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Medilodge of Portage

7855 Currier Dr, Portage, MI 49002 · For profit - Limited Liability company · 117 certified beds · (269) 323-7748 Medicare & Medicaid certified

Call the home — (269) 323-7748 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 2025Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0758)4 actual-harm citations$35,317 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2025
  • 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
  • it has a citation for mishandling residents’ money or property (F0565)
  • it has 4 actual-harm citations
  • a high number of inspection citations overall (36) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $35,317 in federal fines (most recent 2024-02-29)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
7895 Currier Dr · (269) 321-7090 · Call to confirm hours
Pharmacy
7920 Shaver Rd · (269) 324-9988 · Call to confirm hours
Grocery
7634 S Westnedge Ave · (269) 978-6641 · Call to confirm hours
Park
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 improved from 2 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.

Overall rating3★
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 increased11.1%10.8%15.4%better
Long-stay residents who lose too much weight6.0%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.8%0.9%better
Long-stay residents with a urinary tract infection1.1%1.5%2.0%better
Long-stay residents with depressive symptoms1.7%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 injury0.5%3.0%3.3%better
Long-stay residents whose ability to walk worsened10.3%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.2%19.4%18.9%worse
Long-stay residents given the seasonal flu vaccine93.1%95.0%95.3%typical
Long-stay residents with pressure ulcers6.7%5.1%4.7%worse
Long-stay residents with worsening bladder/bowel control21.0%20.0%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table6.6%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine84.7%79.5%79.4%typical
Short-stay residents rehospitalized after admission22.0%24.0%22.6%typical
Short-stay residents with an outpatient ER visit2.6%11.7%12.0%better
Long-stay hospitalizations per 1,000 resident days2.111.841.67worse
Long-stay outpatient ER visits per 1,000 resident days1.431.641.80better

§ 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.

53.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 86 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.3%U.S. median 51.5%
Got home and stayed home
13.0%U.S. median 10.7%
Went back to hospital
63.6%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 63.6% 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 44 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 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 33% 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 SNF53.3%CMS range 44.6–61.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.0%CMS range 8.6–18.910.7%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 discharge63.6%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 discharge61.4%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 discharge52.3%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 identified98.5%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 setting90.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay1.5%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 hospitalization7.6%CMS range 4.2–15.27.1%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

1.08
RN hours/ resident / day
0.45
LPN hours/ resident / day
2.10
Aide hours/ resident / day
3.63
Total nurse hours/ resident / day
0.66
RN hoursweekends
44.8%
Total nursing turnover
34.6%
RN turnover

How full it usually is: this home is certified for 117 beds and averages 106.2 residents a day — about 91% occupied, or roughly 11 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 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.08 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 2.87 hrs/resident/day on weekends vs 3.94 on weekdays — 27% thinner on weekends — a notable drop. RN hours go from 1.25 to 0.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

9
deficiencies at the latest standard inspection (2026-05-14)
5
at the previous standard inspection (2025-04-09)

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.

36 citations, most serious first. The 14 most serious are shown; the remaining 22 are one tap away and print in full.

  • Actual harm · Gcited before2026-05-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #2968884, #3004071, and #3000720Based on observation, interview and record review the facility failed to ensure resident received appropriate care for skin breakdown and pressure ulcer development in 2 of 3 residents (Resident #119 and Resident #5) reviewed for pressure ulcers, resulting in Resident #119 developing a pressure ulcer infection and Resident #5 developing pressure ulcers.Findings include:Resident #119 Review of a Face Sheet revealed Resident #119 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: pressure ulcer of the sacral region (the lower part of the back, base of the spine just above the buttock) stage 4 (most severe form of the pressure ulcer, characterized by a deep, open wound that extends through the skin, underlying tissue, muscle, and bone), sepsis (a life-threatening condition caused by the body's extreme response to an infection), and paraplegia (paralysis of the legs and lower body). In an interview…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2026-01-15 · 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 #2709386.Based on observation, interview, and record review, the facility failed to provide adequate supervision with hot liquids for 1 resident (Resident #101) of 5 residents reviewed for accidents and safety resulting in Resident #101 receiving a second degree burn (causes pain and damages the outer and second layer of the skin) on her left arm on 12/27/2025 and a burn on her left hand on 12/30/2025 and the fear of receiving another burn. Findings include:Resident #101 (R101)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R101 originally admitted to the facility on [DATE] with pertinent diagnoses including nontraumatic intracerebral hemorrhage (serious stroke where bleeding occurs inside the brain), flaccid (lacking firmness, strength or stiffness; limp and flabby) hemiplegia (paralysis of one side) affecting left dominant side, chronic pain and depression. Brief Interview for Mental Status (BIMS) on 1/12/2026 reflected a score of 13 out of 15…

