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The Willows At Okemos

4830 Central Park Drive, Okemos, MI 48864 · For profit - Corporation · 68 certified beds · (517) 349-3600 Medicare & Medicaid certified

Call the home — (517) 349-3600 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

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 (5/5)
  • lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
Worth asking about
  • it has 1 actual-harm citation
  • 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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1667 Hamilton Rd · (517) 349-9550 · Call to confirm hours
Pharmacy
Rite Aid0.2 mi
1664 W Grand River Ave · (517) 349-4410 · Call to confirm hours
Grocery
Kroger0.2 mi
4884 Marsh Rd · (517) 347-0100 · Call to confirm hours
Park
1990 Central Park Dr · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased9.6%10.8%15.4%better
Long-stay residents who lose too much weight7.9%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.8%0.8%0.9%better
Long-stay residents with a urinary tract infection0.7%1.5%2.0%better
Long-stay residents with depressive symptoms1.5%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 injury0.0%3.0%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened13.1%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.5%19.4%18.9%better
Long-stay residents given the seasonal flu vaccine95.3%95.0%95.3%typical
Long-stay residents with pressure ulcers2.6%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control11.4%20.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table5.5%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.3%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine82.5%79.5%79.4%typical
Short-stay residents rehospitalized after admission21.2%24.0%22.6%typical
Short-stay residents with an outpatient ER visit10.3%11.7%12.0%better
Long-stay hospitalizations per 1,000 resident days1.241.841.67better
Long-stay outpatient ER visits per 1,000 resident days1.621.641.80better

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

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

65.8% 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 143 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.8%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
53.5%U.S. median 56.6%
Met the expected recovery
0.55U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.27hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 53.5% 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 71 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 12% 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 SNF65.8%CMS range 57.7–72.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 7.9–14.810.7%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 discharge53.5%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 discharge69.0%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 discharge54.9%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 stay1.2%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or 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 hospitalization7.2%CMS range 4.5–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 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

1.38
RN hours/ resident / day
0.62
LPN hours/ resident / day
1.98
Aide hours/ resident / day
3.99
Total nurse hours/ resident / day
1.34
RN hoursweekends
32.8%
Total nursing turnover
21.7%
RN turnover

How full it usually is: this home is certified for 68 beds and averages 61.5 residents a day — about 90% 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 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.38 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 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 4.09 on weekdays — 9% thinner on weekends. RN hours go from 1.39 to 1.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 33% is below 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 (2026-04-16)
5
at the previous standard inspection (2025-01-29)

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 11 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · G2025-05-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Number MI00152440. Based on interview and record review, the facility failed to ensure adequate supervision, implementation of meaningful and resident-centered care plan interventions, and staff awareness of planned interventions for fall prevention for two residents (Resident #701 and Resident #704) of three residents reviewed, resulting in Residents with a known risk of falls experiencing falls with injury, including a fracture, necessitating emergency medical treatment and unnecessary pain and discomfort. Findings include: Review of intake documentation revealed Resident #701 fell out of their bed on 4/19/25. Per the intake, the Resident was then made to sit in a chair in the hallway so that staff could keep an eye on them and proceeded to have a second fall at appropriately 4:15 AM on 4/20/25 which resulted in the Resident having an open laceration on their head, which required transfer to the hospital for treatment and sutures in the Emergency Department (ED). Resident #701:…

