Oakland Manor Nursing and Rehabilitation Center LL
50 N Perry St, 1st Floor, Pontiac, MI 48342 · For profit - Corporation · 29 certified beds · (248) 221-5300 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0602), cited May 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (64%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 81.2% | 79.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.6% | 24.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.6% | 11.7% | 12.0% | better |
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.
Met the expected recovery: 41.7% 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 24 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 1.07 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 69% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 41.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 45.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 54.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 93.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | 85.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 29 beds and averages 17.0 residents a day — about 59% occupied, or roughly 12 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 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 4.64 hrs/resident/day on weekends vs 4.57 on weekdays — about the same on weekends as weekdays. RN hours go from 0.39 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 64% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.
- Potential for harm · D2026-05-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation relates to Intake #3010953 Based on interview and record review, the facility failed to protect the resident's right to a safe, homelike environment by not properly inventorying and securing their valuables for one Resident (R803) of one resident reviewed. Findings include: Review of an intake received by the State Agency on 4/29/26 revealed: Resident (R803) reported to The Director of Nursing (DON)) that his golden chain with a cross and two rings were missing. (R803) stated that while he was playing (Name of card game) with the Activities Director (Staff E), she took his chain off of his neck, and stated that she had to use the bathroom, and would be right back. When she came back, (R803) stated that he requested for his chain but (Staff E) claimed that she did not have it. (R803) insisted that (Staff E) give him back his jewelry, but she maintained that she did not have it. The (Nursing Home) Administrator (NHA) received a call from The Director of Nursing (DON) reporting the incident. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-05 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 relates to Intake #3010953 Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from misappropriation for one Resident (R803) of four residents reviewed for abuse. Findings include: Review of an intake received by the State Agency on 4/29/26 revealed: Resident (R803) reported to The Director of Nursing (DON)) that his golden chain with a cross and two rings were missing. (R803) stated that while he was playing (Name of card game) with the Activities Director (Staff E), she took his chain off of his neck, and stated that she had to use the bathroom, and would be right back. When she came back, (R803) stated that he requested for his chain but (Staff E) claimed that she did not have it. (R803) insisted that (Staff E) give him back his jewelry, but she maintained that she did not have it. The (Nursing Home) Administrator (NHA) received a call from The Director of Nursing (DON) reporting the incident. The administrator (NHA) initiated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-05 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation relates to Intake 3010953. Based on interview and record review, the facility failed to report an allegation of misappropriation timely for one Resident (R803) of four residents reviewed for abuse. Findings include:Review of an intake received by the State Agency on 4/29/26 revealed: Resident (R803) reported to The Director of Nursing (DON)) that his golden chain with a cross and two rings were missing. (R803) stated that while he was playing (Name of card game) with the Activities Director (Staff E), she took his chain off of his neck, and stated that she had to use the bathroom, and would be right back. When she came back, (R803) stated that he requested for his chain but (Staff E) claimed that she did not have it. (R803) insisted that (Staff E) give him back his jewelry, but she maintained that she did not have it. The (Nursing Home) Administrator (NHA) received a call from The Director of Nursing (DON) reporting the incident. The administrator (NHA) initiated the investigation as it relates to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation relates to Intake 2731788. Based on interview and record review, the facility failed to ensure appropriate documentation for skin and wound treatment for one Resident (R802) of two residents reviewed for skin and wounds. Findings include: A complaint received by the State Agency on 2/02/26 revealed: Complainant states the resident (R802) has developed deep bedsores on her buttocks that staff have to pack. The complainant states he hasn't seen the sores, but his wife said they were deep. The complainant states on an unknown date, an unknown female nurse applied menthol to the resident's buttocks which made her cry in pain. Complainant states the resident is left in a urine-soaked brief for up to 8 hours before being changed. Review of R802's census revealed they were admitted to the facility on [DATE] and were discharged [DATE].Review of R802's profile revealed they were their own responsible party. Review of R802's Minimum Data Set (MDS) assessment revealed they were admitted with diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-01-28 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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 — the official record, unedited, may be distressing
Based on observations, interviews, record review the facility failed to ensure medication and treatment supplies were secured to prevent unauthorized access, as evidence by an unlocked treatment cart accessible in-patient care area. Findings include:On 1/26/26 at 8:44 AM, the facility medication treatment cart was observed unlocked and unsecured across from the nurse's station. On 1/26/26 at 9:18 AM, the medication treatment cart was observed unlocked. Nurse E was interviewed and asked should the treatment cart be locked, Nurse E reported yes and proceeded to lock the cart. On 1/26/26 at 1:32 PM, the facility's medication treatment cart was observed unlocked and unsecured across from the nurse's station. On 1/27/26 at 8:21 AM, the facility's medication treatment cart was observed unlocked and unsecured across from the nurse's station. On 1/27/26 at 12:03 PM, the director of nursing (DON), was interviewed and asked should treatment carts be locked when unattended the DON reported the carts should be locked. There was no additional information provided at the exit of survey.
