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Medilodge of Okemos

5211 Marsh Road, Okemos, MI 48864 · For profit - Limited Liability company · 100 certified beds · (517) 319-1400 Medicare & Medicaid certified

Call the home — (517) 319-1400 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Sep 2025
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1650 Haslett Rd · (517) 853-5588 · Call to confirm hours
Pharmacy
5110 Times Square Pl · (517) 381-8267 · Call to confirm hours
Grocery
Aldi0.2 mi
5165 Marsh Rd · (855) 955-2534 · Call to confirm hours
Park
1960 Gaylord C Smith Ct · (517) 853-4000 · Typically dawn to dusk
Place of worship
1982 W Grand River Ave · (515) 303-5193

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 held steady at 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.1%10.8%15.4%better
Long-stay residents who lose too much weight10.1%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder1.0%0.8%0.9%typical
Long-stay residents with a urinary tract infection1.9%1.5%2.0%typical
Long-stay residents with depressive symptoms1.1%4.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.6%3.0%3.3%better
Long-stay residents whose ability to walk worsened12.5%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.9%19.4%18.9%typical
Long-stay residents given the seasonal flu vaccine69.2%95.0%95.3%worse
Long-stay residents with pressure ulcers4.2%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control24.9%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table12.2%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.9%1.1%1.4%worse
Short-stay residents given the seasonal flu vaccine75.9%79.5%79.4%typical
Short-stay residents rehospitalized after admission16.0%24.0%22.6%better
Short-stay residents with an outpatient ER visit17.1%11.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.281.841.67better
Long-stay outpatient ER visits per 1,000 resident days2.821.641.80worse

§ 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.

56.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.5%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
46.1%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 46.1% 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 39 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 0.27 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.5%CMS range 44.5–67.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 8.3–16.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge46.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge35.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge35.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.9%CMS range 3.3–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.951.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.10
RN hours/ resident / day
0.57
LPN hours/ resident / day
2.58
Aide hours/ resident / day
4.24
Total nurse hours/ resident / day
0.59
RN hoursweekends
41.1%
Total nursing turnover
36.0%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 94.3 residents a day — about 94% occupied, or roughly 6 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 1.10 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.58 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.54 hrs/resident/day on weekends vs 4.53 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.30 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