    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 · F2026-04-16 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 67 residents who consume food, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 04/14/2026 at 8:52 A.M., An initial tour of the food service was conducted with Director of Food Services (DFS) M. The following items were noted:Dry Storage Room: The return air exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. (DFS) M indicated he would have maintenance thoroughly clean the soiled ventilation grill as soon as possible.The 2022 FDA Model Food Code section 6-501.14 states: (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. (B) If vented to the outside, ventilation systems may not create a public health HAZARD or nuisance or unLAWful discharge.Food splash residue was observed on the overhead light assembly and ceiling surfaces, adjacent to the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-16 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 complete a comprehensive assessment timely for three Residents (#12, #58, #68) of seventeen residents reviewed for comprehensive assessments.Findings Included: R12: Review of the medical record reflected R12 admitted to the facility on [DATE], with diagnoses that included Alzheimer's and chronic obstructive pulmonary disease (COPD). The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/4/26, reflected R12 scored four out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 04/15/2026 at 4:39 PM, R12 was observed seated in his wheelchair, in the dining room. As of 4/16/26, the status of R12's Annual MDS, with an ARD of 3/4/26, was Finalized. Section V (Care Area Assessment (CAA) Summary) of the MDS was signed on 4/16/26. In an interview on 04/16/2026 at 9:40 AM, MDS Nurse K stated Section Z of R12's Annual MDS was signed timely. According to MDS Nurse K, work was done…

    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 · D2026-04-16 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    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 complete a quarterly assessment for three Residents (#49, #51, #61) of seventeen residents reviewed for comprehensive assessments.Findings Included:Resident #49 (R49) Review of the medical record revealed that R49 was admitted to the facility 05/08/2019 with diagnoses that included heart failure, chronic kidney disease, type 2 diabetes, atrial fibrillation, hyperlipidemia (high fat content in blood), epilepsy (neurological disorder with seizures), chronic pain, osteoarthritis (degenerative joint disease), osteoporosis (bone weaking), obesity, and chronic obstructive pulmonary disease (COPD). Review of R49's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2025, revealed that R49 had a Brief Interview for Mental Status (BIMS) of 9 (moderate cognitive impairment) out of 15. Review of R49's medical record revealed that the last Minimum Data Set (MDS) was completed with an Assessment Reference Date (ARD) of 11/25/25.20 During an…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-16 · tag F0641 — isolated
    Ensure 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 observation, interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one (R12) of 17 reviewed. Findings include:Review of the medical record reflected R12 admitted to the facility on [DATE], with diagnoses that included Alzheimer's and chronic obstructive pulmonary disease (COPD). The Annual MDS, with an Assessment Reference Date (ARD) of 3/4/26, reflected R12 scored four out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded as not having any applicable oral dental concerns. Broken or loosely fitting full or partial denture and no natural teeth or tooth fragment(s) (edentulous) were listed as coding options. On 04/14/2026 at 9:26 AM, R12 was observed seated in a wheelchair, in his room. R12 reported having dentures, but he had not seen them in a few months and did not know what happened to them. In an interview on 04/15/2026 at 11:40 AM, Licensed Practical Nurse (LPN) N…

    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 · D2026-04-16 · 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 for one (R9) of 17 reviewed. Findings include: Review of the medical record reflected R9 admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis (paralysis/muscle weakness on one side of the body) following cerebral infarction (stroke), affecting the left non-dominant side. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/22/26, reflected R9 scored eight out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 04/14/2026 at 2:44 PM, R9 was observed lying in bed. In an interview on 04/15/2026 at 5:11 PM, Certified Nurse Aide (CNA) R reported R9 transferred via hoyer lift (mechanical lift that uses a sling to lift a person) and two-person assist. CNA R stated transfer status was included in the Care Plan. R9's Care Plan reflected an intervention, dated 11/9/21, for pivot…

