Belle Fountain Nursing & Rehabilitation Center
18591 Quarry Rd, Riverview, MI 48192 · For profit - Corporation · 91 certified beds · (734) 282-2100 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2025
- it has 2 actual-harm citations
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $4,194 in federal fines (most recent 2023-10-17)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (61%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 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 — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.4% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 5.4% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.7% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.5% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 0.0% | 12.0% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 24.4% | 19.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 15.1% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.2% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.7% | 14.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 94.0% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 32.2% | 24.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.9% | 11.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.46 | 1.84 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.53 | 1.64 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 544 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 81.4% 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 188 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 0.61 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.7%CMS range 53.8–63.7 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.9%CMS range 9.8–14.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 81.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 78.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 75.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 99.4% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 95.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.2%CMS range 4.8–9.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 91 beds and averages 77.2 residents a day — about 85% occupied, or roughly 14 beds typically open. It usually has some room. 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 3.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.25 hrs/resident/day on weekends vs 4.18 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.62 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 61% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · Gcited before2026-04-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure staff implemented safe repositioning techniques during incontinence care for one resident (R107) of two residents reviewed for accidents and supervision resulting in R107 falling from the bed and sustaining a dislocated shoulder. Findings include: On 4/26/26 at 10:53 AM, R107 was interviewed and reported they had experienced a fall a few days prior during bed care. R107 said there was only one staff member present providing care when two staff were required. In addition, R107 said that during the attempt to change the pad underneath them, they were rolled onto their left side, which was their weakened side due to a recent stroke, and subsequently fell out of the bed. R107 said they are not sure if CNA F pushed them too hard or if they fell from being turned with too much force. R107 said since the fall they have had pain in the left arm and left knee.On 4/27/26 at 3:00 PM, Certified Nurse Aid (CNA) F was interviewed and reported 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.
- Actual harm · G2025-08-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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
This citation pertains to intake 2581458.Based on observation, interview and record review the facility failed to protect the resident's right to be free from verbal abuse from staff for one resident (R906) out of five residents reviewed for abuse, this failure resulted in the resident experiencing feelings of distress and emotional harm.Findings Include:Review of a Facility Reported Incident dated July 28,2025 revealed an allegation of a staff to resident verbal abuse incident.Record review of R906's electronic medical record revealed admission into the facility on 7/18/25 with a pertinent diagnosis of trochanteric fracture of left femur (thigh). Further review of revealed resident scored 15 out of 15 (intact cognition) on a Brief Interview of Mental Status (BIMS) on 8/4/25. Review of Kardex (Care Notes) dated 8/7/25, R906 required ADL (Activities of Daily Living) assist x1 staff.During an interview on 8/6/25 at 10:57 AM with R906 it was reported that while attempting to get in her wheelchair, Licensed Practical Nurse (LPN) A entered the room and questioned, What are you doing?…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-04-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 4/26/2026 at 8:51 AM observed residue on the shelving surface of the food storage racks in walk in cooler. An interview with Dietary Manager (DM) H at this time found the shelves are cleaned. When asked how often, DM H indicated weekly or monthly.On 4/26/2026 at 8:53 AM observed the stand mixer with a plastic cover over it. When asked if the mixer is used, DM H indicated yes. Upon removal of the cover, brown buildup was observed accumulated on the upper portion of the mixer above the mixing bowl. DM H stated they would get someone to clean it.On 4/26/2026 at 9:15 AM observed red residue buildup on the inside nozzle of the juice gun. An interview at this time regarding cleaning of juice gun found the nozzle is ran through the dishwasher daily.