    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
  • Actual harm · Gcited before2024-02-29 · 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 has two Deficient Practice Statements (DPS). DPS 1 Based on observation, interview, and record review, the facility failed to ensure a safe environment and adequate safety measures for one resident (R9) of 22 residents reviewed for accidents and hazards, resulting in a fall with injury and the potential of additional falls with injuries. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R9 scored 2/15 on her BIMS (Brief Interview Mental Status) indicating the resident was severely cognitively impaired, experienced bowel/bladder incontinence. The resident had no impairment in her arms or legs, high-risk medications included antianxiety, antidepressant and sedative medications. Section J1900- two or more falls since admission. Review of R9's Diagnoses included dementia, diastolic congestive heart failure, hypertension, anxiety, major depressive disorder recurrent mild, urinary tract infection (1/15/2024), repeated falls (1/9/2024), pain in left leg, developmental disorders 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
  • Actual harm · Gcited before2023-12-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 accurately assess a resident's skin integrity, and update interventions to prevent the development and worsening of a medical device related pressure ulcers for 1 (Resident #100) of 4 residents reviewed for pressure wounds, resulting in Resident #100 developing unstageable/non-healing pressure ulcers after a cast like boot (for leg fracture) had not been removed for assessment of skin integrity by nursing staff in accordance with physicians orders. Findings include: Review of an admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic respiratory failure. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 11/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #100 was cognitively intact. Further review of Resident #100's MDS assessment revealed Resident #100 was a 2 person…

    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 before2026-05-14 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # 2790303 & 2968884.Based on interview, and record review, the facility failed to ensure timely response to call lights to meet resident needs in 4 of 5 residents (Resident #8, #14, #58, & #119) reviewed for dignity, and 6 of 13 residents from the confidential group interview, resulting in long call light wait times for incontinence care, frustration, and impaired self-worth.Findings include:Resident #8 Review of a Face Sheet revealed Resident #8 was a female, with pertinent diagnoses which included heart failure, obstructive lung disease, morbid obesity, diabetes, high blood pressure, depression, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 3/6/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a total possible score of 15, indicating she was cognitively intact. Further review revealed Resident #8 was always incontinent of bowel and bladder. In an interview on 5/12/26 at 9:49 AM, Resident #8 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1.) ensure the safety of residents to prevent falls, 2) provide adequate supervision and assistance to prevent falls, and 3.) utilize footrests for wheelchair transport in 3 of 3 residents (Resident #40, #26, and #95) reviewed for accidents and hazards, resulting in Resident #40 having 22 falls over 2 months, Resident #40 and #95 being transferred without wheelchair footrests, and Resident #26 being improperly transferred. This deficient practice placed all 3 residents at risk for injury.Findings include: Resident #40: Review of an admission Record revealed Resident #40 was a male with pertinent diagnoses which included Alzheimer's disease, history of falling, dementia, insomnia, and kidney disease stage 3. Review of the medical record reviewed Resident #40 had 22 falls in two months between 3/11/26 and 5/12/26. Most of the falls indicated the root cause was the resident self-transferred and frequently needed toileting. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-14 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    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 observation and interview, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living.Findings Include:On 5/12/26 at 11:01 AM, observation of the D hall closet containing resident slings, found that the slings were hung up by one side on the hangers and left to drag onto the floor. When asked if this is how the slings are normally kept, Housekeeping Manager M stated that it happens all the time and that staff need to hang both sides of the sling up to keep it off the floor. On 5/13/26 at 9:47 AM, observation of the love seat and chair, located on the far side of the dining room, were found with increased accumulation of debris, sand, wrappers, paper trash and a yellow push pin. Further review of the chair found a sheet of paper with resident's names and rooms numbers for the D hall and an intact plastic vile of Albuterol Sulfate. On 5/13/26 at 10:15 AM, an interview with Housekeeping Manager M found that the furniture in the dining…

