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Intersect Healthcare of Roscommon

1290 East Michigan Highway, Roscommon, MI 48653 · For profit - Corporation · 39 certified beds · (989) 275-8936 Medicare & Medicaid certified

Call the home — (989) 275-8936 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 16 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
135 Lake St · (989) 275-8931 · Call to confirm hours
Pharmacy
412 N 5th St · (989) 275-5600 · Call to confirm hours
Grocery
409 N 5Th St
Park
055-759-002-0000 · (208) 753-7121 · 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 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 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 rating4★
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 increased4.8%10.8%15.4%better
Long-stay residents who lose too much weight3.6%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection2.5%1.5%2.0%worse
Long-stay residents with depressive symptoms0.0%4.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.8%3.0%3.3%better
Long-stay residents whose ability to walk worsened2.8%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.5%19.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers9.3%5.1%4.7%worse
Long-stay residents with worsening bladder/bowel control9.3%20.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table7.6%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%1.1%1.4%typical
Short-stay residents given the seasonal flu vaccine97.0%79.5%79.4%better
Short-stay residents rehospitalized after admission29.2%24.0%22.6%worse
Short-stay residents with an outpatient ER visit12.5%11.7%12.0%typical

* 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.

51.9% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.9%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
86.4%U.S. median 56.6%
Met the expected recovery
0.49U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.28hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 86.4% 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 22 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 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF51.9%CMS range 38.8–63.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 7.9–16.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge86.4%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 discharge63.6%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 discharge81.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 4.1–14.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 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

1.05
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.03
Aide hours/ resident / day
3.97
Total nurse hours/ resident / day
0.41
RN hoursweekends
28.6%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 39 beds and averages 36.3 residents a day — about 93% occupied, or roughly 3 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 3.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.05 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.18 hrs/resident/day on weekends vs 4.29 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 1.32 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% is below 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

5
deficiencies at the latest standard inspection (2026-03-11)
4
at the previous standard inspection (2025-02-11)

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.

16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.

  • Potential for harm · E2026-03-11 · 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, 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 satisfaction of living affecting all residents in the facility. Findings include:On 3/9/2026 at 4:17 PM there was an observed lack of hot water at the two hand sinks in the kitchen. The hand sink closest to the maintenance hallway was observed to have hot water at 81 degrees, and the hand sink on the other end of the kitchen closest to the dish machine room was observed at 80 degrees, as registered on a probe thermometer. On 3/9/2026 at 11:35 AM the dish machine room hand sink temperature was recorded at 82 degrees and the sink closest to the maintenance hall at 80 degrees, using a probe thermometer. During this observation, Maintenance Director G stated that the water heater was recently replaced and the mixing valve was turned down too low. According to the 2022 FDA Food Code section 5-202.12 Handwashing Sink, Installation. (A) A HANDWASHING SINK shall be equipped to…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-11 · 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 identify a change in bowel health for one Resident (#20) of one resident reviewed. This deficient practice resulted in the potential for constipation, intestinal blockage and discomfort.Findings include:Resident #20 (R20)Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/24/2025, revealed R20 was admitted to the facility on [DATE] and had diagnoses including end-stage renal disease, heart failure, right side hemiplegia, bilateral foot amputation, and diabetes. Further review of the MDS assessment revealed R20 received hemodialysis treatment, required supervision/touching assistance with transfers and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the Resident was cognitively intact.On 3/10/2026 at 8:47 a.m., R20 was observed seated on the edge of his bed eating breakfast. R20 was not wearing a shirt and a dialysis access line was observed to be in place in his upper arm right. R20's meal…

    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 · D2026-03-11 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure:(1) the correct dosage of medication was administered and(2) medication administration according to manufacturer recommendations for two Residents (R28 and R38) of three residents reviewed for medication administration. This deficient practice resulted in a medication error rate of 6.4% from 2 of 31 opportunities for error.Findings include:Resident #28 (R28) On 3/10/26 at 8:08 AM, Licensed Practical Nurse (LPN) A was observed administering medications to R28 who required medication administration through a gastrostomy tube (G-tube - a tube in the abdominal wall to provide direct access to the stomach for nutrition, fluids, and medication).LPN A added water to a 30 ml (milliliter) plastic medication cup containing a crushed medication tablet. The medication did not dissolve in the water and LPN A used a plastic spoon to stir the medication in the cup. When the medication was stirred in the 30 ml cup, the medication began spilling over the sides of the cup onto the bedside table. LPN A continued to stir…