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-04-28 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 04/26/2026 at 8:32 AM observed an inoperable water fountain in the front entrance of the building lobby indicating possible stagnant water. The electric plug was observed unplugged and hanging. On 04/26/2026 at 10:36 AM observed an inoperable water fountain in the hearth room indicating a possible stagnant line.On 04/26/2026 at 11:06 AM observed a therapy tub in the spa room A hall. An interview with Housekeeping/Laundry Supervisor (HLS) K at this time found they were not sure if it is used or not.On 04/26/2026 at 11:16 AM observed a shower room converted to a clean linen room in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-28 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement written comprehensive advance directives (Cardiopulmonary Resuscitation/CPR, Artificial Nutrition/Peg Tube, Artificial Hydration/ IV, and Diagnostic Testing) for six (R4, R6, R7, R9, R64, and R70) of 14 residents reviewed for advance directives, resulting in the missed opportunity to grant life sustaining or life withholding decisions known by the resident or legal representative.Findings include:R64 On [DATE] at approximately 9:00AM, R64 was observed in their room in bed. On [DATE] at approximately 9:30AM, R64 was queried regarding their advance directives. R64 said they did not recall making a choice or decision upon admission but would not want chest compressions if their heart or breathing would stop. A record review was conducted and revealed R64s most recent admission to the facility was on [DATE] with diagnoses that included fracture of the right femur, acute kidney failure, pain, dementia, delirium, and urinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-28 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 ensure dignity was maintained for one resident (R38) of one resident reviewed for dignity.Findings include:On 4/26/26 at 8:35 A.M. upon entering the facility walking past R38's room, the resident was observed in the first bed in a supine position (position lying on the back with face upward), with brief and entire upper thighs exposed in full view of the survey team and hallway traffic. The R38's arms were extended to the sides of the bariatric bed, and each exposed leg was positioned at the end of each corner of the bed. The resident's body was not covered and due to the resident's size (480 pounds) and the position of the bed, the resident's brief and body parts were seen from the hallway.In addition to the earlier observation R38 remained in the first bed without a Privacy curtain being pulled or a change of rooms. R38's body was within full view of the hallway showing an exposed brief and no covering of the lower extremities on 4/26/26…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-28 · tag F0679 — failed to provide activities — isolatedProvide 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 age-appropriate meaningful activities for one cognitively intact (R85) of four residents reviewed for activities, resulting in boredom, lack of interest in facility life, and loss of dignity.Findings include:R85-On 4/26/2026 at 11:23 a.m. R85 was observed resting in bed watching television. R85 presented as alert, oriented to person, place, and time and able to make all needs known. R85 has been observed participating in out of room activities, however R85 said they don't bother going to activities anymore due to there not being enough activities of interest to do. R85 stated, They (facility) no longer offer live entertainment or out the facility trips. It's spring and we should be planting a little garden or building a bird feeder. Instead, they have us doing ( kiddie shit) making me feel like an asshole. We should be having activities we enjoy. R85 pointed to the closet door of the bedroom. There was a [NAME] that had cartoon…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-28 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 adequate monitoring of antibiotic use for one resident (R64) of five residents reviewed for antibiotic stewardship, resulting in the potential for the resident to experience unnecessary medication side effects or outcomes. Findings include: On 4/27/2026 at approximately 9:20AM, R64 was observed in their room in bed. R64 was asked about their antibiotic use for a urinary tract infection (UTI). R64 responded, they say I'll always have to take it because I'll always have a UTI. When asked if they had any current symptoms of a UTI such as burning with urination, R64 said no. A record review was conducted and revealed R64s most recent admission was on 3/14/2026 with diagnoses that included fracture of the right femur, acute kidney failure, metabolic encephalopathy, chronic obstructive pulmonary disease, dementia, and urinary tract infection. Section C of the Minimum Data Set with an Assessment Reference Date of 3/20/2026 revealed R64 scored 12/15 on the Brief Interview for Mental Status assessment -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure adequate supervision to prevent a fall for one resident (R904) out of three residents reviewed for falls.Findings include:On 8/7/25 at 9:00 a.m., during an interview with R904, it was reported that on 7/30/25 staff let the resident fall from the bed to the floor while removing a bed pan.Record review of Nursing Progress Notes dated 7/30/25 at 2:18 a.m. documented, CNA notified writer that resident had a witnessed fall, resident was getting taken off of bedpan and CNA (Certified Nursing Assistant) lowered resident to the floor. The writer observed resident lying on her left side on the floor.Review of electronic medical records revealed that the resident was admitted into the facility on 7/7/25 with a pertinent diagnosis of fracture of left ulna (lower arm). An additional review revealed on 7/31/25 that R904 had scored 15 out of 15 (intact cognition).Review of the care plan dated 7/16/25 indicated that R904 required two people for assistance with bed mobility. Review of the Kardex (care notes) R904 was a two 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.
