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Fox Run Village

41215 Fox Run Road, Novi, MI 48377 · Non profit - Corporation · 44 certified beds · (248) 668-8720 Medicare & Medicaid certified

Call the home — (248) 668-8720 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Apr 2026Behavioral-health or dementia-care citation — no harm found (F0758)$12,350 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • 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
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $12,350 in federal fines (most recent 2023-09-18)

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
39475 Lewis Dr · (248) 489-0766 · Call to confirm hours
Pharmacy
39625 Lewis Dr Ste 800 · (800) 688-2024 · Call to confirm hours
Grocery
30012 Montmorency Dr · (586) 894-2985 · Call to confirm hours
Park
41215 Fox Run · (248) 960-1433 · Typically dawn to dusk
Place of worship
40800 W 13 Mile Rd · (248) 668-7000

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 3 of 5
Long-stay residentspeople who live here 4 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 improved from 4 to 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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased22.6%10.8%15.4%worse
Long-stay residents who lose too much weight10.1%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder3.1%0.8%0.9%worse
Long-stay residents with a urinary tract infection8.0%1.5%2.0%worse
Long-stay residents with depressive symptoms0.0%4.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.1%3.0%3.3%better
Long-stay residents on antianxiety or hypnotic medication14.3%19.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers2.7%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control18.0%20.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table7.4%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine95.5%79.5%79.4%better
Short-stay residents rehospitalized after admission24.8%24.0%22.6%typical
Short-stay residents with an outpatient ER visit12.0%11.7%12.0%typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ 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.

53.1% 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 154 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.1%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
57.4%U.S. median 56.6%
Met the expected recovery
0.76U.S. median 0.31
Therapy hours / resident / day
0.39hours / resident / day
Physical therapy
0.29hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 57.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 68 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 0.76 therapist hours per resident per day in 2026Q1 — more than 93% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF53.1%CMS range 46.0–60.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.9–13.210.7%Oct 2022–Sep 2024no 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 discharge57.4%56.6%Oct 2024–Sep 2025CMS 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 discharge45.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge57.4%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 dischargenot 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 stay1.2%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.3%CMS range 2.8–9.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 2022–Sep 2024CMS 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

1.42
RN hours/ resident / day
1.43
LPN hours/ resident / day
2.94
Aide hours/ resident / day
5.79
Total nurse hours/ resident / day
0.91
RN hoursweekends
45.5%
Total nursing turnover
36.4%
RN turnover

How full it usually is: this home is certified for 44 beds and averages 39.6 residents a day — about 90% occupied, or roughly 4 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 5.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.42 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.94 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 4.99 hrs/resident/day on weekends vs 6.10 on weekdays — 18% thinner on weekends. RN hours go from 1.62 to 0.91 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% 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

3
deficiencies at the latest standard inspection (2026-04-29)
5
at the previous standard inspection (2025-03-13)

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.

ABCDEFGHIJKL

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.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · Fcited before2026-04-29 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to maintain best practices in the food service area resulting in the potential to spread foodborne illness to all residents that consume food from the kitchen. Findings Include:On 04/28/2026 at 9:15 AM during the kitchen tour with Dietary Manager (DM) I and Dietary Services Director (DSD) J observed in the walk-in cooler: two clear deep covered plastic containers of facility made tomato soup. The soup in each container was approximately 6 deep and was labeled as being prepared on 4/27. The temperature of the soup measured at the top of the product was in the range of 45 F-49 F. During this observation, when DM I was queried about the cooling of this product, it was confirmed that it had been cooked and cooled on the previous day more than 6 hours prior. DM I said cooling records are typically kept in the production logs binder referred to as the Red Book, but no monitoring records were logged for this item. Cooling practices described by DSD J were to use an ice wand for stirring product while cooling. DM I…