    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 · D2026-05-14 · tag F0679 — failed to provide activities — isolated
    Provide 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 provide individualized activities designed to support the psychosocial well-being of 1 of 1 resident (R65) reviewed for activities, resulting in a potential for feelings of social isolation, loneliness, boredom, and depressed mood.Findings include:Review of R65's Minimum Data Set (MDS) dated [DATE], revealed the resident was unable to complete the BIMS (Brief Interview Mental Status) with a score of 99. Section B- Hearing, Speech, and Vision, stated R65 was absent of spoken words and rarely/never understood. Section GG-Functional Abilities revealed R65 was dependent on staff to provide ADLs (activities of daily living) including positioning and sensory stimulation. Section I-Active Diagnoses indicated R65's active diagnoses included stroke and traumatic brain injury.Review of R65's Care Plan, At Risk for Altered Activity Patterns/Pursuits related to cerebral infarction was dated 9/22/2023. The goal for the resident was revised 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 · Dcited before2026-05-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure a urinary catheter (tube placed in the body to drain and collect urine from the bladder) was maintained in a sanitary manner for 1 (Resident #122) of 2 residents reviewed for urinary catheters, resulting in the urinary catheter bag lying on the floor creating an opportunity for contamination and the potential for urinary tract infection. Findings include: Review of a current Care Plan for Resident #122 reflected a need for an indwelling catheter related to urine retention with interventions to change catheter and drainage system as clinically indicated per order(s). Observe for signs/symptoms of obstruction (leakage, increased sediment, etc.), infection, or if closed system was compromised.Irrigate foley catheter as indicated .Maintain drainage bag below the bladder level .Privacy cover to catheter drainage bag. During an observation on 05/12/2026 at 10:12 AM, outside of Resident #122's door was a sign for enhanced barrier precautions (EBP). Resident #122 was observed seated in his wheelchair located in…

    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 · D2026-05-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received oxygen as ordered in 1 resident of 1 resident (R9) reviewed for oxygen administration, resulting in the potential of respiratory health complications including exacerbation of COPD (chronic obstructive pulmonary disease) and/or retention of carbon dioxide (gas produced by cellular respiration in humans).Findings include:According to R9's Minimum Data Set (MDS) dated [DATE], she was cognitively impaired indicated by a BIMS (Brief Interview Mental Status) score of 8/15. Section GG-Functional Abilities indicated R9 was dependent on staff for transferring and mobility. Section I-Active Diagnoses stated debility due to cardiorespiratory conditions that included heart failure, respiratory failure with hypercapnia, Section O-indicated R9 used oxygen therapy continuously while a resident in the facility. Review of R9's Order Summary dated 3/29/2023, indicated oxygen rate was ordered to run at 2.5 lpm (liters per minute…

