WellBridge of Novi
48300 11 Mile Road, Novi, MI 48374 · For profit - Limited Liability company · 100 certified beds · (248) 662-2300 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $226,525 in federal fines (most recent 2025-10-07)
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 | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 fell from 3 to 2 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 | 8.9% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.1% | 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 | 1.8% | 1.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 1.9% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 8.1% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 8.4% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.5% | 19.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.5% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.3% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 3.6% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.3% | 14.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 77.6% | 79.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 35.0% | 24.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.7% | 11.7% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.06 | 1.84 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.95 | 1.64 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 409 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.5% 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 173 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.2%CMS range 52.1–64.6 | 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 | 10.5%CMS range 8.2–12.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 66.5% | 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 | 56.1% | 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 | 52.0% | 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 | 98.8% | 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 | 97.6% | 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 | 5.9%CMS range 3.6–8.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.82 | 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 100 beds and averages 86.9 residents a day — about 87% occupied, or roughly 13 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 4.24 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.78 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.29 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 3.72 hrs/resident/day on weekends vs 4.45 on weekdays — 16% thinner on weekends. RN hours go from 0.95 to 0.36 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
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.
32 citations, most serious first. The 15 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-05-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00153179. Based on interview and record reviews the facility failed to adequately assess/monitor a resident with an identified change of condition, notify the Physician of continued decline and transfer the resident to a higher level of care in a timely manner, for one of six residents reviewed for a change in condition, resulting in an approximately 12 hour delay in identifying and treating the resident for an acute stroke contributing to the resident's death. The deficient practice resulted in the increased likelihood of serious harm, serious injury and/or death to occur. Findings include: The Immediate Jeopardy (IJ) began on [DATE] when the facility staff failed to adequately assess/monitor R802 who had an identified change of condition and notify the Physician of the continued decline. The IJ was identified on [DATE] and the Administrator was notified of the Immediate Jeopardy on [DATE] at 4:08 PM. A plan of removal was requested at that time to remove the immediacy. 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.
- Actual harm · Gcited beforedisputed · IIDR2025-10-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #2634191Based on interview and record review the facility failed to ensure a resident's safety to prevent a fall and ensure x-rays pertaining to the fall were completed timely for one (R702) of one resident reviewed for falls resulting in R702 falling out of bed, sustaining a fracture to the right femur that required hospitalization, surgery and led to their death. Findings include:Complaints were filed with the State Agency (SA) that alleged R702 fell out of their bed trying to attempt to grab their food tray and feed themselves. The complainant reported R702 required 1:1 feeding assistance for all meals/snacks as they suffered from severe Rheumatoid Arthritis (an inflammation that causes swollen joints causing difficult performing daily activities) and Osteoarthritis (joint disease that causes pain, stiffness and loss of function). The complainant noted that a full lunch tray was placed out of reach of R702 on or about 5/13/25. The resident was sitting on the side of their bed…
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.
- Actual harm · Gcited before2024-04-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00144138. Based on interviews and record review, facility failed to implement interventions and or provide adequate supervision to prevent injuries/falls for one (R901) of two Residents reviewed for falls, resulting in hospitalization for left hip fracture, preceded by emergency room visits, with subsequent decline in overall condition, pain (per the reasonable person concept) and death. Findings include: Review of the complaint received by the State Agency read in part, (relationship omitted) has had multiple falls, with the most previous breaking (gender omitted) hip. A review of R901's death certificate dated 3/6/24 read manner of death Accident; Describe how the injury occurred Fall; place of injury nursing home. R901 was admitted to the facility for skilled nursing care and rehabilitation after hospitalization. R901's admitting diagnoses included respiratory failure, heart failure, acute urinary tract infection, anxiety, and depression. R901 had dysphagia (difficulty with…
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.