    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 · D2026-04-29 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review facility staff failed to report an allegation of sexual assault to the Administrator/Abuse Coordinator and State Agency for one (R7) out of two residents reviewed for abuse. Findings include:A review of R7's clinical record revealed the resident was last admitted to the facility on [DATE] with diagnoses that included: subdural hematoma, repeated falls and Parkinsons. A review of the Minimum Data Set (4/13/26) noted the resident had a Brief Interview for Mental Status of 13/15 (cognitively intact cognition).Continued review of R7's clinical record revealed the following:4/26/26: Nursing Note: .I was sexually assaulted by girls last night. (Authored by Nurse D)4/27/26: Physician Note: .On the 23rd reported wandering trying to leave the facility.later in the day he reported that some of the female aides helping him last night was messing with him. He said there were 3-4 of them and he was tied down and unable to defend himself as they were overpowering him.Seen today up in a…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to prevent an avoidable fall for one resident, (R36) of three residents reviewed for accidents, resulting in a fall requiring a transfer to the emergency room. Findings include: On 4/27/26 at 11:59 AM, an interview was conducted with R36's family member and they reported R36 had a fall from their bed during incontinence care because there was only one nurse aide present rendering care and R36 was supposed to have the care provided by two staff members. They further reported the fall from the bed required a transfer to the emergency room. On 4/27/26 at 2:04 PM, a review of R36's progress notes revealed a note dated 12/22/25 at 11:43 PM entered into the record by Nurse 'F' that read, Writer was called by staff saying resident just fell out of bed. When I went to resident's room saw {sic} resident laying on the floor on her back by the window side, the bed is on {sic} a waist height position .unable to assess her arms legs due to stiffness and contracted extremities, staffs {sic} got her off the floor with the use of…

    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 · E2025-03-13 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices for residents on droplet precautions during an influenza outbreak, and implementation of Enhanced Barrier Precautions (EBP) affecting multiple residents reviewed for infection control, including R93, R21 and R15. This deficient practice has the likelihood to result in cross-contamination and the continued development and spread of infection and disease. Findings include: R93 On 3/11/25 at 10:09 AM, R93's door was closed and the resident was heard coughing very loudly from the hallway. There were several signs taped to the outside of the door which included: a rehab treatment schedule, a sheet that read, STOP PLEASE SEE NURSE, a sheet that showed the sequence of putting on personal protective equipment (PPE) for a gown, mask or respirator, goggles or face shield, and gloves, and a sheet that showed the sequence of removing PPE. There was no signage to identify what type of precautions 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-13 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Nursing standards of practice were followed for medication administration for one resident (R5) of five residents reviewed for medication administration. Findings include: On 03/11/25 at approximately 10:52 a.m., R5 was observed in their room, laying in their bed. R5 was observed to have eye drops and a medication cup with three white pills in it without a Nurse in the room providing supervision. R5 was queried how they received their pills in the cup, and they reported the Nurse had given it to them to take and did not wait for them to take them all, left the room and never returned. At that time, R5 was observed to take their hand and grab the pills one by one out of the cup and swallow them. On 3/12/25 at approximately 9:29 a.m., during a medication administration observation, Nurse E was observed to administer a Cyancobalamin (vitamin B-12) 1,000 mcg tablet in a medication cup with multiple other medications in together in 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 consistently provide assistance with oral hygiene for one (R34) of two residents reviewed for activities of daily living (ADLs). Findings include: On 3/11/25 at 10:18 AM, R34 was observed lying in bed. When asked if they had any concerns with the facility's care R34 reported they had concerns with staff not always assisting them with brushing their teeth most of the time. R34 reported oral care had not been done yet today. On 3/11/25 at 12:39 PM, R34's call light was lit up in the hallway and the door was closed. Upon entering the room, the resident was observed lying in bed on their back with a lunch meal on an overbed tray in front of them. When asked if they had pressed their light for help, R34 reported their bed controller fell to the floor and they couldn't reach it. The bed remote controller was observed on the floor under the bed. When asked if they had received any oral care yet, R34 reported not yet. The resident further reported…