    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 · D2026-05-14 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to (1) ensure medications labeled/dated for 1 resident of 1 resident (R84) reviewed for medication labeling/dating, (2) ensure medications were stored in a secure manner in 2 of 2 treatment carts and 1 medication room/refrigerator (A Hall), resulting in the potential for residents to receive expired medications with altered potency and decreased efficacy, and residents, visitors, and/or staff access the medications, including narcotics, in the facility. Findings include: According to R84's Minimum Data Set (MDS) dated [DATE], the resident's BIMS (Brief Interview Mental Status) was 13/15 (cognitively intact). Section I-Active Diagnoses stated medically complex conditions including heart failure, arthritis (painful joints), non-Alzheimer's dementia (loss of memory), and bipolar disorder (recurring shifts in mood). During an observation, interview, and record review on 5/12/26 at 11:04 AM, R84 was awake in her bed. On a dresser next to R84's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · 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 ensure accurate medical records for 1 (Resident #77) of 21 residents reviewed for accurate medical records, resulting in an inaccurate representation of Resident #77's current care needs and the potential for unmet care needs.Findings include:Resident #77Review of a Face Sheet revealed Resident #77 was a female who originally admitted to the facility on [DATE] and had pertinent diagnosis which included: syndrome of inappropriate secretion of antidiuretic hormone (SIADH- a condition in which excessive antidiuretic hormone causes water retention and low blood sodium).Review of a Minimum Data Set (MDS) assessment for Resident #77, with a reference date of 4/25/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #77 was cognitively intact.On 5/12/26 at 9:15 AM, Resident #77 was in her room, sitting at the bedside, with her breakfast tray in front of her. Noted on the meal tray ticket present 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-15 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 pertains to intake #2709386.Based on observation, interview and record review, the facility failed to report an incident of neglect (a hot liquid burn) for 1 resident (Resident #101) of 5 residents reviewed for accidents/safety when Resident #101 did not have appropriate interventions in place based on an assessment related to hot liquid spills and did not receive the help she needed resulting in a second burn causing Resident #101 pain, distress and fear of getting burned again. Findings include:Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R101 originally admitted to the facility on [DATE] with pertinent diagnoses including nontraumatic intracerebral hemorrhage (serious stroke where bleeding occurs inside the brain and flaccid (lacking firmness, strength or stiffness; limp and flabby) hemiplegia (paralysis of one side) affecting left dominant side. Brief Interview for Mental Status (BIMS) on 1/12/2026 reflected a score of 13 out of 15 which indicated R101…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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: 2575789, 2567564Based on interview and record review, the facility failed to prevent resident to resident sexual abuse in 1 of 3 sampled residents (Resident #102) reviewed for abuse, resulting in the potential for a decline in mental and psychosocial well-being.Findings include: Resident #102: Review of an admission Record revealed Resident #102 was a female with pertinent diagnoses which included major depressive disorder, reduced mobility, hemiplegia and hemiparesis (paralysis) following cerebral infarction affecting left non dominant side, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 6/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #102 was cognitively intact. Review of current Care Plan for Resident #102, revised on 3/19/2025, revealed the focus, .Resident has an impaired mood/psychiatric status related to major depressive do (disorder), anxiety. Has depression…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 22 citations
  • Potential for harm · Dcited before2025-08-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure that a urinary drainage bag was not resting on the floor to prevent the risk of urinary tract infection for 1 (Resident #101) of 3 residents reviewed for urinary catheter use, resulting in the potential for infection. Findings include:A urinary catheter is a tube placed in the body to drain and collect urine from the bladder .An indwelling catheter collects urine by attaching it to a drainage bag. The bag has a valve that can be opened to allow urine to flow out. Some of these bags can be secured to your leg. This allows you to wear the bag under your clothes. An indwelling catheter may be inserted into the bladder in 2 ways: Most often, the catheter is inserted through the urethra. This is the tube that carries urine from the bladder to the outside of the body. Sometimes, the provider will insert a catheter into your bladder through a small hole in your belly. This is done at a hospital or provider's office . A catheter is most often attached to a drainage bag. Keep the drainage bag lower than your…

    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 · F2025-04-09 · 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 observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During the initial tour of the kitchen, at 10:10 AM on 4/7/25, it was observed that the kitchens only hand sink was being blocked by a large dietary cart full of dirty dishes from breakfast. With no other hand sink in the kitchen, the cart had to be repositioned and moved over so that the hand sink could be accessible. An interview with Regional Dietitian VV found that facility staff have thought about adding another hand sink in the kitchen but are not sure of the best location. An interview with Maintenance Director Z, at 11:20 AM on 4/7/25, found that the original location suggested for an additional hand sink was too close to an electrical panel. When asked about adding a sink between the cook line and the three compartment sink, Maintenance Director Z stated one could…