- Actual harm · Gcited before2023-02-15 · 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): MI00134357. Based on interview and record review, the facility failed to discharge on e (R88) of three residents reviewed for discharge, with physician ordered oxygen, resulting in an emergent hospital transfer for acute respiratory failure with hypoxia (low blood oxygen levels) and hypercapnia (high levels of carbon dioxide in the blood) and an admission to the intensive care unit (ICU). Findings include: Review of a complaint submitted to the State Agency on 1/17/23 revealed it was alleged R88 was discharged home without oxygen and was admitted to the hospital in intensive care. On 2/10/23 at 3:56 PM, the complainant reported R88 was started on oxygen while a resident at the facility and discharged without it even though their oxygen was low when not using it. The complainant reported the home health care (HHC) nurse attempted to contact the facility and eventually R88 was sent to the hospital and admitted into intensive care. On 2/14/23 at 11:14 AM, during 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.
- Actual harm · G2023-02-15 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to Intake Number(s): MI00130570, MI00130946, MI00128064, MI00133318. Based on observation, interview, and record review, the facility failed to ensure there was sufficient nursing staff to care for all 84 residents in the facility. This resulted in extended call light response times, delay in incontinence care for R188, and delay in medication administration for R190 and R189 who was tearful due to pain and expressed feeling like they were going to have a panic attack when they did not receive their morning medications until several hours after they were due to be given. Findings include: On 2/12/23 at 8:54 AM, an observation of the call light monitor located on the unit revealed several call lights were activated, including R188's since 7:56 AM (58 minutes earlier) and another resident on the 100 hallway since 8:19 AM (35 minutes earlier). On 2/12/23 at 9:00 AM, R188 was observed in their room with a visitor. When queried about the care in the facility, R188's family member reported there was not enough staff at the facility. They explained they arrived…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-10-07 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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: 2634191.Based on interview and record reviews the facility failed to timely implement orders as directed by the Provider for one (R702) of one resident reviewed for a change of condition. Findings include:A review of the medical record revealed R702 was re-admitted to the facility on [DATE] with a primary diagnosis of acute on chronic diastolic (congestive) heart failure and additional diagnoses of edema, paroxysmal atrial fibrillation and acute embolism and thrombosis of unspecified deep veins of lower bilateral extremity. A Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. A review of the progress notes revealed the following: A nursing note dated 4/25/25 at 6:15 AM, documented . Resident stated she was having chest pain. Given Nitroglycerin x3. She then stated that her whole body is hurting . given.pain medication. She then began to ask where her daughter is & where is she at. Stated…
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 · D2025-10-07 · tag F0777 — isolatedProvide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
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: 2634191.Based on interview and record reviews the facility failed to ensure a STAT (immediate) chest x-ray was ordered and completed as noted by the physician assistant for one (R702) of one resident reviewed for radiology services. Findings include:A review of the medical record revealed R702 was re-admitted to the facility on [DATE] with a primary diagnosis of acute on chronic diastolic (congestive) heart failure and additional diagnoses of edema, paroxysmal atrial fibrillation and acute embolism and thrombosis of unspecified deep veins of lower bilateral extremity. A Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. A review of a Physician progress note dated 4/28/25 at 1:57 PM, documented in part . Reason for visit: request by patient/family/nurse regarding weakness, fatigue, pain. Patient seen and examined. C/O (complaints of) increased weakness and fatigue. Also C/o generalized…
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 · D2025-05-30 · tag F0635 — isolatedProvide doctor's orders for the resident's immediate care at the time the resident was admitted.
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): MI00153132. Based on interview and record review, the facility failed to accurately reconcile and implement physician's orders from the hospital upon admission into the facility for one (R803) of two residents reviewed for admission orders, resulting in increased psychiatric symptoms including agitation, throwing objects, and combativeness. Findings include: A review of a complaint submitted to the State Agency revealed an allegation of R803 not receiving appropriate care by the facility. On 5/27/25 at 11:18 AM, an interview was conducted with the complainant. The complainant reported concerns about how R803 presented when she visited her in the facility prior to being discharged . The complainant reported R803 had a diagnosis of bipolar disorder and had a recent psychiatric hospitalization where she was started on a new medication (Abilify) in addition to the medications she took previously, including Lithium (a mood stabilizer that treats or prevents manic episodes…
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 · D2025-04-17 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 address grievances for two residents (R#'s 29 and 81) of two residents reviewed for grievances, resulting in verbalized complaints and frustration between roommates. Findings include: On 4/15/25 at 9:30 AM, R81 was up in their room seated in their wheelchair. They were asked if they had any concerns and said they do not get along with their roommate, R29. On 4/15/25 at 9:32 AM, R29 was observed in their bed. They were asked if they had any concerns and agreed with R81 saying they did not get along. R29 was asked if facility staff were aware they didn't get along and they said staff were aware and they requested a room change about a month ago. They were asked if they filed a grievance and if the facility had followed up with them and they said they didn't know they could file a form and no one had followed up regarding their concerns. On 4/16/25 at 9:59 AM, grievances for R81 and R29 were requested, and it was reported by the Administrator neither resident had any grievances on file. 4/16/25 at 10:29 AM, 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.