    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 before2026-03-11 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to properly store medications in one medication cart of two medications carts reviewed for medication storage. Findings include:On 3/10/26 at 7:58 AM, Licensed Practical Nurse (LPN) A prepared 11 medications in a medication cup for Resident #15 (R15). LPN A placed the cup of medications on the overbed table in R15's room while she replaced a medication patch on R15's left upper posterior arm. After placing the medication patch, LPN A picked up the cup of medications from the overbed table to administer the medications. R15 told LPN A he didn't want the medications at that time. LPN A took the cup of medications back to the medication cart and placed the cup of medications in the top drawer of the medication cart.On 3/10/26 at 8:08 AM, Licensed Practical Nurse (LPN) A then proceeded to prepare seven medications for Resident #28 (R28), including a losartan tablet (medication to treat high blood pressure) obtained from a blister pack (a medication packaging system that holds individual doses of medication 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-11 · 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 provide barriers for resident care equipment and maintain infection control practices during medication administration for four Residents (#10, #15, #28, & #38) of seven residents reviewed for infection prevention and control.Findings include:Resident #10 (R10)R10 was admitted to the facility on [DATE]. A quarterly MDS (Minimum Data Set) assessment dated [DATE] documented R10 had chronic respiratory failure with hypoxia and required supplemental oxygen and a non-invasive ventilator (respiratory support device). On 3/9/26 at 2:05 PM, R10 was observed wearing a nasal cannula (an oxygen delivery device that provides supplemental oxygen through the nostrils) connected to an oxygen concentrator. An additional nasal cannula was connected to a portable oxygen tank on the back of R10's wheelchair. The nasal cannula on the portable oxygen tank was unbagged and lying across the back of R10's wheelchair without a barrier (a barrier is an item…

    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 · D2025-03-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure interventions to address fall prevention were implemented for two Residents (#5 & #6) of four residents reviewed for falls. Findings Include: Resident #5 (R5) Review of the care plan revealed R5 was identified on 11/21/23 at risk for accidents, injuries, and falls r/t (related to) hx (history) of falls with major injury, insomnia, heart failure, COPD (Chronic Obstructive Pulmonary disease) & emphysema with dependence on oxygen, impaired mobility and balance, generalized weakness, forgetfulness, impaired vision . Interventions on 11/21/23 included: Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. Ensure that I am wearing non-skid footwear prior to assisting me with transfers and/or ambulation. Reduce my risk for falling by cleaning up spills or clutter from my floor, provide glare-free lighting, accessible working call light, bed set at…

    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 · D2025-03-12 · 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 implement and maintain accurate and complete documentation for 15-minute safety checks for two Residents (#5 & #6) of two residents reviewed for documentation related to 15-minute safety checks. Findings include: Resident #5 (R5) Review of R5's Electronic Medical Record (EMR) revealed diagnoses including Chronic Obstructive Pulmonary Disease (COPD), dependence of supplemental oxygen, heart failure, Type II diabetes, presence of artificial eye, and legal blindness. R5 had a Brief Interview for Mental Status (BIMS) score of 15 indicating R5 was cognitively intact. R5 was identified as a fall risk on 11/21/23 as indicated during review of their care plan. R5's care plan was updated on 8/14/24 after a fall with injury, to include 15-minute visual safety checks due to cognitive impairment, failure to use call light consistently, and frequent attempts to ambulate unassisted. R5's Current Care Record was updated to 15-minute checks Q (every) 2…