    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 · E2025-04-09 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    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 that grievances were promptly documented, investigated and resolved for 9 of 9 residents that participated in the Resident Council (RC) meeting. Findings include: Review of RC minutes dated 3/14/25 revealed old business included a concern that call lights on 3 rd shift were not answered timely and light turned off before need was met and that water was not passed consistently. The section of Actions taken was left blank. RC minutes dated 2/7/25 RC revealed old business that call light response time on 3rd shift slow to respond, and water pass was not consistent. New business identified concerns of 1. Call light on 3rd shift long wait time. 2. Turning off call light before addressing issues. 3. Ice water not passed out consistently Action taken changing hours to support third shift RC minutes dated 1/10/25 reflected under old business that call light response time was ongoing actions taken section of the minutes was left blank. New Business concerns were 1. Water not passed consistently 2. Call light response time 3rd…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-09 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY During the RC meeting on 4/8/25 at 10:00 am, 9 of the 9 participants reported the food was always , always cold with overcooked vegetables that were mushy. The RC participants reported items were missing of trays at every meal either a tea bag, salad, bread, dessert, food requests/preferences not honored. RC participants stated the facility had food committee in place, but all 9 RC participants unanimously agreed there had been no improvement. Resident 91 Review of the clinical record including the Minimum Data Set (MDS) dated [DATE], reflected Resident 91 (R91) was admitted to the facility with diagnoses that included sepsis due to escherichia Coli (E. Coli). R91 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 04/07/25 at 02:27 PM during an interview R91 reported food was terrible, had no flavor and always cold. R91 reported making multiple complaints to staff and had missed several meals due to palatability. Based on observation, interview, and record review, 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 · Dcited before2025-04-09 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to dignity with grooming of facial hair in 1 resident (Resident #101) of 5 residents reviewed for dignity resulting in the potential for feelings of diminished self-worth, sadness, and frustration. Findings include: Resident #101(R101) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R101 admitted to the facility on [DATE] with diagnoses including type 2 diabetes (body has trouble controlling blood sugar and using it for energy) and muscle weakness. Brief Interview for Mental Status (BIMS) reflected a score of 11 out of 15 which indicated R101's cognition was moderately impaired (8-12 moderately impaired). During an observation and interview on 4/7/2025 at 11:36 AM, R101 was observed to have approximately 10 long gray facial hairs on her chin. R101 stated that they used to shave her chin in the group home before she came to the facility. R101 said that she hasn't had her facial…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement ordered restorative program services provided to maintain, increase, or improve range of motion for 1 resident (Resident #41) of 2 residents reviewed for positioning/mobility, resulting in the potential for decreased range of motion and related complications such as development/worsening of contractures (shortening and hardening of muscles, tendons or tissue leading to deformity and rigidity of joints) and pain. Findings include: Resident #41(R41) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R41 originally admitted to the facility on [DATE] with diagnoses including type 2 diabetes (body has trouble controlling blood sugar and using it for energy), reduced mobility, depression and anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R41 was cognitively intact (13 to 15 cognitively intact). During an interview on 4/7/2025 at 11:02 AM, R41 stated that he was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-04 · 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

    Based on observation, interview, and record review the facility failed to revise a person-centered care plan for 1 (Resident #106) of 7 residents reviewed for person-centered care plan revisions resulting in an inaccurate reflection of the resident's current care needs. Findings include: Review of an admission Record revealed Resident #106 had pertinent diagnoses which included: adult failure to thrive, restlessness and agitation, and severe protein calorie malnutrition. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 12/20/2024 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #106 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment). Review of Order Summary for Resident #106 revealed Adaptive equipment: plate guard, built-up utensils (a piece of foam with a slit in the center for the handle of eating utensils to be inserted to create a greater gripping surface area), 2-handled cup with straw with a start date of 8/26/2024. Review of Care Plan for Resident #106…

    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 · D2025-02-04 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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

    This citation pertains to intake #MI00146503 Based on interview and record review the facility failed to ensure that professional standards of nursing practice were maintained related to physician orders for 1 (Resident #100) of 1 resident reviewed for professional nursing standards and physician orders resulting in inaccurate physician orders and the potential for medication error. Findings include: Review of an admission Record revealed Resident #100 had pertinent diagnoses which included: pain, muscle spasm, contracture of the left foot, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 12/16/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #100 was cognitively intact. (BIMS score 12-15 indicates little or no cognitive impairment). Review of Medication Administration Record (MAR) for Resident #100 for the month of December 2024 revealed Oxycodone-acetaminophen (Percocet) Oral Tablet 10-325 mg (milligrams) (Oxycodone w/ (with) acetaminophen) Give 1 tablet by mouth every 8…

    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 · D2025-02-04 · 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 proper placement of an aspen collar (immobilization brace for the neck) was in place during a transfer for 1 (Resident #105) of 1 resident reviewed for aspen collar use resulting in the potential for re-fracturing, delayed healing and/or potential re-injury. Findings include: Review of an admission Record revealed Resident #105 had pertinent diagnoses which included: unspecified nondisplaced fracture of the second cervical vertebra (a break in a bone in the neck near the base of the skull). Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 11/6/24 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #105 was severely cognitively impaired (BIMS score 0-7 indicates severe cognitive impairment). Review of Order Summary for Resident #105 revealed Apply Aspen collar prior to rising in the morning with a start date of 5/30/2023; Aspen collar to be worn when up…

    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 before2025-02-04 · 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