7
deficiencies at the latest standard inspection (2025-09-05)
5
at the previous standard inspection (2024-09-13)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · E2025-09-05 · tag F0678 — failed to provide CPR when needed — pattern
    Provide 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 ensure four of 32 Licensed Nurses maintained current cardiopulmonary resuscitation (CPR) certification for Healthcare Providers (HCP), which included a hands-on session, for one (R98) of one reviewed.Findings include: Review of the medical record reflected R98 admitted to the facility on [DATE], with diagnoses that included intraspinal abscess and granuloma, acute respiratory failure with hypoxia, cardiomyopathy, atrial fibrillation, atherosclerotic heart disease, methicillin susceptible staphylococcus aureus and chronic kidney disease. The 5-day Medicare Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R98 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). According to the medical record, R98 died in the facility on [DATE] and was a full code (desired CPR efforts). A Progress Note for [DATE] at 6:37 AM, authored by Licensed Practical Nurse (LPN) H,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-05 · tag F0725 — failed to have enough nursing staff — pattern
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure call lights were answered timely for nine residents (R2, R3, R17, R26, R28, R43, R58, R90, R101) in a facility census of 92.Findings include: Resident #3 (R3) Review of the medical record reflected R3 was admitted to the facility on [DATE] and was readmitted on [DATE]. Diagnoses of trigeminal neuralgia, multiple sclerosis, chronic pain syndrome, polyneuropathy, muscle weakness and lack of coordination. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/14/2025, revealed R3 had a Brief Interview of Mental Status (BIMS) of 13 out of 15 (cognitively intact) and is dependent of all care. During an observation on 09/02/2025 at 1055 AM, R3 turned her call light on to get someone to put her back to bed after her appointment at the pain clinic. R3 stated she asked staff to make/change her bedding when she left at 900 AM, and it had not been changed, observation of stool smeared on her blue pad that covers…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-05 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain respect and dignity to one resident (Resident #3) of one resident's care and services.Resident #3 (R3)Review of the medical record reflected R3 was admitted to the facility on [DATE] and was readmitted on [DATE]. Diagnoses of trigeminal neuralgia, multiple sclerosis, chronic pain syndrome, polyneuropathy, muscle weakness and lack of coordination.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/14/2025, revealed R3 had a Brief Interview of Mental Status (BIMS) of 13 out of 15 (cognitively intact) and is dependent of all care.During an observation and interview on 09/02/2025 at 11:52 AM, R3 stated some of the staff are not very kind, this writer asked if she has told anyone, and R3 stated no not yet, she was going to wait and see if her attitude got any better. Stated the staff are ruff with repositioning her, due to her chronic pain and Multiple Scleroses. Writer passed this information on to the LNA A.During…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-05 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 maintain resident's personal privacy for one resident (resident #6) of one resident reviewed. Review of the clinical record revealed R6 was admitted to the facility on [DATE] with diagnoses that included: multiple sclerosis and Type 1 Diabetes Mellitus. According to the Minimum Data Set (MDS) assessment dated [DATE], R6 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).On 9/2/25 at 2:36 PM, R6 was observed in her room, sitting up in a power wheelchair. When interviewed in her room with the door closed, two staff members (at different times), knocked on the door and entered before R6 was able to provide permission to enter her private room. R6 became upset and stated that this happens routinely (staff not respecting her privacy). R6 added that staff had entered her room in the past, while she was having a private conversation with her attorney and that she had previously had a sign requesting…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-05 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 for not performing a gradual dose reduction (GDR) for one (R90) of five reviewed. Findings include:Review of the medical record revealed R90 was admitted to the facility on [DATE] with diagnoses that included vascular dementia without behavioral disturbance/psychotic disturbance/mood disturbance, anxiety, insomnia, major depressive disorder, and psychotic disorder with hallucinations. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/2/25 revealed R90 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/2/25 at 10:51 AM, R90 was observed seated in a Broda chair in the dining room on the unit. Review of the Physician's Orders revealed R90 was admitted to the facility with an order for Seroquel 200 milligrams (mg) daily. On 6/2/25, the Seroquel was decreased to 150 mg at bedtime for major depressive disorder with psychotic…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent a fall for one (R5) of two reviewed. Findings include:Review of the medical record revealed R5 admitted to the facility on [DATE] with diagnoses that included epilepsy, and morbid obesity. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/24/25 revealed R5 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was dependent on staff for activities of daily living (ADLs). On 9/2/25 at 10:45 AM, R5 was observed lying in a bariatric bed with a perimeter mattress and a fall mat on the right side of the bed. A Broda chair was observed in R5's room. R5 reported she fell out of her Broda chair and fractured her leg. Review of the Witnessed Fall incident report dated 6/9/25 at 10:45 AM revealed R5 had fallen out of her wheelchair outside of the building in the parking lot. The incident report revealed an Activity Aide was propelling the Broda…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-09-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff utilized personal protective equipment (PPE) for one (R70) of one reviewed for Transmission-Based Precautions (TBP). Findings include: Review of the medical record reflected R70 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included Crohn's Disease. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/21/25, reflected R70 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 09/02/2025 at 12:29 PM, a sign was observed, outside R70's room door, which had two STOP signs and read, CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . On 09/02/2025 at 12:29 PM, Staff Member (SM) C was observed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY DPS 2) Based on observation, interview and record review the facility failed to ensure an as needed narcan order was in place for one (Resident #348) of 19 reviewed for quality of care resulting in the potential to not receive the opioid reversing medication in a timely manner. Resident #348 (R348) Review of an admission Record revealed Resident #348 (R348) admitted to the facility on [DATE] with diagnoses which included chronic pain syndrome and spinal stenosis. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/3/24, reflected R348 scored 15 of out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/10/24 at 10:11 AM, R348 was observed in bed. R348 explained that he had frequent pain and was prescribed medications for pain control. Review of R348's Physician Orders revealed active orders for Morphine Sulfate ER (extended release) oral tablet 15 MG (milligrams), Hydrocodone-Acetaminophen Oral Tablet 10-325 MG…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-13 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 restorative services or enabler bars for three residents (R18, R73 and R75) of three residents reviewed for restorative care, out of a total sample of 19 residents, resulting in the potential for residents to decline in their current highest functioning level losing their independence and leading to withdrawal, depression and complications of immobility. Findings Include: Resident #18 (R18) Medical record revealed Resident #18 (R18) was admitted to the facility on [DATE] and readmitted on [DATE] initially with diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia, Congestive Heart Failure, Diabetes, Chronic Kidney Disease, Pressure Ulcer of Sacral Region, stage 3, Obesity, Gastrointestinal Hemorrhage, Other Intervertebral Disc Degeneration Lumbar Region and a Spinal Cord injury. According to R18's Minimum Data Set (MDS) dated [DATE], revealed R18 scored 14 out of 15 (cognitively intact) on the Brief Interview…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-13 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% when two medication errors were observed from a total of 31 opportunities for two residents (Resident #43, #60), resulting in a medication error rate of 6.67%. Findings include: Resident #43 (R43) Review of the medical record revealed R43 was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure. A Physician order dated 10/1/23 included an order for Ayr Saline Nasal Drops Nasal Solution 0.65% (percent) to be administered once a day. Ayr Saline Nasal Drops are used to alleviate the symptoms of dry nostrils. On 9/11/23 at 08:15 AM, Registered Nurse (RN) K reported that she was preparing to administer medications to R43. RN K obtained a cotton tipped swab and Ayr nasal gel from the medication cart. RN K applied AYR nasal gel to the end of the cotton tip swab and assisted R43 with coating both nostrils with the AYR gel. Further review of R43's Physician orders…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2024-09-13 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in two resident rooms (Resident #38, #86) resulting in the potential for unsafe access to medications. Findings include: Resident #38 (R38) On 09/10/24 at 11:16 AM, a bottle of Flonase Nasal Spray was observed on R38's bedside table. The bottle was dated and contained the initials of R38. R38 reported that the Flonase spray was not normally stored in her room and that she does not have permission to store and/or administer medications to herself. Review of R38's Physician orders revealed that R38 had an active order for Fluticasone Propionate Suspension, 1 spray in each nostril in the morning for Rhinitis. Resident #86 (R86) On 09/10/24 at 1:33 PM, two boxes of Voltaren Gel were observed in R86's room. R86 reported that he does not administer the pain-relieving gel to himself and that the boxes were left in the room on a regular basis. Review of R86's Physician orders revealed that R86 had an active order for Voltaren External Gel 1 % (percent) (Diclofenac…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-13 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    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 one out of one residents (Resident #42) received timely dental care to obtain a new set of dentures, resulting in embarrassment and a difficult time eating. Findings Included: In an interview on 9/10/2024 at 2:20 PM, Resident #42 (R42) stated that she had seen the dentist about two months ago, and the dentist told her she needed to get new dentures. R42 said she had not seen the dentist since then and had not had any denture fitting done. R42 was observed to have no visible teeth. R42 stated she wanted dentures as soon as possible because she felt embarrassed having no teeth. Record review of R42's dental notes dated 5/30/2024, revealed the age of R42's dentures was six plus years, the condition of her teeth were poor, had moderate soft plaque/food debris buildup, moderate hard calculus deposits, moderate gingivitis inflammation/swollen bleeding gums. Review of the, Treatment notes: .Patient (R42) has upper complete denture that is very loose and worn. She is having trouble chewing, having also lost her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-27 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to complete a timely Significant Change Minimum Data Set (MDS) assessment for one (Resident #5) of 18 residents reviewed for MDS assessments, resulting in the potential for untimely/inaccurate care plans and unmet care needs. Findings include: Review of the medical record revealed that Resident #5 (R5) was readmitted to facility 6/26/22 with diagnoses including chronic obstructive pulmonary disease and cerebrovascular disease. Review of the MDS with an Assessment Reference Date (ARD) of 6/24/23 revealed that R5 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) of 13 (cognitively intact). Section O of same the MDS indicated that R5 was receiving hospice care. Review of