- Potential for harm · E2026-01-28 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an ongoing resident-centered activities program to provide meaningful activities per resident preferences to support their physical, emotional, cognitive, and psychosocial well-being for five residents (R6, R9, R10, R15 and R30) of five residents reviewed for activities. Findings include:Review of the resident census upon survey entry was 21 residents, confirmed by the Nursing Home Administrator (NHA) / Director of Nursing (DON), who assumed both roles upon hire, on/ near 1/09/26. On 1/26/26 at approximately 10:05 a.m., the NHA/DON described upon entry that the facility was a sub-acute short-stay rehabilitation unit (facility). It was clarified there were only two long-term care residents at the facility, R2 and R3, who would mainly require activities. When asked about resident council, the NHA/DON explained they had no resident council president, as there were no resident council meetings in the facility. This Surveyor asked to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-01-28 · tag F0680 — patternEnsure the activities program is directed by a qualified professional.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure there was a qualified activity professional who directed and oversaw an ongoing activity program to ensure meaningful activities were provided consistently per resident preferences for four Residents (R6, R9, R10, and R15) of four residents reviewed. Findings include: Review of the resident census upon survey entry was 21 residents, confirmed by the Nursing Home Administrator (NHA) / Director of Nursing (DON), who assumed both roles upon date of hire, on/near 1/09/26. On 1/26/26 at approximately 10:05 a.m., the NHA/DON described upon entry that the facility was a sub-acute short-stay rehabilitation unit (facility). It was clarified there were only two long-term care residents at the facility, who would mainly require activities. When asked about resident council, the NHA/DON explained they had no resident council president, as there were no resident council meetings in the facility. This Surveyor asked to speak with the Activity Director for clarification on the resident council process. The NHA/DON reported they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-28 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of 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 an appropriate Geri-chair [reclining chair with wheels] for two (R3 and R30) of two residents reviewed for accommodation of needs. Findings include:R3On 1/26/26 at 9:01 AM, R3 was observed lying in bed. R3 was asked if she was able to get out of bed. R3 explained she wanted to get out of the bed, but she had not been up in a long time. R3 was asked if she used a wheelchair. R3 explained they would bring in a reclining chair and put her in that, but it had been a long time since she had seen it. No wheelchair or geri-chair were observed in R3's room.On 1/26/26 at 12:52 PM, R3 was observed sitting in a tan colored geri-chair in her room. R3 explained with a smile that it was the first time she had been up in a long time and she was happy. Review of the clinical record revealed R3 was admitted into the facility o 7/31/25 with diagnoses that included: metabolic encephalopathy, muscle weakness and need for assistance with personal care.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-28 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the Minimum Data Assessment (MDS) discharge assessment for one Resident (R7) of one resident reviewed for resident assessments. Findings include:Review of the recertification survey documentation software in the triggered task, Resident Assessment, revealed R7 was admitted to the facility on [DATE], and their MDS record was over [AGE] years old (had not been completed).Review of R7's resident census in the Electronic Medical Record (EMR) revealed R7 was admitted to the facility on [DATE] on a Skilled Level of Care and was discharged on 9/16/25.Review of R7's nursing Discharge summary, dated [DATE], closed on 9/18/25 by the MDS nurse, Registered Nurse (RN) C , revealed R7 was discharged from the facility on 9/16/25 with an AMA (Against Medical Advice) status, and had been admitted on [DATE] for therapy.Review of R7's MDS assessment page on 1/28/26 at 1:21 p.m., with RN C , revealed there was no MDS discharge assessment.On 1/28/26 at 1:23 p.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-28 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an accurate, consistent description and assessment of a wound for one Resident (R15) of one resident reviewed for skin management/ wound care, per best practice standards. Findings include:On 1/26/26 at 1:28 p.m., R15 was observed seated in a high-back wheelchair outside their room. A thin gel wheelchair cushion was underneath them in their wheelchair.On 1/26/26 at 1:29 p.m., R15's bed was observed. There was a standard mattress on their bed.Review of R15's Minimum Data Set (MDS) assessment, dated 1/15/26, showed they were admitted to the facility on [DATE] with diagnoses including dementia, arteriosclerotic heart disease, and kidney disease. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 4/15, which showed R15 had cognitive impairment. The assessment revealed that R15 was incontinent of bowel and bladder. Review of R15's Care Plan (CP), accessed 1/27/26, revealed, Problem: I have a pressure ulcer: due…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 11 citations