    This citation pertains to intake #MI00146503 Based on interview and record review the facility failed to maintain clear, concise, and accurate medical records for 1 (Resident #100) of 7 residents reviewed for clear, concise, and accurate medical records resulting in inaccurate documentation of medication orders and the potential for a diminished medical outcome. Findings include: Review of an admission Record revealed Resident #100 had pertinent diagnoses which included: pain, muscle spasm, contracture of the left foot, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 12/16/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #100 was cognitively intact. (BIMS score 12-15 indicates little or no cognitive impairment). Review of Order Summary for Resident #100 revealed Oxycodone-acetaminophen (Percocet) Oral Tablet 10-325 mg (milligrams) (Oxycodone w/ (with) acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain until 12/11/24 at 23:59 (11:59pm) with a start date…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-04 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) specifically face masks, was worn correctly by staff throughout the facility during a covid outbreak, resulting in the potential for the spread of infection and disease transmission for residents residing in the facility. Findings include: On 1/30/25 at 8:19 AM., signage on the entry door to the facility revealed a Covid outbreak and that face masks were required to be worn in the building. On 1/30/25 at 8:22 AM., Office Receptionist (OR) SS unlocked the facility door and when queried, she responded that face masks were required to be worn by staff, but per the Infection Preventionist, visitors could not be forced to wear face masks. On 1/30/25 at 10:30 AM Dietary Aide (DA) LL was observed in the main dining room with his face mask under his nose. On 1/30/25 at 11:23 AM., Registered Nurse (RN) C was observed on the A Hall, moving between the medication cart, supply closet, and resident's rooms with her face mask positioned under her chin and not covering her mouth…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-29 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting residents in following areas: Findings include: In an observation on 2/27/24 at 11:01 AM., noted both privacy curtains in room A-3 were visibly soiled in various areas with dark stains, and an overall soiled/dirty appearance. Bed 1 had multiple missing hanging hooks where the privacy curtain was not attached to the ceiling slide runner, which left the privacy curtain unattached and hanging down. In an observation on 2/27/24 at 11:13 AM., noted both privacy curtains in room A-8 were visibly soiled in various areas with dark stains, and an overall soiled/dirty appearance. In an observation on 2/27/24 at 11:39 AM., noted the floor in room A-11 bed 2 had multiple random medical supply items scattered underneath and next to the bed. The top of a nebulizer-machine was…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-29 · tag F0924 — pattern
    Put firmly secured handrails on each side of hallways.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to provide a safe hand railing on Dogwood Trail, resulting in the potential of injury, affecting all residents with the need of handrail assistance while on that hall, a safe way to stabilize or propel themselves. Findings include: Observed on 2/27/24 at 2:48 PM, the metal hand railing ending at room D10 on Dogwood Trail with a broken and sharp end. During an observation and interview on 2/29/24 at 10:00 AM, Maintenance Director S stated, I have three other buildings besides this one. Observed the hand railing outside of room D10 on Dogwood Trail. Maintenance Director stated, There is no end cap. I would expect the nurses to tell me about this one. It has exposed metal edges. All that needs is an end cap.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-29 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide an environment that promoted and enhanced resident dignity for 1 resident (Resident #6) of 3 reviewed for dignity, resulting in the potential of feelings of embarrassment, loss of self-worth, and decreased quality of life. Findings include: Resident #6: Review of an admission Record revealed Resident #6 was a male with pertinent diagnoses which included dementia, dysphagia (difficulty swallowing foods or liquids), stroke, muscle weakness, diabetes, nutritional anemia (the body does not get enough iron or a few other nutrients from their diet), contracture of left hand, acute subdural hemorrhage (traumatic head injury, such as a blow to the head or a fall), idiopathic orofacial dystonia (involuntary, spasmodic movements of the muscles of the orofacial (mouth and face), masticatory (chewing muscles), and lingual (tongue) region and torticollis (rare condition which the neck muscles contract, causing the head to twist to one side). Review of current Care Plan for Resident #6, revised on 9/9/23, revealed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably 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 a call light was accessible to two residents (R89 and R93) of 22 residents reviewed for accommodations of needs, resulting in the potential of unmeet care needs. Findings include: R89 According to the Minimum Data Set (MDS) dated [DATE], R89 scored 2/15 on her BIMS (Brief Interview Mental Status) indicating the resident was severely cognitively impaired. The resident had no impairment in her arms or legs with diagnoses that included Alzheimer's disease. Observed on 2/27/24 at 10:40 AM, R89 was in bed with her eyes closed. The bed was against the wall on the resident's right side with the call light on the floor under the bed out of sight and reach of the resident. R93 According to the Minimum Data Set (MDS) dated [DATE], R93 did not have a BIMS score indicating her cognition. Her functional abilities in Section GG reported her as having an impairment on one side of her body affecting her arm and leg. Diagnoses included a stroke…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · 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 interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) assessments in 1 of 22 residents (Resident #80) reviewed for accuracy of assessments, resulting in an inaccurate reflection of the resident's status. Findings