    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 before2025-03-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 interview and record review, the facility failed to ensure medications were available for administration for one resident (R143) of one resident reviewed for new admissions. Findings include: On 03/11/25 at approximately 11:17 a.m., R143 was observed to be in their room, laying in their bed. R143 was observed to have a catheter draining amber colored urine into a drainage bag. On 3/12/25 the medical record for R143 was reviewed and revealed the following: R143 was initially admitted to the facility on [DATE] and had diagnoses including Retention of Urine and Encounter for fitting and adjustment of urinary device. A review of R143's March 2025 Medication Administration Record (MAR) revealed R143 was not administered the following medications on 3/11/25 (a day after being admitted on [DATE]): 1. doxycycline hyclate 100 mgcapsule (1) CAPSULE Oral Two Times Daily for Two Days Starting 03/10/2025 .(10:00 AM dose-med on order) .2. midodrine 5 mg tablet (1tab) (TABLET) Oral Three Times Daily Starting…

    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 · D2025-03-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Physician orders were in place and appropriate catheter care was provided for one resident (R143) of two residents reviewed for indwelling catheters. Findings include: On 03/11/25 at approximately 11:17 a.m., R143 was observed to be in their room, laying in their bed. R143 was observed to have a catheter tube draining amber colored urine into a drainage bag. On 3/12/24 at approximately 2:44 p.m., R143 was observed in their room, walking around in their hospital gown, dragging their catheter tubing and urine collection bag on the floor without any privacy bag in it. R143's catheter tubing was not observed to be secured and was observed to be pulling away from their body as they were walking. On 3/12/25 the medical record for R143 was reviewed and revealed the following: R143 was initially admitted to the facility on [DATE] and had diagnoses including Retention of Urine and Encounter for fitting and adjustment of urinary device. A…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-29 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # MI00144708 Based on interview and record review, the facility failed to ensure services met professional standards for medication administration and documentation of controlled substances and medication documentation according to order changes for one resident (R901) of one reviewed for professional standards, resulting in R901 not receiving medication in accordance with the physician order. Findings include: Review of a complaint filed with the State Agency (SA) alleged a physician order for Morphine was ordered around 2:00 PM on 5/8/24 and the facility failed to administer for many hours later in the day resulting in R901 to .suffer for hours without ordered Morphine . A record review revealed that R901 was admitted to the facility on [DATE] for physical therapy rehabilitation and aftercare for spinal surgery from a fractured vertebrae. A comprehensive assessment for R901 was not available due to the short-term stay. A clinical record review documented R901 was alert,…

    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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00144708. Based on interview and record review, the facility failed to ensure adequate, and accurate assessment, investigation, and monitoring of a resident post fall with injury for two (R901 and R904) of three residents reviewed for accidents. Findings include: R901 A complaint filed with the State Agency alleged concerns regarding R901's fall and post-fall investigation. Review of the clinical record revealed R901 was admitted into the facility for skilled therapy on [DATE] around 6:15 PM with diagnoses that included: wedge compression fracture and multiple fracture of ribs. R901 was signed onto hospice following a fall with injury within a few hours of admission on [DATE], which resulted in likely traumatic head injury per Physician evaluation, subsequent significant decline in overall status, and the resident died on [DATE]. According to the Minimum Data Set (MDS) assessment for death in facility dated [DATE], there were no details of the resident's cognition, or falls.…

    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
Show the remaining 11 citations
  • Potential for harm · Dcited before2024-05-29 · 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 and interview, the facility failed to ensure proper storage of medications in two of two medication carts reviewed resulting in the potential of dispensing expired medications and storing unidentifiable medications in the narcotic cart. Findings include: On 5/29/24 at 9:20 AM, An unlocked medication cart was observed containing multiple bottles of Senna (stool softener medication) which had expired in 2023. Registered Nurse (RN) B acknowledged the cart serves as dual purpose as the unit treatment cart and as an overflow medication cart. RN B confirmed medications located in the cart are retrieved if needed and administered. When asked who is responsible for reviewing expiration dates within the cart, RN B responded the nursing staff on midnights should be. At 9:30 AM, The Director of Nursing (DON) arrived on the unit and was informed of the observation of expired Senna medication bottles in the first cart reviewed. The DON acknowledged expired medications are not to be stored and or administered. The DON remained present as the first drawer of the narcotic cart…