- Potential for harm · F2025-03-12 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure an adequate supply of emergency food was available. Findings include: On 3/10/25 at 12:00 PM, an observation and interview regarding the facility's emergency food supply was conducted with Dietary Manager (DM) A. A section in the dry food storage room was delineated by a sign that read, EMERGENCY FOOD DO NOT TOUCH!! DM A stated, They (kitchen staff) have been told not to use the emergency food. DM A said emergency food items were obtained from a commercial food supply company and provided a list of emergency foods that should be on hand. The emergency food supply list was compared to the foods currently available in the emergency food area, and the following items were not available: chicken noodle soup, cheese sauce, and green beans. DM A provided a policy titled, Disaster and Emergency Planning for Food Service, dated 2/3/23, that documented in part the following: The facility provides a disaster and emergency plan to ensure that the food service department will have on hand adequate food, water and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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: 1. Ensure pans were cleaned and air dried before stacking; 2. Properly date-label food in the kitchen; 3. Ensure food items past the use-by-date were not stored with active food; 4. Store cartons of milk in a manner to avoid splash from mop water; and 6. Adequately clean the air gap basin. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: During the initial tour of the kitchen on 3/10/25 at 8:45 AM with Dietary Manager (DM) A, the following was observed: 1. Two wet ½ pans and one ½ pan soiled with food debris were observed nestled and stored with clean pans in the clean pot/pan storage area. 2. Inside of the three-door cooler contained, a.) two opened 16-ounce containers of chicken base and one opened 16-ounce container of vegetable base which were not labeled with an expiration date; b.) a box with 15 four-ounce containers of apple juice which all expired November 2024; and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-12 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a care plan for a communication deficit was developed and implemented for one resident (R282) of nineteen residents reviewed for care plans. Findings include: On 3/10/2025 at 10:40 a.m., R282 was observed in room, alert and sitting on the bed with multiple sheets of writing paper and three ink pens on the bed side table. During an interview, R282 stated, If you are talking to me, you have to write it down because I cannot hear you. R282 pointed to the right ear and stated, This hearing aid I have is useless and I can't hear with it. On a handwritten note, R282 was asked how the hearing loss affects your communication and interaction with others. R282 stated, I avoid being around a crowd of people because I cannot communicate and interact with them. I wish I can try (Name Brand) for hearing aids, maybe they would work better. My ears have ringing sounds sometimes and I cannot hear my phone calls. On 3/12/2025 at 9:29 a.m. Unit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · D2025-03-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI00150118 and MI00150053. Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADLS) in a timely manner for one resident (R23) of three reviewed for ADL care. Findings include: On 3/10/2025 at 10:59 a.m. and on 3/12/2025 at 1:36 p.m. R23 was observed sitting in a wheelchair with facial hairs, greasy unkempt hair, and long dirty untrimmed fingernails. R23 during an interview verbalized wanting to get shaved, hair washed and combed, and nail care. R23 confirmed no one asked to assist with nail care, shaves and grooming of the hair on scheduled shower days. R23 was unable to recall the last day a shower was given and unable to recall scheduled shower days. According to the electronic medical record, R23 was initially admitted into the facility on 6/29/2017 and readmitted on [DATE] with diagnoses of congestive heart failure, major depressive disorder, dementia, chronic kidney disease stage 3, chronic obstructive pulmonary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility to ensure the foley catheter bag (bags used to collect urinary drainage from Foley catheters) was not resting on the floor for one (R37) of three residents reviewed for catheter/UTI (urinary tract infection) potentially resulting in the spread of infections and dislodgement. Findings include: On 3/10/25 at 2:03 p.m. R37 was observed in bed asleep. The bed was in a low position (approximately 4-6 inches from the floor). R37 was also observed with a catheter in which the catheter bag was observed resting on the floor wedged between the floor mat and wheel of the bed. Review of the electronic medical record documented R37 was admitted into the facility on 2/20/25 with diagnoses that included neuromuscular dysfunction of bladder and repeated fall. According to the admission Minimum Data Set assessment dated [DATE], R37 was cognitively intact (BIMS=13) and required dependent two-person assistance with most activities of daily living. R37 was also…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-28 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake MI00148212, MI00149641, and MI00149668. Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergency or routine care and unmet care needs. This deficient practice had the potential to affect all residents who resided in the facility. Findings include: On 1/27/2025 at 12:30 P.M., the Master Schedule for Nurses during the period of 01/01/2025 - 1/26/25, was reviewed for RN coverage for the facility. The following dates revealed there was no consecutive 8 hour scheduled RN coverage: January 12, 2025, Census 72 January 19, 2025, Census 77 January 25, 2025, Census 71 On 1/28/2025 at 2:25 P.M. the Director of Nursing (DON) was interviewed and the schedules dated (1/12/25, 1/19/25, and 1/25/25) were reviewed. The DON confirmed that RNs did not work of those days. When asked how the facility ensured there was daily 8-hour RN coverage the DON replied, We just hired RNs to assist with coverage. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-21 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that one (R506) of three residents reviewed for unnecessary medications had a specific diagnosis for use, clinical indications for use, or a valid informed consent for the use of psychotropic medications (drugs that affects brain activities with mental processes and behaviors). Findings include: According to R506's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with diagnoses that included multiple falls and traumatic ischemia of muscle (muscle tissue not receiving enough blood due to a physical injury) and diabetes. On 9/11/24 a progress note documented by Social Worker (SW) J indicated R506 had a Brief Interview of Mental Status (BIMS) score of 15/15, indicating no cognition impairment. A Behavioral Care and Psychiatric Service form for Consultation Request, Consent, And Authorization To Treat dated 9/11/24 indicated R506 had declined treatment and Did NOT consent to Psychiatric treatment or services. On 9/16/24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 This citation pertains to intake MI00146645. Based on interview and record review, the facility failed to develop or implement a care plan for anticoagulant administration (warfarin, a blood thinner) for two (R801 and R802) of three residents reviewed for care plans resulting in R801 and R802 not having a care plan for monitoring anticoagulation therapy side effects and the potential for healthcare needs to go unmet. Findings include: The State Agency received a complaint that the facility did not monitor a resident that was receiving warfarin for anticoagulation therapy side effects. R801: According to the Electronic Health Record (EHR) R801 admitted to the facility on [DATE] with diagnoses that included history of pulmonary embolism (blood clot in the lungs). On 8/1/24 the physician ordered warfarin 7.5 mg (milligrams) daily at bedtime. The order summary for warfarin included a black box warning (the strictest and most serious type of warning that the FDA gives a medication that alerts consumers when a serious…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-05 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 This citation pertains to intake MI00146645. Based on interview and record review, the facility failed to maintain complete and accurate medical records for one (R801) of three residents reviewed for medical records, resulting in R801's INR results not accurately documented or maintained in the resident's Electronic Health Record (EHR) resulting in the potential for an unclear picture of the resident's blood clotting times and health care needs. Findings include: The State Agency received a complaint that the facility did not monitor a resident that was receiving warfarin for anticoagulation therapy side effects. R801: According to the Electronic Health Record (EHR) R801 admitted to the facility on [DATE] with diagnoses that included history of pulmonary embolism (blood clot in the lungs). On 8/1/24 the physician ordered warfarin 7.5 mg (milligrams) daily at bedtime. The order summary for warfarin included a black box warning (the strictest and most serious type of warning that the FDA gives a medication that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-06-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