    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 · D2026-04-16 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to implement pharmacy recommendations for one resident (#36) of five residents reviewed for pharmacy services.Findings Included:Resident #36 (R36)Review of the medical record revealed that R36 was admitted to the facility 11/04/2021 with diagnoses that included right ulna fracture, dysphagia (difficulty swallowing), depression, insomnia, anxiety, stroke, type 2 diabetes, hypertension, and pain. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/01/2026 revealed that R36 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15.On 04/14/2026 at 08:57 a.m. during observation R39 was observed lying in bed. R39 was pleasant during interview and expressed no concerns.Review of R36's medical record revealed a Pharmacist Drug Regimen Review, dated 07/29/2025, which stated Resident is receiving the statin: Atrovastatin. Please consider adding a fasting lipid panel with next lab draw and annually. The same document revealed the Response 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-16 · 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 a timely dental services referral for one (R54) of two reviewed. Findings include: Review of the medical record reflected R54 admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side and vascular dementia. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/26/26, reflected R54 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). According to the medical record, R54 had a Medicaid payer source.On 04/14/2026 at 1:36 PM, R54 was observed seated in a wheelchair, in her room. She reported she had seen the dentist for an issue with a tooth on the bottom, left side of her mouth. She reported she was supposed to do a follow-up but had not heard anything about it yet. A Dental consult for 9/12/25 reflected, .Patient complains of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake Number MI00152440. Based on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) and hygiene care were provided to one resident (Resident #704) of three residents reviewed. Findings include: Resident #704: On 5/6/25 at 12:15 PM, Resident #704 was observed sitting in a wheelchair at a table in the dining room of the facility. The Resident's fingernails were long. When asked questions, the Resident made eye contact but did not provide verbal responses. Record review revealed Resident #704 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, dementia with other behavioral disturbance, anxiety, right foot hallux rigidus (limited movement, stiffness, pain in the big toe joint), falls, and displaced fracture of the right and left femurs with surgical repair. Review of the Minimum Data Set (MDS) assessment, dated 4/15/25, revealed the Resident was severely…

    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 · Ecited before2025-01-29 · tag F0641 — pattern
    Ensure 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 Resident #34 (R34) Review of the Face Sheet and Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/4/24, reflected R34 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), malnutrition and depression. The MDS reflected R34 had a BIM (assessment tool) score of 10 which indicated his ability to make daily decisions was moderately impaired. During an observation and interview on 1/27/25 at 11:45 AM, R34 was in room sitting in wheelchair with some difficulty answering questions. R34 family was present and reported was currently receiving hospice services. Review of R34's Physician Orders, dated 9/26/24, reflected an order for Hospice services. Review of R34's Significant Change MDS, dated [DATE], reflected no evidence that resident 34 was on Hospice services. During an interview on 1/28/25 at 4:44 PM, MDS staff C reported had been in position about five months and received support from regional support staff. MDS C reported…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-29 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure appropriate storage of medications, including narcotics in 2 of 5 medication carts, resulting in the potential for misuse, and medication administration errors. Findings include: During an observation on 1/28/25 at 9:15 AM, 100 hall medication cart was unlocked with no staff present. Continued observation with two non-nurse staff members passing medication cart. Observed nurse staff exit resident room and return to medication cart and lock cart at 9:18 a.m. prior to exiting hall 100. Review of the 100 hall medication cart on 1/28/25 at 11:22 AM, Registered Nurse (RN) K unlocked 100 hall medication cart, revealed a unlabeled medication cup with at least 2 unidentified pills in the top drawer. RN K grabbed the cup of medications and reported was resident 11:00 am medications and needed to administer medications now, locked medication cart and entered resident room [ROOM NUMBER]. This surveyor heard RN K tell resident she had her Norco…