    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 · Fcited before2024-02-07 · 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 ensure food items were stored, dated, and discarded appropriately, failed to maintain the kitchen in a sanitary manner, and failed to ensure the dry storage room was free from pests. This deficient practice had the potential to affect all residents in the facility. Findings include: On 2/5/24 from 10:27 AM to 11:00 AM, an initial tour of the kitchen was conducted with the General Manager (GM 'E'). The following concerns were observed: 1) The flooring in the dry storage room was littered with debris (plastic utensils, unidentified food crumbs, and dried stains on the floors underneath the metal storage racks). 2) The dry storage room had three separate cardboard boxes of dry food items (one box with real semi-sweet chocolate chips, one box with cran-raisins, and one box with walnuts). Each of these food items were stored in a blue plastic bag inside the cardboard box. These blue plastic bags were not adequately sealed and were left open to air. When GM 'E' turned these boxes around on the metal shelving unit,…

    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 · E2024-02-07 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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

    Based on observation, interview and record review, the facility failed to ensure residents were treated in a dignified and respectful manner. This deficient practice had the potential to affect multiple residents that resided on the Cardinal unit. Findings include: According to the facility's policy titled, Resident Rights - Continuing Care dated 6/6/2023 documented: .The facility will promote and protect the rights of each resident and places and strong emphasis on individual dignity .The facility will adhere to state and federal regulatory requirements pertaining to Resident Rights .Residents have a right .to be treated with respect and dignity . On 2/5/24 at 2:02 PM, an observation was made from the inside the nursing station which revealed three employees talking in the main hallway of the Cardinal unit, in direct view of open resident rooms and residents in the lounge area, loudly discussing their concerns with not being able to have a break. One of the three employees was then observed to swear loudly, stating F* this multiple times. When one of the employees attempted 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-07 · tag F0761 — failed to label and store drugs safely — pattern
    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 properly store, secure, and/or dispose medications, including controlled drugs in one of two medication carts and one of two medication rooms, resulting in increased potential for diversion and misappropriation. Findings include: According to the facility's policy titled, Narcotics/Controlled Substances dated 5/2021: .All controlled substances/medications are kept under double lock . On 2/6/24 at 8:02 AM, observation of the medication cart on the Cardinal unit revealed one of the two medication carts positioned on the outside of the nursing station was unlocked without any nursing staff present or in direct supervision. The cart was able to be opened without a key and contained various blood glucose monitoring supplies as well as a locked compartment in which controlled drugs were stored. On 2/6/24 at 8:04 AM, an employee (Nurse 'Q') was observed to slowly pull the cart around the corner of the nursing station. When queried about the unlocked cart, Nurse 'Q' reported they just saw that and proceeded to lock…

    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 · D2024-02-07 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 observations, interviews, and record reviews the facility failed to ensure a level one OBRA screening (Omnibus Budget Reconciliation Act) was submitted to the Community Mental Health Services Program (CMHSP) for a level two evaluation for two (R's 7 and 2) of two residents reviewed for PASAR (Preadmission screening/resident review). Findings include: R7 On 2/5/24 at 10:35 AM, R7 was observed lying on their back in bed and an interview was conducted with the resident at that time. Review of a Level I OBRA screening dated 7/24/23, documented the resident to have diagnoses of anxiety and bipolar and documented the resident to have been prescribed antipsychotic, antidepressant, and antianxiety medications. Further review of the medical record revealed no documentation of a Level two evaluation to have been completed. Review of the medical record revealed R7 was admitted to the facility on [DATE], with diagnoses that included: anxiety disorder and bipolar disorder. Review of the physician orders documented…