    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 · Ecited before2025-02-11 · tag F0880 — failed to prevent and control infections — pattern
    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: (1) Ensure proper hand sanitizing during hall tray pass; (2) Ensure donning of proper personal protective equipment (PPE) in droplet precaution resident rooms and; (3) Ensure disinfection of an insulin pen prior to returning it to the medication storage cart during a facility influenza outbreak, (4) Ensure infection control practice was maintained for respiratory equipment, (5) Ensure opened containers of distilled water were dated for proper identification of expiration and discarding. These deficient practices resulted in the potential for transmission of infections and further spread of an influenza outbreak to all 36 facility residents and staff. Findings include: Resident #1 (R1) Review of R1's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 1/18/21, with diagnoses including: chronic obstructive pulmonary disease, and sleep apnea. R1 scored a 15 of 15 on the Brief Interview of Mental Status…

    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 · D2025-02-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and monitor a resident's urostomy for complications, skin integrity, and proper function for one Resident (#238) of one resident reviewed for bowel and bladder. Findings include: Resident #238 (R238) A review of medical records indicated R238 was admitted to the facility on [DATE] with diagnoses including urinary tract infection, history of malignant neoplasm of bladder, acquired absence of other parts of urinary tract, and chronic kidney disease stage 3. On 2/9/25 at 1:54 PM, R238 was interviewed and indicated they had a urostomy (a surgical procedure that creates an opening [stoma] in the abdomen to divert urine from the kidneys directly into a bag on the outside of the body) and was currently being treated for a urinary tract infection (UTI). R238 stated the urostomy had been present for about three years and they were accustomed to caring for it themselves. R238 stated facility staff had asked R238 to alert the facility if…

    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 before2025-02-11 · 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 appropriately store topical treatment medication for one Resident (#1) of twelve residents reviewed for medication storage. Findings include: Resident #1 (R1) Review of R1's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 1/18/21, with diagnoses including obesity. R1 scored a 15 of 15 on the Brief Interview of Mental Status (BIMS) assessment reflective of intact cognition. On 2/9/25 at 10:10 AM, R1 was observed in her room, lying in bed. R1 had a tube of Nystatin (an antifungal or anti-yeast cream) 100,000 units per 30 grams sitting on her nightstand. The topical cream order for application was completed two days ago according to the physician's order below. Review of R1's physician order, dated 12/1/24, read, Nystatin External Cream 100,000 units/gram, apply to vaginal folds topically every shift starting on the 1st and ending on the 7th every month for preventative skin care and candidiasis…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 6 citations
  • Potential for harm · D2025-02-11 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    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 dining adaptive equipment for one Resident (#17) of three residents reviewed for dining assistive devices. Findings include: Resident #17 (R17) Review of R17's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with diagnoses including ataxia (impaired coordination). R17 scored a 13 of 15 on the Brief Interview of Mental Status (BIMS) assessment reflective of intact cognition. On 2/9/25 at 1:02 PM, R17 was observed in his room, lying in his bed when his lunch tray was delivered. R17 sat upright in his bed and looked at his lunch meal. R17's meal tray and ticket were reviewed, and it was identified R17 did not get his adaptive equipment of built-up utensil handles on silverware. R17 was asked how often he does not receive the adaptive equipment and replied, It happens quite frequently. It seems like every other day. On 2/11/25 at 8:45 AM, R17's breakfast tray was observed in his room. R17…

    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 · F2024-03-13 · 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in a food borne illness among any and all 38 residents. Findings include: On 3/11/24 at approximately 11:55 AM, [NAME] C was observed to be preparing food for the noon meal. [NAME] C removed his gloves, lifted the lid to the 35 gallon garbage can, disposed of the gloves, removed two clean gloves from a box of gloves on the food serving line, and returned to prepare additional food. An interview with [NAME] C at this time who acknowledged that he didn't think to wash his hands prior to donning the clean gloves after contamination from the lid of the garbage can. The FDA Food Code 2017 states: 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped…

    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 · E2024-03-13 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #9 (R9): Review of R9's Electronic Medical Record (EMR) revealed initial admission to the facility on 2/8/22 with diagnoses including congestive heart failure, bipolar disorder, panic disorder, and cognitive communication deficit. Review of R9's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. On 3/12/24 at 9:30AM, R9 was observed sleeping in bed in his private room. A white [Brand Name] camera was observed on the bedside dresser, aimed at R9. A green light was observed next to the camera power switch reading, ON, indicating the unit was in use. On 3/12/24 at 9:32AM, R9 was observed on a [Brand Name] video monitor screen which was unattended at the nurse's station in a high traffick, central location within the facility. A review of a Nursing Progress note dated 1/25/24 at 9:01AM, read in part: .Remote video monitor placed in [R9's] room upon return from ED (emergency department) last…

