Novi Lakes Health Campus
41795 W 12 Mile Rd, Novi, MI 48377 · For profit - Corporation · 54 certified beds · (248) 449-1655 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has 1 actual-harm citation
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- about 18% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.3% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.1% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 4.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 3.0% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 14.0% | 19.4% | 18.9% | better |
| Long-stay residents with pressure ulcers | 2.2% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 29.4% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.1% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.2% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 30.8% | 24.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.0% | 11.7% | 12.0% | better |
* 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.
64.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 352 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.1% 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 159 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 0.63 therapist hours per resident per day in 2025Q4 — more than 90% of the 13,714 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 14% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 64.5%CMS range 58.8–69.7 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.9%CMS range 9.7–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 71.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 67.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 64.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 97.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 4.6–10.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 54 beds and averages 50.8 residents a day — about 94% occupied, or roughly 3 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 4.18 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.12 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.79 hrs/resident/day on weekends vs 4.48 on weekdays — 15% thinner on weekends. RN hours go from 0.92 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · Gdisputed · IDR2026-07-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: 3073158.Based on interviews and record reviews the facility failed to timely implement appropriate treatment and interventions for pressure wounds and failed to identify and timely respond to the worsening of the wound for one (R201) of one resident reviewed for wounds. This resulted in the prompting of the family to insist on the transfer of the resident to a higher level of care and subsequently required multiple debridements and multiple Intravenous antibiotics therapy to treat the infected decubitus ulcer with an associated abscess and fat necrosis of the buttock wound and pain.Findings include:A review of a complaint submitted to the State Agency (SA) reported concerns of the facility failure to promptly treat a wound infection and transferring to a higher level of care timely.A review of the medical record revealed R201 was admitted to the facility on [DATE] and transferred to the hospital two weeks later on 5/30/26. R201 was admitted with diagnoses that included:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-07-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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: 3072746.Based on interview and record reviews the facility failed to follow current standards of practice for obtaining weights for one (R202) of one resident reviewed for Nutritional concerns. Findings include:A review of a complaint submitted to the State Agency (SA) noted concerns of the resident's enteral pump malfunctioning, enteral feeding to have not been provided as ordered and staff failing to promptly correct the issue.A review of the medical record revealed R202 was admitted to the facility on [DATE] and discharged on 7/20/26, with diagnoses that included: cerebral infarction (stroke), dysphagia (swallowing difficulties) and severe protein-calorie malnutrition. R202 required staff assistance for Activities of Daily Living (ADLs).A review of the weights obtained for R202 revealed one documented weight dated 7/5/26 AT 12:59 pm at 167 lbs. (pounds).There were no other weights obtained nor documented in the medical record.A review of a Nurse Practitioner (NP) note 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.
- Potential for harm · Fcited before2026-07-08 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to implement key elements of an effective water management plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility . Findings include:On 7/7/2026 at 9:45 AM reviewed Water Management Program (WMP) documents with the Director of Plant Operations (DPO) N. Review of the document titled Legionella Water Management Plan (undated, 6 pages) identified the Water Management Team (WMT) as: Executive Director, Director of Plant Operations, Director of Health Services, and Director of Environmental Services. When asked about how the WMT functions, DPO N indicated that they do not meet regularly and have not met in the past year. The current WMP has not been reviewed/updated annually by the WMT.The WMP documents did not include a facility risk assessment to identify areas where Legionella and other opportunistic waterborne pathogens could grow and spread. The WMP did not include…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-07-08 · tag F0554 — patternAllow residents to self-administer drugs if determined clinically appropriate.