    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 11 citations
  • Potential for harm · Dcited before2025-01-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADL's), including bathing/showering for one dependent resident (R4) reviewed of ADL care, resulting in increased likelihood of feelings of worthlessness, disrespect and the potential for uncleanliness. Resident #4(R4) Review of the Face Sheet and Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/2/24 , reflected R4 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), venous insufficiency (decreased blood flow in legs), cirrhosis of the liver (decreased liver function), pressure ulcer stage III, and depression. The MDS reflected R4 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact, and she required partial to moderate assist with transfers, dressing, and bathing. During an observation on 1/27/25 at 10:04 AM, R4 was in room sitting in wheelchair 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-29 · 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 This citation pertains in intake MI00148900. Based on observation, interview, and record review, the facility failed to ensure care and services was provided for two of 17 residents (R3 and R4) reveiwed resulting in a delay in treatment to maintain the highest practical level of wellbeing and care needs not being met. Findings include: Resident #3 (R3) Review of the medical record reflected R3 was an initial admission to the facility on [DATE] and readmitted on [DATE]. Diagnoses of fracture of upper end of right tibia, subsequent encounter for closed fracture with routine healing, presence of right artificial knee joint, periprosthetic fracture around internal prosthetic right hip joint, arthritis of left hip, muscles weakness, difficulty walking, Type 2 Diabetes Mellitus with Diabetic Kidney Disease, and Depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, revealed R3 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-29 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    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 ophthalmology services for one (Resident #49) of one reviewed for vision, resulting in lack of timely eye care services and the missed treatments. Findings include: Resident #49 (R49) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R49 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus with unspecified diabetic retinopathy, hypertension (high blood pressure), chronic kidney disease, and depression. The MDS reflected R49 had a BIM (assessment tool) score of 12 which indicated his ability to make daily decisions was moderately impaired. During an observation and interview on 1/27/25 at 12:33 PM, R49 was sitting at table in dining room with another resident. R49 reported appeared pleasant and able to answer questions without difficulty. R49 reported concern related to facility bus was not functioning and had missed two to three eye…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-29 · 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 observation, interview and record review, the facility failed to maintain complete and accurate medical records for two (R7, R49) of 17 residents reviewed for medical records. Findings include: Resident # 7 (R7) Review of the Narcotic Record binder, on 1/28/25 at 11:19 a.m., located on the 100 hall medication cart, revealed, R7 had, Controlled Drug Use Record for Norco 10/325 mg 1 tablet, Xanax 0.25mg 1 tablet, and Tramadol 50mg 1/2 tablet all documented as given at 11:00 a.m. Review of the 100 hall medication cart and interview on 1/28/25 at 11:22 AM, Registered Nurse (RN) K unlocked 100 hall medication cart, revealed a unlabeled medication cup with at least 2 unidentified pills in the top drawer. RN K grabbed the cup of medications and reported was resident 11:00 am medications and needed to administer medications now, locked medication cart and entered R7. This surveyor heard RN K tell R7 she had her Norco and Tramadol(Controled narcotics). RN K returned to the medication cart and opened the cart.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-30 · 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 This citation pertains to intake number MI00146626. Based on observation, interview and record review the facility failed to ensure one out of three residents (Resident #1) Physician's orders and treatment were correct and documented. Findings Included: Per the facility face sheet Resident #1 (R1) was admitted to the facility on [DATE] with a diagnosis of diabetes. Review of R1's Hospice records revealed R1 was admitted to Hospice on 8/8/2024. Review of Physician's orders dated 8/14/2024, revealed R1 was made a no code (DNR). Review of R1's medication administration record (MAR) for the month of August 2024 revealed R1 was to have her blood sugar level checked before each meal and at bedtime. The MAR revealed a scale was ordered for the amount of insulin R1 was to receive such as, if R1's blood sugar level was anywhere between 151-200 R1 was to receive 3 units of Humalog insulin, and so forth. Further review of the MAR revealed that on 8/26/2024 at the R1's bedtime check her blood sugar level was 60, on…