    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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 interview and record review the facility failed to effectively collaborate with the hospice agency for one resident (R2) of one resident reviewed for hospice services. Findings include: On 2/5/24 at 10:06 AM, R2 was observed laying on her back with her breakfast on her chest, asleep, with pillows under both arms. Review of the medical record revealed R2 was admitted to the facility on [DATE] with diagnoses that included: stroke, hallucinations, dementia. On 2/6/24 at 10:28 AM Nurse S was queried regarding how the facility collaborates care with the hospice agency, Nurse S reported that she was unsure and that she had only worked at the facility for a short time. They stated that they began working October of 2023. When asked where the hospice care plan is she again reported that she was unsure. They referred me to the facility visit and collaboration sheet in the hospice binder, which was found to be blank. Nurse S stated that their (hospice) visits are sporadic and not care planned. On 2/6/24 at 12:34…

    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 before2024-02-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure the required assistance level for bed mobility was provided to one (R18) of four residents reviewed for accidents. Findings include: On 2/5/24 at 1:19 PM, R18 was observed sitting in their wheelchair in their room. A limited interview was conducted with the resident at that time. Review of the medical record revealed R18 was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease and dementia and required a two person staff assistance for bed mobility. Review of a Nursing note dated 12/17/23 at 10:24 PM, documented in part . Staff was attempting to change resident, while turning res. (resident) towards staff res. Started to pull on the fame <sic> of the bed, and res. Fell. Staff nurse assessed res. And noted an abrasion on the left side of the lower back measuring 10 cm (centimeters) by 1 cm, and redness noted to the back of the head slightly raised . Review of the medical record confirmed R18…

    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 · D2024-02-07 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 consistently provide a rationale for declination of the pharmacist's monthly medication regimen review for two residents (R2 and R15) of the two residents reviewed. Findings include: R2 On 2/5/24 at 10:06 AM, R2 was observed laying on her back with her breakfast on her chest, asleep, with pillows under both arms. Review of the medical record revealed R2 was admitted to the facility on [DATE] with diagnoses that included: stroke, hallucinations, dementia. Pharmacy consultation report dated December 18, 2023, indicated that Physician C chose to decline the pharmacist recommendation to consider attempting a GDR (Gradual dose reduction) from Seroquel (a psychiatric medication) 25 mg (milligrams) twice daily to Seroquel 25 mg at bedtime. The rationale provided on the consultation report deferred the decision to behavioral health services with no further supporting information. On 2/7/24 at 11:28 AM an interview was conducted with the DON…

    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 · D2024-02-07 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to justify the use of antibiotics in according with current practice/guidance for one (R8) of four residents reviewed for antibiotic medication use. Findings include: According to the Centers for Disease Control (CDC) and Prevention NHSN (National Healthcare Safety Network) updated January 2024: Healthcare-associated Infection Surveillance Protocol for Urinary Tract Infection (UTI) Events for Long-Term Care Facilities .Criterion For residents with an indwelling catheter in place .One or ore of the following (Signs and Symptoms and Laboratory and Diagnostic Testing) .4. New onset confusion/functional decline with no alternate diagnosis AND Leukocytosis [defined by NHSN as > 10,000 cells/mm^3, or Left shift (> 6% or 1,500 bands/m^3)] .AND A positive urine culture with no more than 2 species of microorganisms, at least one of which is a bacterium of =105 CFU (Colony Forming Units)/ml . According to the facility's policy titled, Antibiotic Management dated…

    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 · D2024-02-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure gradual dose reductions (GDRs) for psychotropic medications were completed, implement a care plan that identified targeted behaviors and non-pharmacological interventions for behaviors, and maintain behavioral data for two (R's 7 and 25) of five residents reviewed for unnecessary medications. Findings include: R7 On 2/5/24 at 10:35 AM, R7 was observed lying on their back in bed and an interview was conducted with the resident at that time. Review of the medical record revealed R7 was admitted to the facility on [DATE], with diagnoses that included: anxiety disorder and bipolar disorder. Further review of the medical record revealed R7 was prescribed Rexulti 1 mg for depressive disorder in November 2023 and also was prescribed Cymbalta 30 mg (milligrams) for depressive disorder and Lamotrigine 25 mg for bipolar disorder. Review of the medical record revealed no documentation of targeted behaviors identified by the facility staff.…