- Potential for harm · D2026-01-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure wound care was implemented per physician orders, as evidence by missed and incomplete wound care treatments for one(R2) of three residents reviewed for wound care. Placing the resident at risk for infection, delayed wound healing and further skin break down. Findings include: On 1/26/26 at 9:30 AM, R2 was observed lying in the bed with a green wedge placed under their left side. R2, was then interviewed about their stay at the facility but the conversation was not coherent due the resident having a Brief interview for mental status(BIMs) score of 7 which indicated severe cognitive impairment. A review of the record revealed that, R2 was admitted to the facility on [DATE] with the admitting diagnosis of metabolic encephalopathy, Pressure Ulcer of the sacral region, unstageable and muscle weakness. A further review of the record revealed that on 1/16/26, R2 was seen by wound care, the consult report stated, Resident has two new wounds…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one Resident (R15) of one resident reviewed for accidents/falls had their fall interventions implemented after two falls out of bed. Findings include:On 1/26/26 at 1:28 p.m., R15 was observed seated in a high-back wheelchair outside their room. R15 was seated on a thin gel wheelchair cushion in their wheelchair.Review of R15's Minimum Data Set (MDS) assessment, dated 1/15/26, showed they were admitted to the facility on [DATE]. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 4/15, which showed R15 had cognitive impairment. Review of R15's profile revealed they had diagnoses including metabolic encephalopathy (brain dysfunction from metabolic causes), dementia, heart disease, kidney disease, a fall with a fractured clavicle, and a history of bilateral (both) hip replacements.Review of R15's Fall Care Plan, accessed 1/27/26, dated 1/10/26, revealed, Problem: I am at risk for falling r/t (related to):…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-28 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain physician orders for care and monitoring of a peripherally inserted central catheter [PICC] for one (R19) of one resident reviewed for PICC lines. Findings include:On 1/26/26 at 8:56 AM, R19 was observed walking from his bathroom to his bed. An intravenous [IV] pole with an IV bag and tubing was observed next to the bed. R19 was asked if he was receiving IV medication while at the facility. R19 explained he was receiving antibiotics through is PICC line. R19 was asked how often the facility changed the dressing on his PICC line. R19 explained he was not sure if they had changed the dressing. Observation of the PICC line dressing on R19's right upper arm revealed a dressing held on with tape at the top and bottom and faintly dated either 1/12/26 or 1/22/26.Review of the clinical record revealed R19 was admitted into the facility on 1/9/26 and readmitted [DATE] with diagnoses that included: osteomyelitis of vertebra, heart disease and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-28 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop 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 observations, interview and record review, the facility failed to provide administration of the Influenza vaccine for one (R6) of five residents reviewed for immunizations. Findings include:Review of the clinical record revealed R6 was admitted into the facility on [DATE] with diagnoses that included: stroke, heart failure and diabetes.Review of R6's Preventive Health Care tab revealed on 12/23/25 documentation of R6 having received Pneumococcal, RSV [respiratory syncytial virus] and COVID-19 vaccines previous to admission to the facility. There was no documentation of the Influenza vaccine.On 1/27/26 at 3:21 PM, the Administrator, who was also serving as the Director of Nursing [DON] and Infection Preventionist, was asked to provide documentation of R6's consent or declination form for the Influenza vaccine.Review of a Resident - Vaccine Consent form, signed by R6 and dated 12/23/25 revealed a check mark in the Accept circle for the FLU Vaccine.On 1/27/26 at 4:05 PM, R6 was observed sitting in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-10-30 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to maintain a pest free environment. This deficient practice had the potential to affect all residents in the facility. Findings include: On 10/29/24 at 9:00 AM, during a tour of the kitchen serving area with Dietary Manager G, there was standing water and cobwebs observed in the corner under the steam table. Several gnats were observed near the standing water and flying about the kitchen area. When queried, Dietary Manager G stated the water was from filling the wells of the steam table. No explanation was provided for the gnats observed in the kitchen area. On 10/29/24 at 9:20 AM, several gnats were observed flying about in the hallway near the resident rooms. According to the 2017 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .4. (D) Eliminating harborage conditions.