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 determine self-administration of medications was safe and appropriate for three (R5, R46, R30) of four observed with medications at the bedside. Findings Include. R46 On 7/6/26 at 10:11AM, R46's bedside table was observed revealing two tubes of Vitamin A&D ointment (moisture barrier topical medication) and one tube of Calmoseptine (zinc and menthol topical medication). Record review of R46's Medication Administration Record (MAR) did not indicate Vitamin A&D and Calmospetine was ordered and no prescriber's order to self-administer. On 7/7/2026 at 8:11AM, During medication administration for R11, one tube of Vitamin A&D ointment was observed on the bedside table. Record review of R11's MAR did not indicate Vitamin A&D was ordered and no prescriber's order to self-administer. On 7/7/26 at 12:21 PM, R46 was interviewed with their daughter at bedside. When inquired about having Vitamin A&D ointment and Calmoseptine, R46 could not explain the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-07-08 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were stored safely, securely, and properly, in one of two medication administration carts, two of two treatment carts, and one of one medication room observed for medication storage and labeling. Findings include:On 7/7/26 at 7:56 AM, the [NAME] Trail treatment cart was observed unlocked, the top drawer revealed resident treatment medications.On 7/7/26 at 8:16 AM, the [NAME] Trail medication cart was observed for medication storage with Licensed Practical Nurse (LPN) C and revealed a bottle of lubricating eye drop medication and a nasal spray medication with no patient identifiers. LPN C acknowledged they did not know who they were prescribed to and commented they would have to find out. The second drawer revealed a round orange colored pill tablet unpackaged. The third drawer was observed with two round white colored pills unpackaged.On 7/7/26 at 8:56 AM, the Assistant Director of Nursing (ADON) E provided access to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-07-08 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 clean, comfortable, homelike environment for one [R69] of two residents reviewed for environment. Findings include:On 7/6/26 at 9:27 AM, R69 was observed sitting in a wheelchair in their room. R69 was asked if they had any concerns about the facility. R69 explained on Saturday [7/4/26] they were taking a shower in the bathroom when they had an accident [bowel movement]. the aide just put a towel over it. on Sunday [7/5/26] they told Licensed Practical Nurse [LPN] 'L' about the bathroom floor not being cleaned up and he sent three people in to clean it, but it still was not clean. Observation of the floor in R69's bathroom between the toilet and the shower area revealed multiple spots of brown material, some approximately the size of a quarter, some approximately the size of a dime and some dot like. An area of grout between the tiles that had the appearance of a brown colored liquid dried on the grout. When told of the observation of the bathroom floor, R69 explained they kept a very clean, tidy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-07-08 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure tube feeding automatic water flush was administered per the physician order for one [R70] of one resident reviewed for tube feeding. Findings include:On 7/6/26 at 9:45 AM, R70 was observed lying in bed. A tube feeding pole was observed next to R70's bed. Two bags were hanging from the top of the pole, one contained the tube feeding formula and one contained water. The tube feeding pump indicated it was delivering the formula. The bag containing the water for automatic flush appeared to be full, it was at the 1000 milliliters [ml] mark at the top of the bag. Upon further observation, the pump was not set for automatic water flush, the settings were blank. R70 was asked if they were able to eat or drink food or water in addition to their tube feeding. R70 explained they only received tube feedings, they did not eat or drink any food or water.Review of the clinical record revealed R70 was admitted into the facility on 7/3/26 with diagnoses that included: stroke, dysphagia [difficulty swallowing] and lung…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-07-08 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident's medical record was accurate and complete for one (R73) of one resident reviewed for accurate resident records. Findings include:On 7/6/26 at approximately 10:39 AM, R73 was observed lying in bed. The resident was alert but had difficulty answering questions asked due to a language barrier. The resident's family member was present and noted that the resident was admitted to the facility on [DATE] following a fall at home.A review of R73's electronic medical record was conducted utilizing the Quick Guide for Surveyor form. The form noted that to obtain resident's diagnoses the Surveyor should review the residents face sheet by scrolling to current IDC-10 (international classification of diseases). An attempt was made to obtain R73's diagnoses via their face sheet, but no diagnoses were noted.Continued review of R73's clinical record revealed, in part the following:7/7/26 (9:24 AM): Resident admitted with dx (diagnosis) 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.