include: Resident #80 Review of an admission Record revealed Resident #80 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: adult failure to thrive. Review of a MDS assessment for Resident #80, with a reference date of 12/14/23 indicated 0 unhealed pressure ulcers, 2 venous and arterial ulcers, and was checked for diabetic foot ulcers. Review of a Significant Change of Condition MDS assessment for Resident #80, with a reference date of 9/23/23 indicated 0 unhealed pressure ulcers, 0 venous and arterial ulcers, and was checked for diabetic foot ulcers. In an interview on 02/29/24 at 02:18 PM, MDS Nurse QQ reported that the information used to complete the MDS assessment was taken from actual observation of 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · 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 person centered, comprehensive care plans for 2 residents (Resident #408 and Resident #82) of 22 sample residents reviewed for care planning, resulting in a potential for re-traumatization of a Resident with PTSD (post-traumatic stress disorder), and a potential for unmet care needs for a resident with an implanted medical device. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident 's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident 's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · 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 ensure assistance with activities of daily living (ADL) care was provided for 1 (Resident #6 ) of 2 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's dependent on staff for assistance. Findings include: Resident #6: Review of an admission Record revealed Resident #6 was a male with pertinent diagnoses which included dementia, dysphagia (difficulty swallowing foods or liquids), stroke, muscle weakness, diabetes, nutritional anemia (the body does not get enough iron or a few other nutrients from their diet), contracture of left hand, acute subdural hemorrhage (traumatic head injury, such as a blow to the head or a fall), idiopathic orofacial dystonia (involuntary, spasmodic movements of the muscles of the orofacial (mouth and face), masticatory (chewing muscles), and lingual (tongue) region and torticollis (rare condition which the neck muscles contract,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 a resident who was a trauma survivor received care and services that addressed their psychosocial needs in 1 of 3 residents reviewed (Resident #408) for trauma-informed care, resulting in Resident #408 experiencing emotional distress, and thoughts of physical aggression toward others. Findings include: Review of Key ingredients for Successful Trauma Informed Care published by the Substance Abuse and Mental Health Services Administration (SAMHSA), 2021, revealed trauma informed care acknowledges the need to understand a patient's life experiences to deliver effective care . Resident #408 Review of an admission Record dated 2/25/23 revealed Resident #408 was admitted to the facility with pertinent diagnoses that included: depression. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Inventory for Mental Status (BIMS) score of 15/15 which indicated Resident #408 was cognitively intact. Review of a current Care Plan…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to discontinue psychotropic medications prescribed as needed (PRN), after 14 days and/or document rationale to extend prn psychotropic medication use in 1 of 5 residents (Resident #80) reviewed for unnecessary medications, resulting in the potential for adverse side effects and inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence. Findings include: Resident #80 Review of an admission Record revealed Resident #80 was originally admitted to the facility on [DATE], with pertinent diagnoses which included, alzheimer's disease. In an interview on 02/28/24 at 10:26 AM, Family Member (FM) SS reported that Resident #80 had anxiety in the afternoon, and that the facility applied a cream to calm her down. FM SS reported that it was her understanding that the cream had not been working, and that was why the resident was being prescribed an new antidepressant medication. Review of Resident #80's Medication…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-29 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed to ensure 1). proper hand hygiene was performed during brief change for one resident (R89), 2). adequate condition for cleanliness of personal equipment (R89), and 3). appropriate PPE (Personal Protection Equipment) use in a Transmission-Based Precautions Isolation room, of 22 residents reviewed for infection control, resulting in the potential for bacterial harborage, cross contamination, and the spread of disease to a vulnerable population. Findings include: R89 According to the Minimum Data Set (MDS) dated [DATE], R89 scored 2/15 on her BIMS (Brief Interview Mental Status) indicating the resident was severely cognitively impaired. The resident had no impairment in her arms or legs with diagnoses that included Alzheimer's disease. Hand Hygiene During an observation and interview on 2/27/24 at 10:49 AM, Certified Nursing Assistant (CNA) DD entered R89's room with CNA W to perform a brief…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-07 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 Based on interview and record review the facility failed to report and injury of unknown origin in 1 of 1 residents (Resident #100) reviewed for abuse reporting resulting in the potential for further injuries to go undetected , and not reported and/or thoroughly investigated. Findings include: Review of an admission Record revealed Resident #100, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic respiratory failure. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 11/6/23 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated Resident #100 was cognitively intact. Review of Resident #100's Incident/Accident: report dated 8/29/23 at 10:00 AM., revealed: Nursing Description: Resident complained of left leg pain On 08/28/23 a tib/fib x-ray was ordered with results noting Obliquely oriented fracture through the mid distal tibial shaft Resident Description: -Do you remember anything happening to your…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“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