This citation pertains to intakes MI00144980 and MI00145055. Based on observation, interview, and record review, the facility failed to ensure expired food was not stored with active food stock resulting in the potential for food borne illness to affect all residents who consume food from the kitchen. Findings include: The State Agency received a complaint that a resident was served a sandwich with mold on the bread. During a tour of facility's kitchen on 6/25/24 at 11:20 AM with Registered Dietitian (RD) A, Kitchen [NAME] (KC) B, and Dietary Aide (DA) C the following was observed in the active food stock area; -two 8-packs of hamburger buns were opened and undated with small amounts of white fuzzy substance in a circular pattern on the bottom of the buns. Six additional 8-packs of hamburger buns did not have delivery date or use by date on them. -two 8-packs of hot dogs buns were unopened, undated, and had small amounts of white/grayish fuzzy substance in a circular pattern on the buns. Six additional 8-packs of hamburger buns did not have delivery date or use by date on them.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-07 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably 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 This citation pertains to intakes: MI00144232, MI00144376, MI00144543, and MI00144585. Based on observation, interview, and record review, the facility failed to ensure call lights were answered promptly for four residents (R810, R811, R812, and R805) reviewed for accommodation of needs resulting in various unmet health care needs. Findings include: Review of multiple complaints reported to the State Agency (SA) included allegations that call lights were not answered timely (beyond half an hour and longer). Observations on 6/5/24 at 2:00 PM revealed that three call lights were on for the A/B hall (R810, R811, and R812). It is unknown when the call lights were originally activated by the residents. Resident 810 On 6/5/24 at 2:10 PM R810's call light remained on. R810 was observed seated on the edge of the bed with the call light in hand. R810 said she needed assistance to go to the bathroom and the call light had been on for over 15 minutes. R810 said, It takes a long time for them to answer the call light.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-07 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 MI0014232. Based on interview and record review the facility failed to ensure information for transfer was communicated to the receiving hospital for one (R802) of two residents reviewed for discharges and transfers resulting in the receiving hospital being potentially unaware of the resident's reason for transfer, current medical treatments or allergies along with the resident's care needs to be unmet. Findings include: According to R802's closed Electronic Health Record (EHR) the resident admitted to the facility on [DATE] for multiple diagnoses that included dementia and history of a fall with fractured Tibia (shin bone). A Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognition impairment with a Brief Interview for Mental Status score of 4/15 and required substantial to maximum assistance from staff for all mobility including sit-to-stand. A progress note On 4/26/24 at 2:46 PM reported that R802 was observed on the floor with a skin tear to the right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes: MI00144232, MI00144376, and MI00144868. Based on interview and record review the facility failed to implement fall interventions for three (R802, R807, and R809) of seven residents reviewed for falls resulting in all three residents not having initial fall risk assessments completed in a timely manner and all three residents sustaining falls without injury. Findings include: Resident 802 According to R802's closed Electronic Health Record (EHR) the resident admitted to the facility on [DATE] for multiple diagnoses that included dementia and history of a fall with fractured Tibia (shin bone). A Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognition impairment with a Brief Interview for Mental Status (BIMS) score of 4/15 and required substantial to maximum assistance from staff for all mobility including sit-to-stand. The MDS identified 'falls' as a triggered care area. There was no fall risk assessment including a fall risk score completed for the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-06 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00142576. Based on observation, interview, and record review the facility failed to provide rationale, behavioral monitoring, or a physician evaluation for the extended use of a PRN (as needed) psychotropic medication for one (R502) of three residents reviewed for medications. Findings include: The State Agency received a complaint that R502 was not receiving her anti-anxiety medication as prescribed. On 3/5/24 at 12:40 PM, R502 was observed in her room in her wheelchair eating lunch. R502 said she had trouble getting her Ativan (anti-anxiety medication) at times because the nurses said it was either not ordered or they could not give it to her at the time she requested it. R502 said she had been taking Ativan for years at home and was afraid she would go through serious withdrawal symptoms if she did not get it (Ativan) every day. R502 reported she was not being seen by psychiatry services. R502 could not recall if she was asked about psychiatry services or if she had any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-09 