- Potential for harm · D2025-06-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake #MI00153247. Based on interview and record review the facility failed to administer blood pressure medications per physician's orders for one resident, (R901) of one resident reviewed for medication administration. Findings include: On 6/18/25 at 8:30 AM, a review of R901's closed clinical record revealed they re-admitted to the facility after a hospital stay on 5/7/25 with diagnoses that included: chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, chronic kidney disease, diabetes, and anxiety disorder. A review of R901's physician's orders and medication administration record (MAR) for May 2025 was conducted and revealed an order for metoprolol (a blood pressure medication) 25 milligrams to be given daily between 6 AM and 10 AM. The order contained, Special Instructions that read, HOLD FOR SBP (systolic blood pressure) LESS THAN 110 OR HR (heart rate) LESS THAN 60. R901's MAR indicated indicated the medication had been given on 5/8/25 with a documented blood pressure of 101/56, and on 5/11/25 with a 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.
- Potential for harm · Fcited before2025-05-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: On 5/6/25 during an initial observation of the kitchen between 7:10 AM-7:40 AM, the following items were observed with the Dining Services Assistant (Staff 'B'): The top loading/reach-in ice cream cooler did not have an internal thermometer and had visible thick build-up of ice around the top perimeter of the inside wall (near the top sliding doors about 8 inches in depth. Four of the six large cardboard containers of ice cream had a sticker with a use by date of 6/4, but the lids were not fitted properly and exposed the ice cream which was observed to have a darker colored top layer of ice cream covering. Staff 'B' reported the ice cream freezer was not hooked up to their electronic temperature monitoring via the iPad as the other walk-in/reach-in coolers and freezers were and should…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-08 · tag F0711 — patternEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
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 Physician/Physician Extender progress notes were entered into the clinical record in a timely manner for four residents (R#'s 13, 29, 138, and 37 ) of four resident's reviewed for Physician/Physician Extender progress notes. Findings include: R13 On 5/7/25 at 10:00 AM, a review of R13's clinical record revealed a note entered into the record by Nurse Practitioner (NP) 'I' on 3/30/25 for an acute care visit for pain management that occurred on 2/26/25. R29 On 5/7/25 at 10:08 AM, a review of R29's clinical record revealed the following: A note entered into the record by NP 'I' on 3/28/25 for an acute care visit that occurred on 2/25/25. A note entered into the record by NP 'I' on 2/19/25 for an acute care visit that occurred on 1/29/25. A note entered into the record by NP 'I' on 2/4/25 for an acute care visit that occurred on 1/13/25. R138 On 5/7/25 at 9:10 AM, a review of R138's clinical record revealed they admitted to the facility on [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · E2025-05-08 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
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 the exterior dumpster area in a clean manner. This deficient practice had the potential to affect all residents, staff and visitors. Findings include: On 5/6/25 at 11:45 AM, during an observation of the garbage/refuse area with the Director of Food Services (DFS), there was an accumulation of trash and leaf debris around and behind the two dumpsters. Additionally, one of the two dumpsters was unable to be closed properly due to a large wooden object that prevented the lid from closing. When asked how often garbage was picked up, the DFS reported daily. When asked who was responsible for maintaining the surrounding area, they reported that was between Dietary staff and Maintenance. On 5/6/25 at 11:52 AM, an interview was conducted with the Maintenance Director (Staff 'G'). When informed of the observation with DFS, they reported they were aware there was some debris on the ground behind the dumpsters which was mostly leaves. They were informed that there was much more than leaves, including gloves and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-08 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
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 appropriate infection control practices during medication administration for one (R88) of three residents observed. Findings include: On 5/6/25 at 7:48 AM, Nurse 'C' was requested to observe medication pass with R88. Nurse 'C' reported they had just obtained the resident's vital signs and began retrieving medication from the medication cart. Nurse 'C' was not observed using hand sanitizer, or washing their hands after opening the medication drawers, touching the water pitcher, or using the laptop to review the medications. On 5/6/25 at 7:55 AM, while Nurse 'C' poured out the medication from the pre-packaged plastic packets into a small clear plastic cup, one of the pills fell onto the top of the medication cart. Nurse 'C' picked the pill up with their bare hands and placed the pill into the plastic cup and proceeded to administer the medication to R88. Nurse 'C' was not observed to use hand sanitizer until after the med pass was completed (not after opening of the