    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 · F2024-01-04 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 59 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 01/03/24 at 09:05 A.M., An interview was conducted with Director of Plant Operations C regarding the facility maintenance work order system. Director of Plant Operations C stated: We have the Direct Supply TELS software system for entering and monitoring maintenance work orders. On 01/03/24 at 01:15 P.M., An environmental tour of sampled resident rooms was conducted with Director of Environmental Services D. The following items were noted: 101: The drywall surface was observed (etched, scored, particulate), adjacent to the restroom entrance door. The damaged drywall surface measured approximately 2.5-feet-wide by 3-feet-high. 105: The Bed 2 drywall surface was observed (etched, scored, particulate), directly behind the motorized reclining chair. The damaged drywall surface measured approximately…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-04 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 develop a comprehensive care plan for one (Resident #22) of 15 reviewed for care plans, resulting in the potential for unmet care needs. Review of the medical record reflected Resident #22 (R22) admitted to the facility on [DATE], with diagnoses that included pulmonary embolism (blood clot in the lung), pulmonary fibrosis (damaged and scarred lung tissue), pneumonia and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/23, reflected R22 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded for oxygen use and frequent bowel and bladder incontinence. The MDS completion date was 12/26/23. On 01/02/24 at 04:00 PM, R22 was observed seated in her room, in a wheelchair, with oxygen via nasal cannula in place. R22 reported she had a blood clot in her lung prior to facility admission and 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 · Dcited before2024-01-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure timely assessment and follow-up for a change in condition for one (Resident #22) of 15 reviewed, resulting in the potential for delayed identification of changes in condition and delay in treatment. Findings include: Review of the medical record reflected Resident #22 (R22) admitted to the facility on [DATE], with diagnoses that included pulmonary embolism (blood clot in the lung), pulmonary fibrosis (damaged and scarred lung tissue), pneumonia and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/23, reflected R22 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded for oxygen use and frequent bowel and bladder incontinence. A Physician's Order with a start date of 12/13/23 and a discontinue date of 12/27/23 reflected R22 had a previous order for two liters of oxygen per…

    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 before2023-09-14 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 MI00139030. Based on interview and record review, the facility failed to ensure laboratory tests were performed timely for two (Resident #2 and #4) of five reviewed for laboratory services, resulting in the potential for delayed treatment and lack of care coordination. Findings include: Resident #2 (R2): Review of the medical record reflected R2 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included osteomyelitis, diabetes, chronic kidney disease and unspecified dementia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/8/23, reflected R2 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and required supervision to total assistance of one person for activities of daily living (ADLs). A Nurse Practitioner Progress Note for 8/12/23, for a 8/10/23 date of service, reflected R2 had anemia (lack of enough healthy red blood cells…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-23 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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: MI00138495 Based on interview and record review the facility failed to ensure Physician ordered laboratory diagnostic tests were completed for one resident (#1) of three residents reviewed for completion of Physician ordered laboratory services resulting in the potential for delayed medical services and coordination of medical care. Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, duodenal ulcer with perforation, sepsis, thrombocytopenia (deficient platelets in blood), phantom limb syndrome with pain, hypertension, type 2 diabetes, gastro-esophageal reflux, hypothyroidism (low thyroid hormone in blood), severe protein-calorie malnutrition, depression, obstructive sleep apnea, hyponatremia (low sodium level in blood), hyperkalemia (high potassium level in blood), vitamin D deficiency, abdominal pain, Insomnia, anxiety, and anorexia (eating disorder). The most…

    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.

    Administration Deficiencies · Past Non-Compliance
  • No harm found · C2024-01-04 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 post the actual daily Nursing Staffing Data resulting in the potential for all 59 Residents and/or family and/or visitors to be well informed of the facility's staffing information. Findings Included: During observation on 01/04/2024 at 03:21 p.m. the facility document entitled Todays Staffing was observed to be posted outside of the Director of Nursing Office, which was located at the beginning of the 200 hall. The Todays Staffing, dated 01/04/2024, listed the scheduled hours for all nursing staff but did not list any actual hours worked. The facility did not have actual hours worked for the previous date of 01/03/2024. In an interview on 01/04/2024 at 03:36 p.m. Nursing Schedular E explained that she post the scheduled nursing hours daily. She explained that she does not post the actual nursing hours used for the past shifts. In an interview on 01/04/2024 at 03:38 p.m. Nursing Home Administrator (NHA) A explained that the facility does not post the actual nursing hours used for the past shifts. She explained…