the Significant Change MDS with an ARD of 12/22/22 indicated that R5 received hospice care within the last 14 days. R5's Physician's Order dated 1/23/2023 stated, Admit to (name of hospice company) effective 12/6/22 . In an interview on 7/25/23 at 1:08 PM, Licensed Practical Nurse/Minimum Data Set Nurse (LPN/MDS Nurse) G stated that 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-27 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 the Minimum Data Set (MDS) assessment was accurately coded for two (Resident #22, #30) of 18 residents reviewed for MDS, resulting in the potential for inaccurate care plans and unmet care needs. Findings include: Resident #22 Review of the medical record revealed that Resident #22 (R22) was readmitted to facility 1/25/2021 with diagnoses including cerebral infarction, unsteadiness on feet, and muscle weakness. Review of the MDS with an Assessment Reference Date (ARD) of 4/18/23 revealed that R22 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 12 (moderately impaired cognition). Section G of the same MDS reflected that R22 had functional limitations in upper and lower extremity range of motion (ROM) on one side. Annual MDS with an ARD of 10/16/2022 reflected that R22 had no functional limitation in ROM with assessments prior to (Quarterly MDS with ARD of 7/16/22) and after (Quarterly MDS with ARD of 1/6/23) reflecting that R22 had functional limitations in upper 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-27 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise the care plan in 2 of 18 residents reviewed for care plans (R29 and R54), resulting in unmet needs. Findings include: Resident # 54 (R54) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R54 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included peripheral neuropathy, diabetes mellitus, benign prostatic hyperplasia, anxiety, and depression. The MDS reflected R54 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required set up assist with all activities of daily living and occasional assistance with bathing and hygiene. R54's MDS reflected frequent incontinence(more than 7 episodes of incontinence). During an observation and interview on 7/24/23 at 3:05 PM, R54 was observed in hall self propelling in wheelchair. R54 entered his room and gave permission for this surveyor to enter room to discuss…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide physician ordered services and assistance to restore bowel and bladder continence for one Resident (R54) of one reviewed for bowel and bladder, resulting in decrease quality of life, lost sleep, frustration and the potential worsening incontinence. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R54 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included peripheral neuropathy, diabetes mellitus, benign prostatic hyperplasia, anxiety, and depression. The MDS reflected R54 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact, and he required set up assist with all activities of daily living and occasional assistance with bathing and hygiene. R54's MDS reflected frequent incontinence(more than 7 episodes of incontinence). During an observation and interview on 7/24/23 at 3:05 PM, R54 was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-27 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when three medication errors were observed from a total of twenty-five opportunities for two residents (Resident #11 and #64) of six reviewed for medication administration, resulting in a medication error rate of 12% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects. Findings include: Resident #11 On 7/25/23 at 8:29 AM, Registered Nurse (RN) C was observed preparing multiple medications for Resident #11 (R11) including four oral medications as well as an Albuterol Sulfate (Ventolin) and a Symbicort Inhaler. After entering R11's room and administering oral medications, RN C was observed to shake and then hand Albuterol Inhaler to R11 with R11 observed to place inhaler to and close lips around inhaler mouthpiece and self-administer 2 consecutive puffs prior to handing inhaler back to RN C. RN C proceeded to immediately shake and hand Symbicort Inhaler to R11 with R11 observed to place inhaler to 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-27 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 that prescribed medications were given on time and per physician's orders for one resident (R6) of one reviewed for significant medication error, resulting in several missed doses of Physician ordered prescription eye drops, inaccurate dosing and the potential for preventable decline and/or loss of vision. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R6 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, schizoeffective disorder, chronic obstructive pulmonary disease, end stage renal disease with dialysis, anxiety, and depression. The MDS reflected R6 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required one person physical assist with transfers, dressing, hygiene, and bathing. During an observation and interview on 7/24/23 at 12:53 PM, R6 was…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-27 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure timely coordination of dental services for one (Resident #22) of one resident reviewed for dental services, resulting in the potential for untreated and unmet dental needs. Findings include: Review of the medical record revealed that Resident #22 (R22) was readmitted to facility 1/25/2021 with diagnoses including cerebral infarction, aphasia, and type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/23 revealed that R22 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 12 (moderately impaired cognition). Section L of the Annual MDS with an ARD of 10/16/2022 reflected that R22 had obvious or likely cavity or broken natural teeth. In an observation and interview on 7/24/23 at 12:46 PM, R22 stated that she had broken and loose teeth, denied seeing a dentist recently but verbalized need to do so, and although denied any chewing issues did admit 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-27 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 interview and record review, the facility failed to maintain complete and accurate medical records for two Residents (R6 and R54)) of 18 reviewed for medical records, resulting in untimely entry of provider notes in the medical record, significant medication