med cart drawers, touching the water…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-08 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 obtain a resident's code status in a timely manner for two residents, (R#'s 138 and 139) who were their own responsible parties, of two resident's reviewed for code status, resulting in the potential for end of life wishes not being met. Findings include: R138 On [DATE] at 11:06 AM, a review of R138's clinical record revealed they admitted to the facility on [DATE] with intact cognition and was their own responsible party. A review of an admission note entered into the record by Nurse 'A' on [DATE] read, .Resident requested status for DNR (Do Not Resuscitate, or no Cardiopulmonary Resuscitation) and was given DNR paperwork but was educated that she would remain a CPR (Full Code) until she speaks with social worker and Consent to Treat signed, dated and recorded . A review of R138's orders revealed an order dated [DATE] that indicated they were a full code. The order was discontinued on [DATE] and an order for DNR was entered on [DATE]. R139 On [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-04-17 · tag F0842 — failed to keep accurate, complete medical records — widespreadSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 readily accessible Medication Regimen Review (MMR) documentation within the Electronic Medical Record (EMR) to ensure the residents condition, care, and services were obtainable by all disciplines for five residents (R17, R27, R33, R150, R15, R251) of five reviewed for unnecessary medications. Findings include: On 4/15/24, The following Residents (R17, R27, R33, R150, R15) were selected for an unnecessary medication review investigation and included evaluation of the facilities MMR process, documentation, and pharmacy recommendations. On 4/16/24, The EMR was reviewed for R17, R27, R33, R150, and R15, and MMR documentation was not readily accessible. The Director of Nursing (DON) was questioned how to obtain the MMR within the EMR and confirmed MMR documentation is not located in EMR and uploaded into a different software program. The DON indicated to obtain the MMR medical records, the names of the residents would have to be disclosed and forwarded and retrieved by designated staff members. R251 On 04/15/24 at 1:36…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-17 · tag F0880 — failed to prevent and control infections — patternProvide 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 R20 On 4/15/24 at 9:57 AM, R20 was observed sitting in a wheelchair, upon entering the room there was no precaution sign on the resident's door. The Resident was observed to have a foley catheter with a collection bag hanging from the underside of the wheelchair. On 4/15/24 at approximately 11 AM, there was no EBP documentation on their door. A review of R20's clinical record revealed the resident was initially admitted on [DATE] with diagnoses that included: urinary tract infection, sepsis and kidney failure. A review of Resident Progress Notes from 3/4/24 at 9:29 PM revealed that the resident had a foley catheter in place at that time. A review of R20's order history revealed an order for Enhanced Barrier Precautions entered on 4/15/24 at 3:41 PM which read in part Staff to use enhanced barrier precautions, wearing a gown and gloves at minimum during high-contact care activities. A review of the facility Enhanced Barrier Precautions (EBP) policy stated EBP will be in place during high-contact care activities…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-17 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) detailing estimated charges of continued services for three residents (R26, R7, and R33) out of three sampled residents reviewed for SNF Beneficiary Protection Notification. Findings include: On 4/15/24 at approximately 3:47 PM, the facility provided a completed resident SNF Beneficiary Protection Notification Review form. The form contained the 88 residents who were discharged from Medicare covered part A stay (10/16/24-4/12/24) with benefit days remaining who either discharged from the facility or decided to remain. The following residents were selected for review to determine when they were notified of their discontinuance of service coverage and rights to proceed: 1. R7: discharged from the facility on 4/3/24. 2. R26: Date of discharge 3/4/24 (remained in the facility). 3. R33: Date of discharge: [DATE] (remained at the facility). On 4/16/24 at approximately 1:15 PM, an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 ensure a dependent resident was provided unwanted facial hair removal for one (R39) of three residents reviewed for Activities of Daily Living (ADL). Findings include: On 4/15/24 at approximately 10:00 AM, R39 was observed lying in bed with long facial hair (approximately ½ inch) on their chin. The resident was asked about ADL care provided by facility staff including facial hair removal. R39 reported that they were receiving bed baths only and had not had their hair removed in a long time. R39 stated that they would like it removed. On 4/16/24 at approximately 8:30 AM, R39 was observed in their room. The resident still had long chin hair and again reported that they would like them removed. A review of R39's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: bacteremia (bacteria in the blood stream), pneumonia and respiratory failure. A review of the Minimum Data Set (MDS) 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.