- Potential for harm · D2025-04-17 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 Minimum Data Set (MDS) Assessments were completed accurately for one (R2) of 20 reviewed. Findings include: According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. Link to the LTCF RAI User's Manual: https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf: .an accurate assessment requires collecting information from multiple sources .Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician . Review of the clinical record revealed R2 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included: gastrostomy status, aphasia, altered mental status, other seizures, acute kidney failure, type 2 diabetes mellitus with hyperglycemia, moderate protein-calorie malnutrition, adult failure to thrive, myelopathy, unspecified dementia, and malignant neoplasm of thyroid gland. Review 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 · Dcited before2025-04-17 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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
Based on observation, interview and record review the facility failed to ensure consistent professional standards of practice were utilized by two nurses (Licensed Practical Nurse- LPN) LPN A and LPN B of four nurses reviewed for medication administration observation for one resident (R31). Findings include: On 4/16/25 at 8:41 AM, LPN A was observed preparing the morning medications for R31. LPN A completed their medications checks and instructed LPN B (a newly hired nurse in training) to obtain clonazepam from the controlled medication cabinet in the hallway. At 8:46 AM LPN B returned and gave LPN A the pill in a medication cup. LPN A added the pill to the rest of R31's morning medications. LPN A then gave LPN B the cup containing R31's morning medications to administer. LPN B administered the morning medications to R31. LPN A then signed off on the medications as administered. A review of a facility policy titled Medication Administration dated 9/1/23, documented in part . Right resident, right drug, right dose, right route, right reason, right documentation and right time, are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain neurology consult documentation and implement recommendations to start medication for multiple sclerosis (MS) and ensure timely follow-up evaluation was coordinated per recommendation for one (R47) of one resident reviewed for quality of care. Findings include: On 4/15/25 at 9:17 AM, R47 was observed lying in bed, eating their breakfast meal. When asked about whether they had any concerns with the care at the facility, R47 reported they were concerned they were not receiving medication like they should and at times felt weaker. Review of the clinical record revealed R47 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: multiple sclerosis, pneumonia, acute and chronic respiratory failure with hypoxia, and interstitial pulmonary disease. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R47 had intact cognition. Review of a neurology consultation document 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 · Dcited before2025-04-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an environment free from accident hazards for one (R64) of four residents reviewed for accidents. Findings include: On 4/15/25 at 9:40 AM, R64 was observed lying in bed. The entire left side of the bed was against the wall and the wall outlet which had two white and two red outlets was observed to have the entire right portion of the outlet cover broken off and missing. The mattress was observed directly touching the outlet. R64 was also observed to have a breakfast tray on the overbed tray table that was within three feet of the outlet. Additionally, next to the head of the bed was a tall metal pole used to hang tube feeding that was observed broken and leaning to the left. On 4/15/25 at 9:42 AM, R64 pressed their call light and stated they needed someone to help change my diaper. On 4/15/25 at 9:43 AM, Certified Nursing Assistant (CNA 'C') was observed to respond to the call light. On 4/15/25 at 3:00 PM, Nurse 'G' was asked to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 one (R87) of one resident reviewed for bowel and bladder, who was continent of bladder and bowel, received assistance to maintain continence. Findings include: On 4/15/25 at 9:50 AM, R87 was observed sitting up in bed. Family members were present in the room and R87 was getting ready to go to an appointment. An interview was conducted with R87 and his family members. R87 reported having to wait a long time for his call light to be answered at times. When asked what he needed assistance with, R87 reported he had to wait for his brief to be changed after urinating or having a bowel movement. R87 reported he did not use the toilet in the bathroom. R87's family member reported they were working on getting a bedside commode so R87 could use that instead of going to the bathroom in a brief. A review of R87's clinical record revealed R87 was admitted into the facility on 3/3/25 with diagnoses that included: right femur fracture. A review…
