Sanilac Medical Care Facility
137 North Elk Street, Sandusky, MI 48471 · Government - County · 104 certified beds · (810) 648-3017 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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 (33) — 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 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 | 6.6% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.1% | 5.4% | 5.4% | better |
| 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 | 2.2% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 1.4% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 2.1% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 9.9% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.7% | 19.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.5% | 20.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.3% | 14.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.1% | 1.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 98.5% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 15.5% | 24.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 20.8% | 11.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.19 | 1.84 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.23 | 1.64 | 1.80 | worse |
* 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.
46.0% 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 64 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 28.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 42 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 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.0%CMS range 35.0–58.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 6.6–13.7 | 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 | 28.6% | 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 | 40.5% | 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 | 19.1% | 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 | 100.0% | 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 | 100.0% | 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 | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 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 | 9.5%CMS range 4.7–17.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 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 104 beds and averages 75.9 residents a day — about 73% occupied, or roughly 28 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 5.32 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.44 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.62 hrs/resident/day on weekends vs 5.61 on weekdays — 18% thinner on weekends. RN hours go from 0.63 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as 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 fewer than at the previous inspection — improving. 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.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · Gcited before2024-07-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Numbers MI00140471 and MI00142854. Based on observation, interview, and record review the facility failed to ensure comprehensive documentation and evaluation to prevent the development of an unstageable facility-acquired pressure ulcer for one resident (Resident #63) of seven residents reviewed for alterations in skin integrity, resulting in Resident #63 acquiring and developing an unstageable pressure ulcer. Findings include: Resident #63: During initial tour on 6/25/2024, Resident #63 was observed sitting in bed visiting with his wife. He stated his goal was to return home but know he has some work to do before that can occur. On 6/25/2024 at approximately 1:30 PM, a review was completed of Resident#63's medical records and it revealed he initially admitted to the facility on [DATE] with multiple readmissions with diagnoses that included, Chronic Osteomyelitis, Diabetes, Acute Kidney Failure, Metabolic Acidosis, Monoplegia, Pressure Ulcer of Sacral Region, Stage 4, Bipolar…
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 · G2024-07-01 · 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 Intake Numbers MI00144103 and MI00144517. Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place, interventions were followed and supervision was provided to prevent falls with injury for 2 residents (Resident #38, and Resident #44) of 5 residents reviewed for falls, resulting in Resident #38 falling during a transfer, having pain and a decline in transfer status to a Hoyer lift, and Resident #44 sustaining fractures in her right foot during a transfer. Findings Include: Resident #44: Accidents: On 6/25/24 at 10:56 AM, Resident #44 was observed sitting in a wheelchair in her room. She was alert and talkative. She said she broke some of her toes on her right foot during a transfer in the bathroom. She said she was supposed to have 2 people help her with the transfer and only one staff member assisted her; She stated, I have a twist it board to stand on with transfers and my foot wasn't on it quite right. They said I broke…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Past Non-Compliance (PNC) was identified during the investigation of the deficient practice and was accepted by the survey team upon exit from the facility for this citation. Following discussion with the State Manager, Past Non-Compliance was accepted with a Compliance Date of 01/28/2026.Based on observation, interview and record review, the facility failed to ensure resident safety when care-planned interventions were not followed during a transfer to a wheelchair for one resident (Resident #1) of four residents reviewed for an injury of unknown origin. Findings include:Resident #1 (R1):On 2/2/26 at 12:29 PM, an observation was made of Resident 1 (R1) sitting in their wheelchair in the dining area of the secured unit of the facility. The Resident had her right leg elevated with a cast on it. The Resident had drinks in front of her and the residents in the dining area were getting ready to eat. An observation was made of a sling with red trim positioned underneath the Resident. The sling was a mechanical lift…
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 before2025-08-21 · 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 kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include:On 08/19/2025 at 8:45AM during the initial kitchen tour with the Certified Dietary Manager (CDM) N, the rag sanitizer bucket was tested with Hydrion quaternary ammonia test strips, and the result was zero. The CDM N changed out the bucket and retested it, and the second result was between 150-200ppm. On 08/20/2025 at 9:03 AM the rag sanitizer bucket was retested with the quaternary test strips, and the result was zero. Conducted interview with the Certified Dietary Manager N on the desired concentration range for the sanitizer and she answered 50-100 ppm. When questioned about how often the sanitizer bucket was changed out, she stated that it is changed every morning and evening shift. She then proceeded to tell dishwashing staff to change out the bucket. Record review of the sanitizer with the label EPA Reg No. 10324-81, according to the product…