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 340 (R340) Record review of Resident #340 (R340)'s face sheet revealed admitted to facility on 12/30/23 diagnoses included wedge compression fracture of first lumbar vertebrae, anemia, difficulty in walking. Review of the Minimum Data Set (MDS) dated [DATE] for R340 revealed a Brief Interview for Mental Status (BIMS) of 15/15 intact cognition and required moderate assistance for mobility. Record Review of physician orders dated 12/31/23 revealed Tylenol Oral Tablet 325 MG (Acetaminophen) Give 2 tablets by mouth every 6 hours for Pain, Lidocaine 24 Hours External Patch 4 % (Lidocaine) Apply to Lower back topically two times a day for Pain. Record Review of R340's MAR revealed on 12/31/23 and 1/1/24 for Lidocaine 24 Hours External Patch 4 % (Lidocaine) Apply to Lower back topically two times a day for Pain no record of administration. For dates 1/1/24 PM until 1/8/24 PM revealed a code 9 which indicated to see nurse notes. Record Review of the nurses' notes revealed the pain patch was not administered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-09 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake MI00138960. Based on observation, interview, and record review the facility failed to notify the physician when a prescribed medication (pain patch) was not available for administration for 2 of 6 residents (R77 and R87) reviewed for medication administration, resulting in the physician being unaware of the missed medication and the potential for the resident's pain to go untreated. Findings include: Resident 77 (R77): During a 'Medication Administration' observation on 1/8/2024 at 8:30 AM with Licensed Practical Nurse (LPN) C, R77's pain patch 'Lidocaine 4%' was not available for administration. R77 said that he had not received the pain patch in weeks but his pain was controlled by another medication. LPN C said the 'Lidocaine 4%' pain patches were floor stock items that had not been available in a while. LPN C said she would notify the nurse manager, (LPN D) that the resident did not receive his pain patch. Upon further inquiry LPN C said, When medications are missing the physician should be notified to determine if another medication could be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure floor stock items (laxative) were not expired and failed to refrigerate unopened Insulin (hormone used to control blood sugar) in one of four medication carts resulting in the potential for decreased effectiveness of the medications. Findings include: During observation of a medication administration on 1/08/24 at 8:09 AM with Licensed Practical Nurse (LPN) B, a floor stock medication (Biscodyl 5 mg, a laxative) was observed to have an expiration date of July 2023. LPN B removed the medication from the cart and said, The night shift nurse is responsible for ensuring the floor stock medications are not expired. Upon further observation, two bottles of unopened insulin (Lispro) for residents R77 and R342 were each sealed in a plastic bag clearly labeled refrigerate until opened. The insulin bottles had no delivery date on them. LPN B was unable to determine when the insulin bottles were left unrefrigerated and placed in the medication cart. LPN B removed the insulin bottles from the cart and said, These…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$4,194 in federal fines across 1 penalty.
- $4,194 — penalty dated 2023-10-17
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 OPTALIS HEALTH & REHABILITATION — 36 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.4 | +0.6 vs chain |
| Health inspection | 2 of 5 | 1.9 | +0.1 vs chain |
| Staffing | 2 of 5 | 2.4 | -0.4 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 35 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| METRO MAN II INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/30/2006 |
| DUNN, CHARLES | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 100% | since 05/30/2006 |
| OPTUM MANAGEMENT SOLUTIONS. INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/30/2006 |
| ATTO, GHASSAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| BRIGHT, JULIANA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2024 |
| BROWN, TYREE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2025 |
| PATEL, RAJAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2024 |
| SHARON, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/13/2024 |
| SHAH, HEMANT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 04/09/2026 |
| CLIFTONLARSONALLEN LLP | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| METRO MAN III LLC | Organization | ADP OF THE SNF | — | since 05/30/2006 |
| SCHLAUPITZ MADHAVAN | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| CONNER, MARIANNE | Individual | ADP OF THE SNF | — | since 05/13/2024 |
CMS files one row per role, so the 19 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235376. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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