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 · D2025-04-17 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
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 physician documented an assessment for a competency evaluation for one resident, (R84) of one resident reviewed for competency. Findings include: On 4/15/25 at 9:25 AM, R84 was observed in their room sitting at the bedside. An interview was conducted with R84 and they said they were no longer receiving rehab and were not sure why they were still residing in the facility. They had no complaints but did express their desire to no longer reside in a long term care setting. R84 was asked what precipitated their admission to the facility and said in September 2024 they were living alone, independently in the community where they sustained a fall, broke numerous bones and admitted to the facility for rehab after hospitalization. On 4/15/25 at 3:04 PM, a review of R84's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: tibia, fibula, and radius fractures, osteoarthritis, diabetes, adjustment…
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 17 citations
- Potential for harm · D2025-04-17 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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 ensure an antibiotic medication was administered within the prescribed parameters and not in excessive dose for one (R2) of five reviewed for unnecessary medication. Findings include: Review of the clinical record revealed R2 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included: urinary tract infection, extended spectrum beta-lactamase (ESBL - a bacteria resistant to some antibiotics). According to the Minimum Data Set (MDS) assessment dated [DATE], R2 had severe cognitive impairment, did not receive antibiotic medication during this review period of seven days. Review of R2's urine culture results collected 4/1/25, reported on 4/6/25 documented a result of SOURCE URINE, ORGANISM 1 10,000 CFU (Colony Forming Unit)/ML (Milliliters) PROTEUS MIRABILIS, ESBL. Review of the physician orders included two orders for an antibiotic medication which included: Start Date - 4/7/25 at 7:00 AM, Discontinue Date 4/9/25 at 12:02 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 reviews the facility failed to ensure all expired medications were removed from the residents medication storage units for one (R31) of five residents observed for the medication administration observation. Findings include: On 4/16/25 at 8:41 AM, LPN A was observed preparing the morning medications for R31. Included in the morning medications was a senna-plus pill. The expiration date on the senna-plus bottle was observed to be 12/2024. LPN A and LPN B failed to check the expiration date of the senna-plus medication. LPN A then gave LPN B the cup containing R31's morning medications to administer and LPN B administered the morning medications to R31. After the medication observation, LPN A and LPN B were both asked to check the expiration date of the senna-plus bottle and LPN A and LPN B stated the medication should have not been administered and removed the medication from R31's medication storage cabinet. A review of a facility policy titled Storage of Medications dated June 2019 documented in part, . The nurse will check the expiration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 enhanced barrier precautions (EBP) policies and protocols were followed and maintained for one (R64) of seven residents reviewed for infection control. Findings include: On 4/15/25 at 9:00 AM, R64's door was observed closed. Signage on the hallway wall near the doorframe indicated the resident was on EBP and a storage bin contained various PPE (Personal Protective Equipment) which included disposable face masks, gloves, and gowns. The EBP signage further read, STOP ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound care: any skin opening requiring 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.