- Potential for harm · D2024-04-17 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 competency documentation with proficiency of skills and techniques necessary to care and assure resident safety for three Certified Resident Care Associate/Certified Nursing Assistants (CRCA/CNA J, K, M) out of five reviewed resulting in the potential for staff incompetency and/or harm to the residents' well-being. Findings include: On 4/16/2024 at 12:01 PM, the Nursing Home Administrator was requested to provide documentation of proficiency of skills and techniques for the following CRCA's: CRCA J Hired 1/20/2023 CRCA K Hired 12/5/2017 CRCA M Hired 7/1/2020 On 4/16/24 at 3:27 PM, the Nursing Home Administrator (NHA) indicated there was a delay in retrieving three of the five CRCA's competencies and a support call was placed (to the company) into the Internal Technology (IT) department. On 4/17/24 at 11:21 AM, the NHA confirmed retrieval of CRCA J, K, M was unsuccessful, and the facility could not verify documentation of proficiency of skills and techniques were complete. The NHA revealed there is no acting 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.
- Potential for harm · D2024-04-17 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
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 documentation of annual performance reviews and minimum 12-hour in-service education competencies for three Certified Resident Care Associate/Certified Nursing Assistants (CRCA/CNA J, K, M) out of five reviewed resulting in the potential for staff incompetency and/or harm to the residents' well-being. Findings include: On 4/16/2024 at 12:01 PM, the Nursing Home Administrator was asked to provide the annual competencies/inservice hours for the following CRCA's: CRCA J Hired 1/20/2023 CRCA K Hired 12/5/2017 CRCA M Hired 7/1/2020 On 4/16/24 at 3:27 PM The Nursing Home Administrator (NHA) indicated there was a delay in retrieving three of the five CRCA's competencies . and a support call was placed into the Internal Technology (IT) department. On 4/17/24 at 11:21 AM, The NHA confirmed retrieval of CRCA J, K, M was unsuccessful, and the facility could not verify if annual performance reviews and minimum 12-hour in-service education competencies were complete. The NHA revealed there is no acting staff educator for the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-17 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident food items stored in the [NAME] Parlor refrigerator, were labeled, dated and discarded when expired. This deficient practice had the potential to affect all residents that store food in the resident refrigerator. Findings include: On 4/15/24 at 9:30 AM, in the resident refrigerator located in the [NAME] Ice Cream Parlor, the following items were observed: an undated container of green colored pudding, a sub sandwich with a use-by (UB) date of 4/11, 3 brown bags labeled leftover meal with UB dates of 3/31 and 4/11, an undated Pyrex container of meat and vegetables, a half eaten cheeseburger dated 4/9, 2 bags labeled leftover meal with a UB date of 4/11, a container of pasta with a UB date of 3/20, and a plastic bag of unknown food that was undated. In addition, the temperature for the refrigerator had not been logged since 4/9/24. On 4/15/24 at 11:30 AM, Dietary Manager (DM) H was queried about the undated and expired food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-30 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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: MI00142272. Based on interview and record review the facility failed to ensure the required documentation for a resident's transfer was documented and contained in the medical record for one (R706) of one resident reviewed for discharges and transfers. Findings include: Review of the medical record revealed R706 was admitted to the facility on [DATE] and transferred to another skilled nursing facility six days later on 1/16/24. R706 was admitted with diagnoses that included Multiple sclerosis. Review of the last note documented in the progress notes, a Nursing note dated 1/16/24 at 11:16 AM, documented in part . Resident was discharged from facility at around 11 am, (Registered Nurse name) gave resident his . discharge summary, Resident educated about his medication, resident safe to leave . It was identified during the survey that R706 was transferred to another skilled nursing facility. Review of the medical record revealed no documentation and/or consultation from a physician…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-15 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