    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 · D2024-02-07 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to maintain an antibiotic stewardship program that included consistent implementation of protocols for appropriate antibiotic use for two (R233 and R234) of four residents reviewed. Findings include: Review of the facility's antibiotic stewardship line listings for October 2023 revealed R234 was prescribed Macrobid for a urinary tract infection, no signs or symptoms were included. Clinical record review revealed .dysuria-complaining of burning with urination per daughter ., no documentation of an assessment of the resident was found to confirm the daughters report of dysuria. A urinalysis was provided which was positive for nitrates, protein and leukocytes, however a culture and sensitivity test was not provided. Further review of the medical record revealed no signs or symptoms identified by the nursing staff. Review of line listing for September 2023 indicated that R233 met criteria for appropriate use of an antibiotic (Macrobid) however the Antibiotic Prescribing Review form completed by Infection Preventionist O indicated…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$12,350 in federal fines across 5 penalties.

  • $3,176 — penalty dated 2023-09-18
  • $2,823 — penalty dated 2023-09-11
  • $2,470 — penalty dated 2023-09-05
  • $2,117 — penalty dated 2023-08-28
  • $1,764 — penalty dated 2023-08-21

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

Part of a chain

This home belongs to ERICKSON SENIOR LIVING — 17 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 →

RatingThis homeChain avg
Overall 5 of 54.2+0.8 vs chain
Health inspection 4 of 53.6+0.4 vs chain
Staffing 5 of 54.8+0.2 vs chain
Quality measures 3 of 54.1-1.1 vs chain
The other 16 homes this chain runs (chain average 4.2★, 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 / managerTypeRoleShareSince
NATIONAL SENIOR COMMUNITIES, INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 01/14/2021
BROWN, IANIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 04/01/2023
BROWN, PATRICIAIndividualCORPORATE DIRECTORsince 04/01/2022
CLUPPER, KATHERINEIndividualCORPORATE DIRECTORsince 04/01/2024
COLINS, MARYIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 04/01/2018
ERSTAD, EILEENIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 04/01/2018
JACQUE, ZINAIndividualCORPORATE DIRECTORsince 06/18/2008
LEONARD, MONTYIndividualCORPORATE DIRECTORsince 04/01/2022
MOSCATO, MARYIndividualCORPORATE DIRECTORsince 04/01/2024
PAULK, PAMELAIndividualCORPORATE DIRECTORsince 04/01/2022
POMERANZ, WILLIAMIndividualCORPORATE DIRECTORsince 04/01/2025
REEL, STEPHANIEIndividualCORPORATE DIRECTORsince 04/01/2018
ROSKIEWICZ, MICHAELIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 04/01/2019
SHARP, RUSSELIndividualCORPORATE DIRECTORsince 04/01/2023
WALLICK, DANIELIndividualCORPORATE DIRECTORsince 04/01/2025
EMBLEY, MARKIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/27/2021
GANTERT, NEALIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2018
HALL, JOHNIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/30/2010
SAWICKI, SCOTTIndividualCORPORATE OFFICERsince 04/01/2024
STINER, PAMELAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2024
TYLER, DANIELIndividualCORPORATE OFFICERsince 04/01/2025
ERICKSON SENIOR LIVING LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/09/2025
BUTLER, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2014
SUNEJA, VRINDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/08/2025
SWEETSER, CHRISTIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2022
YACENICK, MALLISSAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/14/2023
BISON, MICHAELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/17/2025
RIDLEY, FREDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/17/2025
SONES, RANDALLIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/17/2025
ERICKSON LIVING HOLDINGS LLCOrganizationADP OF THE SNFsince 02/12/2010
OAK INVESTMENT TRUSTOrganizationADP OF THE SNFsince 01/01/2025
OAK INVESTMENT TRUST IIOrganizationADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 49 rows in the source record cover these 32 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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.

$7.6M
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses
$7.6M
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 1%Medicare 21%Other / private 77%

This home reported $7.6M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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.

What families pay in MI

Paying with Medicaid

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.

Typical monthly cost in Michigan
$11,254/mo
Nursing home (semi-private)
$11,969/mo
Nursing home (private)
$5,818/mo
Assisted living

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 235634. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-29, 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.

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