error and the potential for an inaccurate reflection of resident conditions. Findings include: Resident #6(R6) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R6 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, schizoeffective disorder, chronic obstructive pulmonary disease, end stage renal disease with dialysis, anxiety, and depression. The MDS reflected R6 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required one person physical assist with transfers, dressing, hygiene, and bathing. During an observation and interview on 7/24/23 at 12:53 PM, R6 was sitting in 100 hall dining room…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-27 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 offer a pneumococcal vaccine in one of five residents reviewed for vaccinations (Resident #13) resulting in the increased potential for pneumococcal disease. Findings include: Resident #13 (R13) R13's Minimum Data Set (MDS) with assessment reference date of 5/26/23, revealed a Brief Interview for Mental Status (BIMS), a short cognitive screener for nursing home residents, score of 15 (cognitively intact); and he had the diagnoses of coronary artery disease (CAD, damage in hearts major blood vessels), high blood pressure, stroke, and asthma. During an interview with Infection Control Practitioner (ICP) D on 7/26/23 at approximately 1:00 PM she confirmed R13 had not been offered a pneumococcal vaccine five years after his last pneumococcal vaccine. ICP D stated R13 had signed an outdated consent form. Informed Consent for Pneumococcal Vaccine signed by R13 on 10/21/20, included parts of the document that were excerpted from Centers for Disease Control's…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2023-07-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespread
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to properly store hazardous chemicals (pesticide), resulting in potential access and exposure to chemicals by residents, affecting all residents who independently access the courtyard. Findings include: On 7/24/23 at 12:12 PM, a bulk chemical sprayer with a wand, that was 3/4 full, was observed to be stored on the sidewalk in the courtyard. At this time, no staff were observed to be in the courtyard, and pesticide was observed to have a small puddle underneath where the wand had dripped. During an interview on 7/24/23 at 3:30 PM, Nurse R was queried if any residents are able to access the courtyard independently and she stated, that they can. On 7/24/23 at 3:50 PM, the bulk chemical sprayer was observed to still be in the courtyard. At this time, Maintenance Director Q stated that the bulk chemical sprayer container grass and weed killer. Maintenance Director Q proceeded to remove the bulk chemical sprayer to a proper storage location.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MEDILODGE — 53 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.1+0.9 vs chain
Health inspection 4 of 52.7+1.3 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 52 homes this chain runs (chain average 3.1★, per CMS)
1 of 5Medilodge of FarmingtonFarmington, MI 1 of 5Medilodge of Grand BlancGrand Blanc, MI 1 of 5Medilodge of Grand RapidsGrand Rapids, MI 1 of 5Medilodge of HowellHowell, MI 1 of 5Medilodge of MarshallMarshall, MI 1 of 5Medilodge of Montrose IncMontrose, MI 1 of 5Medilodge of MunisingMunising, MI 1 of 5Medilodge of Sault Ste. MarieSault Ste. Marie, MI 1 of 5Medilodge of SouthfieldSouthfield, MI 1 of 5Medilodge of WestwoodKalamazoo, MI 2 of 5Medilodge at the ShoreGrand Haven, MI 2 of 5Medilodge of Capital AreaLansing, MI 2 of 5Medilodge of CheboyganCheboygan, MI 2 of 5Medilodge of East LansingEast Lansing, MI 2 of 5Medilodge of FrankenmuthFrankenmuth, MI 2 of 5Medilodge of GTCTraverse City, MI 2 of 5Medilodge of KalamazooKalamazoo, MI 2 of 5Medilodge of LudingtonLudington, MI 2 of 5Medilodge of St. ClairEast China, MI 2 of 5Medilodge of Sterling HeightsSterling Heights, MI 2 of 5Medilodge of West BloomfieldWest Bloomfield, MI 3 of 5Medilodge of Campus AreaEast Lansing, MI 3 of 5Medilodge of HillmanHillman, MI 3 of 5Medilodge of LivingstonHowell, MI 3 of 5Medilodge of LivoniaLivonia, MI 3 of 5Medilodge of Mt. PleasantMt. Pleasant, MI 3 of 5Medilodge of PortagePortage, MI 3 of 5Medilodge of ShorelineSterling Heights, MI 3 of 5Medilodge of Tawas CityTawas City, MI 3 of 5Medilodge of TaylorTaylor, MI 3 of 5Medilodge of ZeelandZeeland, MI 3 of 5The Lodge at TaylorTaylor, MI 4 of 5Medilodge of GaylordGaylord, MI 4 of 5Medilodge of HollandHolland, MI 4 of 5Medilodge of LansingLansing, MI 4 of 5Medilodge of LeelanauSuttons Bay, MI 4 of 5Medilodge of MilfordMilford, MI 4 of 5Medilodge of RichmondRichmond, MI 4 of 5Medilodge of Traverse CityTraverse City, MI 5 of 5Medilodge of AlpenaAlpena, MI

Showing 40 of 52; 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 / managerTypeRoleShareSince
ARK OPCO GROUP, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2015
B&Y HEALTHCARE S CORPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2015
B&Y TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2015
CODY HEALTHCARE S CORPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2015
CRAIG FLASHNER 2007 TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2015
NORCROSS, ROBERTIndividualCONTRACTED MANAGING EMPLOYEEsince 07/02/2015
ROGERS, STACEYIndividualCONTRACTED MANAGING EMPLOYEEsince 07/01/2015
KIRK, KRISTINEIndividualW-2 MANAGING EMPLOYEEsince 09/02/2016
FLASHNER, CRAIGIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2015
PERLSTEIN, YITZCHOKIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2015
NOBLE HEALTHCARE MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2015
PRESTIGE ADMINISTRATIVE SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2016

CMS files one row per role, so the 14 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

7 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.

$10.7M
Net patient revenuemost recent cost report
+4.9%
Operating marginrevenue minus expenses
$1.4M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 6%Other / private 23%

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 13% 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

$353per resident / day
operating cost
$10,716per month
≈ monthly operating cost
$371per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235647. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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