- Potential for harm · Dcited before2025-01-09 · 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 #MI00149107. Based on interview and record review the facility failed to involve a court appointed-legal guardian in the discharge process for one resident (R502) of three residents reviewed for discharge planning, resulting in R502 signing themselves out of the facility without the legal guardian's knowledge. Findings include: On 1/9/25 a complaint submitted to the State Agency was reviewed and alleged R502 had signed themselves out of the facility against medical advice (AMA) without the legal guardian being involved in the decision on 11/17/24. On 1/9/25 the medical record for R502 was reviewed and revealed the following: R502 was initially admitted to the facility on [DATE] and had diagnoses including Adult failure to thrive, Cognitive communication deficit and Heart failure. A patient demographics hospital document from R502's initial admission in June 2024 was reviewed and revealed R502 had a legal guardian. A letters of guardianship document signed by the [NAME] County…
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 before2024-03-20 · 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 observation for three residents (R284, R59, R20) of four resulting in the increased likelihood for the spread of infection. Findings include: On 3/19/24 at 8:22 AM, medication administration was conducted with Licensed Practical Nurse (LPN) N for R284. Medications were identified to be administered without observing hand hygiene. LPN N confirmed when asked if hand hygiene was performed and acknowledged it was not. As this surveyor exited the room, LPN N removed the blood pressure equipment from the room that was used on R284 and left it in the hallway. It was observed that no sanitation of the equipment was provided. LPN N was asked if there was a process of handling the equipment in between residents. After this surveyor questioned if it was cleaned, LPN N stated Oh yes, it should be cleaned, let me go get the stuff to wipe it down. On 3/19/24 at 8:47 AM, medication administration was conducted with LPN O for R59. As medication…
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 before2024-03-20 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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(s) MI00137603, MI00138610 and MI00138725 Based on observation, interview and record review, the facility failed to ensure resident's medications were stored securely and medication/treatment administration were followed per professional standards of practice for three residents (R2, R233 and R29). Findings include: R2 On 3/18/24 at approximately 9:34 AM during the initial tour of the facility, R2 was observed sitting in bed. The resident was waiting for assistance to get dressed and out of bed. The medication storage cabinet located next to their bed was slightly open and the keys were inside the lock. The cabinet contained several different medications. Nurse E entered the resident's room to address the call light. When asked if nursing staff should leave the keys in the resident's medication storage cabinet, Nurse 'E reported they should not. On 3/19/24 at 11:36 AM, an interview was conducted with the Director of Nursing (DON). The DON was asked if the keys should remain 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.
- Potential for harm · Dcited before2024-03-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practice statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to accurately assess a resident upon readmission to the facility and during subsequent skin assessments for one (R56) of two residents reviewed for an ostomy (a surgical procedure that creates an opening from an area inside of the body to the outside), resulting in the lack of monitoring and removal of stitches to the site where R56's cholecystostomy tube (a tube inserted into the gallbladder to drain fluid) was removed. Findings include: A review of a Physician Progress Note dated 2/28/24, written by Nurse Practitioner (NP) 'G', revealed R56 removed her biliary tube (cholecystostomy tube) that morning and was sent to the emergency department (ED) for evaluation. On 3/19/24 at 8:30 AM, a review of R56's electronic medical record (EMR) revealed the following documentation: R56 was admitted into the facility on 2/9/24 with diagnoses that included: acute cholecystitis. A review…
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 before2024-03-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 evaluate and implement interventions and services for removal of a urinary catheter resulting in a Catheter Associated Urinary Tract Infection (CAUTI) for one resident (R43) reviewed for urinary catheter. Findings include: On 3/18/24 at 12:33 PM, during an interview, Resident 43 (R43) was observed awake lying in bed with a foley catheter (urinary tube placed in bladder to aid in draining the bladder) containing clear yellow urine hanging from the left side of bedframe. Conversing appropriately, R43 stated the urinary catheter was new for her and did not have one prior to admission to the hospital nor at their prior residence. R43 indicated she believed it was placed because it is hard for her to get to the bathroom due to her weakness on one side. She acknowledged she can get to the bathroom; it just takes time because she needs to get stronger. On 3/19/24, A clinical record reviewed revealed R43 was 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.