    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

“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 TRILOGY HEALTH SERVICES — 123 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 54.2+0.8 vs chain
Health inspection 4 of 53.5+0.5 vs chain
Staffing 5 of 53.3+1.7 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 122 homes this chain runs (chain average 4.2★, per CMS)
1 of 5Heritage TheFindlay, OH 1 of 5The Oaks Rehabilitation and Healthcare CenterZanesville, OH 2 of 5Homewood Health CampusLebanon, IN 2 of 5Violet Springs Health CampusPickerington, OH 2 of 5Woodmont Health CampusBoonville, IN 3 of 5Cobblestone Crossings Health CampusTerre Haute, IN 3 of 5Creasy Springs Health CampusLafayette, IN 3 of 5Cumberland Pointe Health CampusWest Lafayette, IN 3 of 5Forest Park Health CampusRichmond, IN 3 of 5Franciscan Health Care CenterLouisville, KY 3 of 5Greenleaf Health CampusElkhart, IN 3 of 5River Terrace Health CampusMadison, IN 3 of 5Scenic Hills At The MonasteryFerdinand, IN 3 of 5Smiths Mill Health CampusNew Albany, OH 3 of 5Springhurst Health CampusGreenfield, IN 3 of 5Springs Of Richmond, TheRichmond, IN 3 of 5St Mary Healthcare CenterLafayette, IN 3 of 5Stonegate Health CampusLapeer, MI 3 of 5Sun Prairie Senior LivingSun Prairie, WI 3 of 5Taylor Springs Health CampusGahanna, OH 3 of 5The Willows at Fritz FarmLexington, KY 3 of 5The Willows at HamburgLexington, KY 3 of 5The Willows at HarrodsburgHarrodsburg, KY 3 of 5The Willows at SpringhurstLouisville, KY 3 of 5Villages At Oak Ridge, TheWashington, IN 3 of 5Waunakee Valley Senior LivingWaunakee, WI 3 of 5Wellbrooke Of CarmelCarmel, IN 4 of 5Arlington Place Health CampusIndianapolis, IN 4 of 5Ashford Place Health CampusShelbyville, IN 4 of 5Aspen Place Health CampusGreensburg, IN 4 of 5Avalon Springs Health CampusValparaiso, IN 4 of 5Bethany Pointe Health CampusAnderson, IN 4 of 5Blair Ridge Health CampusPeru, IN 4 of 5Bridgepointe Health CampusVincennes, IN 4 of 5Cedar Creek Health CampusLowell, IN 4 of 5Clearvista Lake Health CampusIndianapolis, IN 4 of 5Forest Springs Health CampusLouisville, KY 4 of 5Glen Oaks Health CampusNew Castle, IN 4 of 5Glen Ridge Health CampusLouisville, KY 4 of 5Meadows Of Delphos TheDelphos, OH

Showing 40 of 122; 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
CONTINENTAL MERGER SUB LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
NORTHSTAR HEALTHCARE INCOME INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
NORTHSTAR HEALTHCARE INCOME OPERATING PARTNERSHIP LPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
TRILOGY HOLDINGS NT-HCI, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 10/01/2021
KEYBANK NATIONAL ASSOCIATIONOrganization5% OR GREATER MORTGAGE INTERESTsince 08/01/2018
CORBIN, KATHYIndividualW-2 MANAGING EMPLOYEEsince 01/11/2011
FIGHTMASTER, LISAIndividualW-2 MANAGING EMPLOYEEsince 12/01/2015
BARNEY, LEIGHIndividualCORPORATE OFFICERsince 11/01/2019
BRYANT, WILLIAMIndividualCORPORATE OFFICERsince 01/05/2016
BUFFORD, RANDALLIndividualCORPORATE OFFICERsince 11/01/2019
CONNER, GREGORYIndividualCORPORATE OFFICERsince 06/03/2021
DAVIS, DAVIDIndividualCORPORATE OFFICERsince 08/21/2017
PROSKY, DANNYIndividualCORPORATE OFFICERsince 12/01/2015
STREIFF, MATHIEUIndividualCORPORATE OFFICERsince 12/01/2015
TRILOGY MANAGEMENT SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2021
ERMIGER, JOSEPHIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/07/2020

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$10.9M
Net patient revenuemost recent cost report
+7.9%
Operating marginrevenue minus expenses
$1.5M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 42%Medicare 7%Other / private 51%

This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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
$10,726per month
≈ monthly operating cost
$383per 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 235701. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-16, 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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