, metoprolol succinate ER 25 mg one tab, and isosorbide mononitrate ER 30 mg half tab (15 mg) one tab. LPN D also dispensed two inhalers; fluticasone furoate and vilanterol one puff, and tiotropium bromide two puffs. LPN D completed her preparation for morning medication pass for R7 which included 0800 (8:00 AM)…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-28 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure safe storage of medications and labeling for one medication cart of one medication cart reviewed for medication storage. Findings include: On 8/27/2025 at 7:30 AM, in the main dining room an observation was made of a round circular orange pill lying on the main dining room floor with the imprint on one side an Xa and on the other side 15 and an upside-down triangle and identified as a Rivaroxaban. At the time the pill was observed there were 14 unidentified residents sitting in the dining room. Licensed Practical Nurse (LPN) D confirmed that the identified pill was rivaroxaban and was an anticoagulant which is a blood thinner medication that belonged to Resident #4. On 8/27/2025 at 11:30 AM, an interview was conducted with the Registered Nurse (RN) A who was made aware of the observation of the rivaroxaban lying on the main dining room floor during residents' morning breakfast and stated, That's not good especially that medication a blood thinner. RN A asked this Surveyor if the nurse [LPN D] dropped…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-09-26 · tag F0625 — pattern
  Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to provide written notification of the facility bed hold policy for four Residents/Resident Representatives (R1, R4, R8, and R16) of four residents reviewed for notice of bed hold policy. Findings include: Review of the facility Electronic Medical Record (EMR) confirmed that R1 was discharged from the facility on 8/19/24 Review of the facility EMR confirmed R4 was discharged from the facility on 8/9/24 to acute care Review of the facility EMR confirmed R8 was discharged from the facility on 8/19/24 to acute care Review of the facility EMR confirmed R16 was discharged from the facility on 8/9/24 to acute care During an interview on 10/25/24 at 7:48 a.m., the Chief Nursing Officer A stated, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) B take care of all .discharges, we do not have a social worker. During an interview on 9/25/24 at approximately 10:20 a.m., Administrative Assistant F stated, we have not given or sent a bed hold policy letter to residents or families since July of 2022 .I mail out all…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-26 · tag F0604 — failed to not use physical restraints improperly — isolated
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure freedom from physical restraints for one Resident #10 (R10) of one resident reviewed for restraints. This deficient practice resulted in the restriction of freedom of movement, physical discomfort, and psychosocial distress. Findings include: Resident #10 (R10) Review of R10's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 8/29/23, with active diagnoses that included: Parkinson's disease, hypertension, dementia, and hyperlipidemia. R10 scored a 15 of 15 on the Brief Interview of Mental Status (BIMS) reflective of intact cognition. Review of R10's care plan last revised 5/4/24, read in part .Wander guard to left ankle to alert staff when I am near an exit door. During an interview on 9/26/24 at approximately 9:15 a.m., R10 stated, I don't know why that thing is on my ankle .it is tight on my ankle though and uncomfortable. During a review of R10's Elopement Risk Evaluation dated 8/30/24…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$15,873 in federal fines across 1 penalty. 3 Medicare payment denials on record.

• $15,873 — penalty dated 2025-08-28
• Medicare payment denial — starting 2025-11-28 for 46 days
• Medicare payment denial — starting 2025-07-02 for 13 days
• Medicare payment denial — starting 2024-11-14 for 1 days

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

Who owns this facility

CMS files one row per role, so the 20 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

What families pay in MI