- Potential for harm · D2024-03-20 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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 interview and record review, the facility failed to ensure pharmacist recommendations were addressed during a monthly medication regimen review (MMR) for two (R71, R52) of five residents reviewed for unnecessary medications. Findings include: R71 On 3/19/24 at 12:08 PM, record review revealed R71 was originally admitted to the facility on [DATE] with anxiety, bipolar, diabetes and gastroesophageal reflux disease GERD (stomach contents enter into the throat). Minimum data set assessment dated [DATE] indicated a brief interview for mental status (BIMS) score totaling 12, indicating cognitively intact. The Monthly Medication Review (MMR) from pharmacy documented the following recommendations for R71's currently prescribed Famotidine (medication that decreases stomach acid): 11/18/2023 Pharmacist recommends: The resident has been on Famotidine 20 milligram(mg) two times daily since 6-23. Acute dose therapy of H-2 antagonists is not usually indicated for a duration longer than 60 days. Please consider…
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 · D2024-03-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 observation, interview and record review, the facility failed to provide justification and consent for the use of antipsychotic (Quetiapine) medication for one (R52) of five residents reviewed for unnecessary medication. Findings include: On 3/18/24 at approximately 1:28 AM, R52 was observed lying in bed. The resident was alert but not able to answer any questions asked. A review of R52's clinical record revealed the resident was initially admitted to the facility on [DATE], the last readmission was noted as 7/13/23 with diagnoses that included: unspecified dementia without behavioral disturbance, Type II diabetes, and major depressive disorder. A review of the resident's Minimum Data Set (MDS) dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of three (severely cognitively impaired). There were no behaviors noted on the residents MDS. Continued review of R52's clinical record noted the following: Order (7/13/23 ): .Quetiapine Fumarate Oral Tablet 25 MG (Brand name is…
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 before2024-03-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This intake pertains to Intake Number(s): MI00142258. Based on interview and record review, the facility failed to thoroughly assess and timely address a resident experiencing a change in condition and administer medications according to physician's orders for one (R802) of one resident reviewed for changes in condition, resulting in a delay in care. Findings include: A review of a complaint submitted to the State Agency revealed allegations that included R802 contacting the complainant at 2:30 AM on [DATE] and reported that the facility was mismanaging his medications, was unable to get assistance to the bathroom, and that the nurse told him that he almost died. The complainant arrived at the facility later that morning and R802's skin was yellow and he was gasping for air. The complainant reported having difficulty finding assistance and notified the dietician who went to get further assistance. the complainant explained the nurse manager and a physical therapist came to R802's room, the nurse manager reached…
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 before2024-03-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to Intake Number(s): MI00142602. Based on interview and record review, the facility failed to apply a thermal hot pack safety to one (R801) of one resident reviewed for burns, resulting in a burn to the right foot. Findings include: A review of a complaint submitted to the State Survey Agency revealed an allegation that the facility placed a hand warmer between her foot and sock by a nurse which resulted in a third degree burn to the right foot which developed gangrene. A review of a Physical Therapy Treatment Encounter Note(s) for R801 that was attached to the complaint revealed on 9/25/23, Pt (patient) c/o (complained of) R (right) foot pain this date, with consent pt allowed PTA (Physical Therapy Assistant) to examine foot. Upon inspection PTA noticed a burn on the dorsum (top) of the R foot. Pt reported having a hot pack in that area last night. Reported the burn to RN (Registered Nurse) for further skin assessment and treatment. A review of R801's clinical record revealed R801 was admitted into the facility on 9/20/23 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 · Ecited before2023-02-15 · 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 This citation pertains to intake# MI00131276 Based on observation, interview and record review, the facility failed to ensure medications were appropriately dated and stored in five (R70, R55, R22, and R243) resident's rooms. Findings include: On 2/12/23 at 11:56 AM, an observation of R70's room medication storage cabinet was conducted with Licensed Practical Nurse (LPN) B. A vial of Lispro Insulin was undated. It was confirmed with LPN B the vial was open and had been used. On 2/13/23 at 11:46 AM, an observation of R55's room medication storage cabinet was conducted with LPN C. A vial of Levimir Insulin was undated, and a vial of Aspart Insulin was undated. It was confirmed with LPN C that both vials were open and had been used. LPN C was asked when should a vial of Insulin be dated. LPN C explained vials should be dated as soon as they were taken out of the refrigerator and put in a resident ' s medication cabinet. On 2/13/23 at 11:55 AM, an observation of R22 ' s room medication storage cabinet was conducted…