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 Number(s): MI00137446. Based on interview and record review, the facility failed to implement an appropriate discharge plan that included a referral to home health care (HHC) to meet the continuing needs of a resident who was discharged home for one (R803) of two residents reviewed for discharge planning. Findings include: Review of a complaint submitted to the State Agency revealed an allegation that the facility failed to transmit orders to the home health care company that was to provide care for (R803) upon her discharge. On [DATE] at 4:19 PM, a phone interview was conducted with the complainant. The complainant reported R803 was discharged home on [DATE], was transferred to the hospital on [DATE], and died on [DATE]. The complainant explained the HHC agency contacted them on [DATE] to follow up about R803's discharge, but the resident had already died. The HHC agency explained they did not have any prescriptions from the facility which they needed in order to to provide HHC…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 This citation pertains to Intake Number(s): MI00137446. Based on interview and record review, the facility failed to ensure there was a physician's order for oxygen therapy for one (R803) of one resident reviewed for respiratory care. Findings include: Review of a complaint submitted to the State Agency revealed an allegation that R803 was discharged from the facility without an adequate supply of oxygen. Review of R803's clinical record during an unannounced, onsite investigation, revealed R803 was admitted into the facility on 2/8/23 and discharged home on 3/2/23 with diagnoses that included: peripheral vascular disease (PVD). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R803 had intact cognition. The section for special treatments that included oxygen therapy was not completed. Review of R803's progress notes revealed the following: On 2/22/23, Nurse Practitioner (NP) 'G' evaluated R803 and documented, Patient is being seen today for cough today. The patient states that the cough is dry…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to TRILOGY HEALTH SERVICES — 127 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 3.5 | -0.5 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.8 | +0.2 vs chain |
The other 126 homes this chain runs (chain average 4.2★, per CMS)
Showing 40 of 126; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CONTINENTAL MERGER SUB LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2021 |
| NORTHSTAR HEALTHCARE INCOME INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2021 |
| NORTHSTAR HEALTHCARE INCOME OPERATING PARTNERSHIP LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2021 |
| TRILOGY HOLDINGS NT-HCI, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2021 |
| REGIONS BANK | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 07/20/2018 |
| CORBIN, KATHY | Individual | W-2 MANAGING EMPLOYEE | — | since 12/01/2015 |
| FIGHTMASTER, LISA | Individual | W-2 MANAGING EMPLOYEE | — | since 12/01/2015 |
| BARNEY, LEIGH | Individual | CORPORATE OFFICER | — | since 11/01/2019 |
| BRYANT, WILLIAM | Individual | CORPORATE OFFICER | — | since 01/05/2016 |
| BUFFORD, RANDALL | Individual | CORPORATE OFFICER | — | since 11/01/2019 |
| CONNER, GREGORY | Individual | CORPORATE OFFICER | — | since 06/03/2021 |
| DAVIS, DAVID | Individual | CORPORATE OFFICER | — | since 08/21/2017 |
| MEHAFFEY, TODD | Individual | CORPORATE OFFICER | — | since 01/31/2022 |
| PIETROWSKI, CRISTINA | Individual | CORPORATE OFFICER | — | since 01/31/2022 |
| PROSKY, DANNY | Individual | CORPORATE OFFICER | — | since 12/01/2015 |
| STREIFF, MATHIEU | Individual | CORPORATE OFFICER | — | since 12/01/2015 |
| TRILOGY MANAGEMENT SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2021 |
| REARDON, TIMOTHY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/16/2018 |
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-09-01 — CMS provider number 235718. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-08, 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 →
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