$35,317 in federal fines across 2 penalties.

  • $19,724 — penalty dated 2024-02-29
  • $15,593 — penalty dated 2023-12-07

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

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

RatingThis homeChain avg
Overall 3 of 53.1-0.1 vs chain
Health inspection 2 of 52.7-0.7 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 5 of 54.0+1.0 vs chain
The other 52 homes this chain runs (chain average 3.1★, per CMS)
1 of 5Medilodge of FarmingtonFarmington, MI 1 of 5Medilodge of Grand BlancGrand Blanc, MI 1 of 5Medilodge of Grand RapidsGrand Rapids, MI 1 of 5Medilodge of HowellHowell, MI 1 of 5Medilodge of MarshallMarshall, MI 1 of 5Medilodge of Montrose IncMontrose, MI 1 of 5Medilodge of MunisingMunising, MI 1 of 5Medilodge of Sault Ste. MarieSault Ste. Marie, MI 1 of 5Medilodge of SouthfieldSouthfield, MI 1 of 5Medilodge of WestwoodKalamazoo, MI 2 of 5Medilodge at the ShoreGrand Haven, MI 2 of 5Medilodge of Capital AreaLansing, MI 2 of 5Medilodge of CheboyganCheboygan, MI 2 of 5Medilodge of East LansingEast Lansing, MI 2 of 5Medilodge of FrankenmuthFrankenmuth, MI 2 of 5Medilodge of GTCTraverse City, MI 2 of 5Medilodge of KalamazooKalamazoo, MI 2 of 5Medilodge of LudingtonLudington, MI 2 of 5Medilodge of St. ClairEast China, MI 2 of 5Medilodge of Sterling HeightsSterling Heights, MI 2 of 5Medilodge of West BloomfieldWest Bloomfield, MI 3 of 5Medilodge of Campus AreaEast Lansing, MI 3 of 5Medilodge of HillmanHillman, MI 3 of 5Medilodge of LivingstonHowell, MI 3 of 5Medilodge of LivoniaLivonia, MI 3 of 5Medilodge of Mt. PleasantMt. Pleasant, MI 3 of 5Medilodge of ShorelineSterling Heights, MI 3 of 5Medilodge of Tawas CityTawas City, MI 3 of 5Medilodge of TaylorTaylor, MI 3 of 5Medilodge of ZeelandZeeland, MI 3 of 5The Lodge at TaylorTaylor, MI 4 of 5Medilodge of GaylordGaylord, MI 4 of 5Medilodge of HollandHolland, MI 4 of 5Medilodge of LansingLansing, MI 4 of 5Medilodge of LeelanauSuttons Bay, MI 4 of 5Medilodge of MilfordMilford, MI 4 of 5Medilodge of OkemosOkemos, MI 4 of 5Medilodge of RichmondRichmond, MI 4 of 5Medilodge of Traverse CityTraverse City, MI 5 of 5Medilodge of AlpenaAlpena, MI

Showing 40 of 52; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

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

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

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

Follow the money — this home’s finances

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

$11.0M
Net patient revenuemost recent cost report
-3.6%
Operating marginrevenue minus expenses
$591K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 4%Other / private 37%

This home reported $591K 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

$311per resident / day
operating cost
$9,455per month
≈ monthly operating cost
$300per 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 235399. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, 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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