- Potential for harm · D2024-10-30 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 notify, in writing, the reason for a discharge out of the facility to a representative of the State Long term Care Ombudsman for two Residents (R15 and R17) of two residents reviewed for discharge. Findings include: Resident #15 (R15) Review of the Minimum Data Set (MDS) assessment, dated 7/31/24, revealed R15 was admitted to the facility on [DATE] and discharged from the facility on 7/31/24. Review of facility report of discharges for month of July 2024 did not reveal R15 on the discharge report sent to the Ombudsman. Resident #17 (R17) Review of the MDS assessment, dated 9/2/24, revealed R17 was admitted to the facility on [DATE] and discharged from the facility on 9/2/24. Review of facility report of discharges for the month of September 2024 did not reveal R17 on the discharge report sent to the Ombudsman. During an interview on 10/30/24 at approximately 12:55 p.m., Social Worker C stated, R17 is not on the list for the ombudsman and should be.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification of the bed hold policy to resident or their representative prior to hospital transfer for one Resident (R17) of two residents reviewed for hospitalization, resulting in the potential of resident and/or resident representative being uninformed of the bed hold policy. Findings include: Resident #17 (R17) Review of the Minimum Data Set (MDS) assessment, dated 9/2/24, revealed R17 was admitted to the facility on [DATE] and discharged from the facility to the hospital on 9/2/24. During an interview on 10/30/24 Social Worker C stated, I don't know that I have a bed hold policy that was given to the resident or resident representative .it was not given to them, and I don't know what to tell you it just wasn't done .it was not given to R17 upon discharge. Review of facility policy titled Bed Hold Notice Upon Transfer last reviewed/revised 3/13/24, read in part . At the time of transfer for hospitalization .the facility will provide…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 discharge summary for one Resident (R17) of two residents reviewed for discharge from the facility. This deficient practice resulted in the potential for compromised continuity of care. Findings include: Resident #17 (R17) Review of the MDS (minimum data set) assessment, dated 9/2/24, revealed R17 was admitted to the facility on [DATE] and discharged from the facility on 9/2/24. A Review of R17's Electronic Medical Record (EMR) revealed no discharge summary or recapitulation of stay was present in the record. Review of facility policy titled Discharge Summary date implemented 11/1/22, read in part . It is the policy of this facility to ensure that a discharge summary is provided upon a residents discharge .the discharge summary provides necessary information to continuing care providers pertaining to the residents course of treatment while the resident was in the facility and the residents plan of care after discharge .It must include an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents received assistance with showering for one Resident #13 (R13) of one resident reviewed for ADL (activities of daily living) care, resulting in the potential for embarrassment, frustration, and unmet care needs. Findings include: Resident #13 (R13) Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 9/20/24, with active diagnoses that included: diabetes mellitus, hypertension, and arthritis. R13 scored a 13 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of intact cognition. Further review of MDS assessment revealed the resident needed substantial/maximal assistance for showers/bathing. During an interview on 10/29/24 at 10:51 a.m., R13 stated, I have only had one shower since being here .I got a shower last month and I look forward to getting a shower this month. Review of the Electronic Medical Record (EMR) revealed that R13 had one shower since admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure weekly weights were completed for one Resident #4 (R4) of one resident reviewed for nutritional needs. This deficient practice resulted in the potential for missed weight fluctuations. Findings include: Resident #4 (R4) Review of R4's Minimum Data Set (MDS) assessment, dated 10/7/24 revealed admission to the facility on [DATE], with active diagnoses that included: diabetes mellitus, malnutrition, anxiety disorder, and depression. R4 scored a 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. During an interview on 10/29/24 at 1:03 p.m., R4 stated I don't get enough food or snacks. I have lost weight since being here . I have been weighing myself by the Activity room and have lost several pounds . I have told the staff, but they did not believe me and told me you have not lost weight. Review of R4's Electronic Medical Record (EMR) revealed a Doctors order for weekly weights, R4 had an admission weight, and no…
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.
- No harm found · C2024-10-30 · tag F0732 — widespreadPost 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 required nurse staffing information resulting in the inability of residents to determine the number of staff available to provide resident care and had the potential to affect all 14 residents in the facility. Findings include: During an observation on 10/29/24 at approximately 8:15 a.m., the daily nursing staffing sheet for 10/28/24 was located near the entrance to the wing of the facility where residents did not have direct access to the required nurse staffing information. During an observation on 10/30/24 at approximately 1:55 p.m., the daily nurse staffing sheet was not located or available for the residents to review. During an interview on 10/30/24 at 2:03 p.m., the RN/MDS (Registered Nurse/Minimum Data Set) A stated, there is not a nursing staffing sheet located for the residents to view. During an interview on 10/30/24 at 2:15 p.m., the Certified Nurse Assistant B acknowledged that the residents do not go out by the entrance to the wing of the facility and stated, The residents don't go out…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to PIONEER HEALTHCARE MANAGEMENT — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.3 | +0.7 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 3 of 5 | 3.0 | ≈ chain avg |
| Quality measures | 3 of 5 | 2.9 | +0.1 vs chain |
The other 8 homes this chain runs (chain average 2.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| UDDIN, FAHIM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/25/2013 |
| MATHIS-SMITH, LAVETTE | Individual | W-2 MANAGING EMPLOYEE | — | since 03/01/2022 |
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $15K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235703. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-28, 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.