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 · D2023-02-15 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify the appropriate decision maker for one (R188) of one resident reviewed for advance directives and ensure there was accurate and consistent documentation of the resident's medical treatment wishes. Findings include: On [DATE] at 7:56 AM, R188 was observed seated in a wheelchair visiting with a family member. At that time R188 did not engage in conversation. On [DATE] at approximately 9:00 AM, R188 was observed visiting with another family member. R188 was engaged in conversation and able to answer questions clearly about their care. On [DATE] at 1:44 PM, review of R188's clinical record revealed the following: R188 was admitted into the facility on [DATE] with diagnoses that included: fracture of right femur, history of non-Hodgkin lymphoma, atrial fibrillation, hyperlipidemia, hypertension, and dementia. Review of R188's profile in the electronic medical record (EMR) indicated R188's code status was Do Not Resuscitate (DNR).…
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 · D2023-02-15 · tag F0644 — isolatedCoordinate 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 interview and record review the facility failed to ensure a Change in Condition level one screening 3877 (Department of Community Health Form-3877) was sent to the local Community Mental Health Services Program (CMHSP) for a level two OBRA (Omnibus Budget Reconciliation Act) evaluation upon an identified change in the resident's condition for one resident (R57) of three residents reviewed for Preadmission Screening/Annual Resident Review (PASARR). On 2/12/23 the medical record for R57 was reviewed and revealed the following: R57 was initially admitted to the facility on [DATE] and had admitting diagnoses including Schizophrenia, Depression and Anxiety disorder. A review of R57's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/18/22 revealed R57 needed extensive assistance from facility staff with their activities of daily living. A Physician's order dated 11/28/22 revealed the following: Quetiapine Fumarate Tablet (Antipsychotic medication) 50 MG (milligrams) Give 1 tablet by mouth…
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 · D2023-02-15 · 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 This citation pertains to intake#'s MI00126112 and MI00128467. Based on observation, interview and record review, the facility failed to complete and/or document the completion of regular bathing and/or nail care for three residents (Resident #'s 45, 94 and 97) of seven reviewed for activities of daily living (ADL's) Findings include: On 2/12/23 a concern submitted to the Stage Agency was reviewed which indicated R97 was not provided regular bathing during their stay at the facility. On 2/12/23 The medical record for R97 was reviewed and revealed the following: R97 was last admitted to the facility on [DATE] and had diagnoses including Failure to thrive and Congestive heart failure. A review of R97's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/5/21 revealed R97 needed extensive assistance from facility staff with most of their activities of daily living. A review of R97's careplan revealed the following: Focus-Actual ADL/Mobility deficit, r/t (related to) syncope, falls, dementia,…
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 · D2023-02-15 · 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 MI00133334. Based on interview and record review, the facility failed to implement timely interventions and prevent pressure ulcers for one (R90) of two residents reviewed for pressure ulcers, resulting in R90 developing a Deep Tissue Pressure Injury (DTPI - intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) and a Stage 1 (intact skin with a localized area of non-blanchable redness) Pressure Injury. Findings include: A complaint was filed with the State Agency that alleged in part, .(R90) also received SDTIs (Suspected Deep Tissue Injury) on both of her heels during her 2 weeks stay . Review of the closed record revealed R90 was admitted into the facility on [DATE] with diagnoses that included: right hip fracture, atrial fibrillation and hypertension. According to the Minimum Data Set (MDS) assessment dated [DATE], R90 was cognitively intact and required the extensive to total assistance 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.
“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
$226,525 in federal fines across 2 penalties.
- $92,130 — penalty dated 2025-10-07
- $134,395 — penalty dated 2025-05-30
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 THE WELLBRIDGE GROUP — 8 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 | 3 of 5 | 3.5 | -0.5 vs chain |
| Health inspection | 3 of 5 | 3.1 | -0.1 vs chain |
| Staffing | 4 of 5 | 3.9 | +0.1 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 7 homes this chain runs (chain average 3.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| E2G, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 30% | since 05/01/2014 |
| FRANK M WRONSKI LIVING TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 30% | since 04/14/2009 |
| BRANSCUM, JAMES | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 30% | since 07/31/2014 |
| PERRY, MICHAEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 5% | since 01/01/2016 |
| PENNINGTON, LEEANN | Individual | W-2 MANAGING EMPLOYEE | — | since 04/01/2016 |
| TODOS, CRISTINA | Individual | W-2 MANAGING EMPLOYEE | — | since 07/27/2021 |
| SANGSTER, TODD | Individual | CORPORATE OFFICER | — | since 05/01/2014 |
| NEXCARE HEALTH SYSTEMS, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2016 |
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235702. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, 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.