    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 before2024-03-13 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a secured/locked medication cart and maintain clean and sanitary medication carts for two of two medication carts reviewed for medication storage and one of one medication rooms. This deficient practice had the potential for medications to be misappropriated, medication loss, and contamination. Findings include: On 3/12/24 at 8:20 AM, and inspection was conducted in the medication storage room and was found to have lorazepam [a scheduled IV medication] 2 mg (milligram) vials approximately three stored in the refrigerator in a plastic clear box with labeling on the outside and secured with a single plastic serial numbered device. The medication storage room refrigerator did not have a key lock on the outside of the door or key looking device affixed to the inside of the refrigerator so the lorazepam was easily accessible and removable to anyone that entered the medication storage room door. On 3/12/24 at 10:15 AM, an inspection was conducted of the medication cart for 100 hall and was found to have one…

    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 · D2024-03-13 · 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 store oxygen supplies per standards of practice and administer oxygen services per physician orders for one Resident (#30) of two residents reviewed for oxygen services. This deficient practice resulted in the potential for respiratory infection and hypoxia (below-normal level of blood oxygen) resulting in respiratory and/or medical decline. Findings include: Resident #30 (R30): During an initial tour of the facility on 3/11/24 at 10:50 AM, a CPAP (continuous positive airway pressure) machine was observed on R30's bedside nightstand. The CPAP hosing and facemask were in direct contact with the nightstand with no protective covering. On 3/11/24 at 10:51 AM, an interview was conducted with R30. R30 reported he had a concern regarding a connection piece on his CPAP machine because it had been damaged and was no longer functioning. Review of R30's electronic medical record (EMR) revealed initial admission to the facility on 8/24/22 with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-13 · 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: a) Staff donned appropriate personal protective equipment (PPE) for one (Resident #8) of five residents reviewed for Enhanced Barrier Precautions (EBP). b) Catheter care was performed in accordance with acceptable standards of practice for one (Resident #30) of one residents reviewed for urinary catheters. These deficient practices resulted in the potential for the development and transmission of communicable disease and infections. Findings Include: Resident #8 (R8): Review of R8's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including a non-pressure chronic ulcer of the left ankle, acquired absence of the right leg below the knee, and history of infectious and parasitic diseases. Review of R8's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicative of intact cognition. During an initial tour 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to MISSION POINT HEALTHCARE SERVICES — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 52.8+2.2 vs chain
Health inspection 4 of 52.3+1.7 vs chain
Staffing 4 of 53.9+0.1 vs chain
Quality measures 5 of 54.1+0.9 vs chain
The other 13 homes this chain runs (chain average 2.8★, 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 / managerTypeRoleShareSince
MISSION POINT NORTHERN MICHIGAN HOLDING LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/01/2020
MALI, HARIIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2023
MITCHELL, MARKIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2023
FLORES, DAWNIndividualW-2 MANAGING EMPLOYEE; ADP OF THE SNFsince 09/12/2012
WILT, ROBERTAIndividualW-2 MANAGING EMPLOYEEsince 10/01/2020
MISSION POINT MANAGEMENT SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2020
HIGHAM, JENNIFERIndividualTRUSTEE OF THE SNFsince 04/14/2023
OEGEMA, JAMESIndividualTRUSTEE OF THE SNFsince 04/14/2023
WILKINS, JOHNIndividualADP OF THE SNFsince 07/05/2018

CMS files one row per role, so the 15 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$4.5M
Net patient revenuemost recent cost report
-6.1%
Operating marginrevenue minus expenses
$686K
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 68%Medicare 6%Other / private 26%

This home reported $686K paid to related parties — landlords or management companies under common ownership — equal to about 14% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$374per resident / day
operating cost
$11,364per month
≈ monthly operating cost
$352per 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 235511. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-11, 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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