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 · F2025-08-21 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake 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 ensure cleanliness of the water system and the use of appropriate backflow prevention on cross connections. This deficient practice increases the likelihood of contamination of the water supply due to uncleanliness and a potential backflow event, potentially affecting all residents, staff, and visitors who consume water at the facility. Findings include:On 08/19/2025 at 1:30PM during the environmental tour with the Director of Operations K, Maintenance Assistant L, and Maintenance Assistant M, observed the water softener brine tank filled with a black foam substance in the main boiler room. Conducted interview with Maintenance Assistant L, he stated that the brine tank is cleaned out every three years and that the cleaning is due. On 08/19/2025 at 1:45 - 2:20PM observed black foam inside the brine tank of the water softener located in the boiler room in the 800 hallway. On 08/19/2025 at 1:45 - 2:20PM observed the drain line to the water softener sitting inside the drain, located in the boiler room in 800…
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 · E2025-08-21 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 staffing to meet the care needs of the residents for a confidential group of residents, and Residents #10, # 50, #52, and #89, resulting in long call light wait times, scheduled activities being cancelled and delayed resident care. Findings include:Facility On 08/20/2025 at 2:00PM, a resident council meeting was held with a confidential group of residents. One confidential resident stated they have numerous long call light wait times. A review of call light response times revealed that on 8/16/25 the resident waited 36 minutes and 26 minutes. On 8/17/25 the resident had wait times 32 minutes, 28 minutes and 26 minutes. On 8/18/25 the resident had a wait time of 49 minutes. Another confidential resident stated, we only have one certified nursing assistant (CNA) per hall and if they are busy then we can wait too long. We need more help around here; the CNA's are so busy they can't answer call lights on time. The confidential group stated they believe the facility needs more CNA staff, they think…
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 · D2025-08-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent verbal abuse for one (Resident #40) of 19 residents reviewed for abuse, resulting in refused care, frustration with the likelihood of increased behavioral disturbances. Findings include:This citation pertains to intake 2594908 On 8/19/2025, at 12:10 PM, Resident #40 was asked if they were happy with their room and Resident #40 offered, that it was a new room. Resident #40 complained there was a girl that worked there and that they had laughed at their grandmother. Resident #40 offered, that they always say hi to them but this girl has got it in for me. Resident #40 was unable to detail the girl's appearance other than she wore pink outfits. On 8/19/2025, at 12:30 PM, the Director of Nursing (DON) offered, they called CNA H to interview them regarding Resident #40 as they left out of the facility prior to the DON arriving. The DON stated, that CNA H was alerted they would be reported for verbal abuse and that CNA H stated, no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-21 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 Preadmission Screening/Annual Resident Review (PASARR) form DCH-3877 and DCH-3878 were completed for one resident (Resident #67) of two residents reviewed for PASARR evaluation.Findings Include: A review of Resident #67's medical record revealed an admission into the facility on 7/30/2003 and readmission on [DATE] with diagnoses that included history of traumatic brain injury, anxiety, mood disorder, mental disorder due to known physiological condition, dementia and need for assistance with personal care. A review of the Minimum Data Set assessment revealed the Resident had severely impaired cognitive skills for daily decision making and was dependent on helper for activities of daily living and mobility. A review of Resident #67's medical record revealed PASARR Level I Screening dated 10/12/2023. The form (Form-3877) indicated Section II-Screening Criteria items 1-6 revealed the following:-1. Yes, The person has a current diagnoses of Mental…
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 before2025-08-21 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failure to ensure availability and accurate documentation for Lexapro (antidepressant medication) for one resident (34) of 5 reviewed for medication management, resulting in Resident #34 not receiving her medications for approximately three weeks and imprecise medication administration documentation.Findings Include:On 8/20/2025 at approximately 9:15 AM, a review was conducted of Resident #34's medical record and it indicated she admitted to the facility on [DATE] with diagnoses that included Dementia, Hyperlipidemia, Hypertension, Adjustment Disorder with mixed anxiety and depressed mood and Anxiety. Further review revealed the following:Physician Orders:Lexapro Oral Tablet 5 MG (milligram)- Give one tablet by mouth one time a day for agitation, irritability, depressed mood.August 2025 MAR (Medication Administration Record)Of the twenty days reviewed on the MAR, Lexapro was administered 10 times. It can be noted Resident #34 did not have lexapro available for…
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 · D2025-08-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure restorative therapy services were provided for two Residents (#36 and 50), of three reviewed for limited range of motion. Findings include: Resident #36 On 8/20/2025, at 2:15 PM, a record review of Resident #36's electronic medical record revealed an admission on [DATE] with diagnoses that included muscle weakness, difficulty in walking and need for assistance with personal care. Resident #36 required assistance with all Activities of Daily Living and had intact cognition. A review of the physician orders revealed NURSING REHAB/RESTORATIVE: ACTIVE ROM Program AROM: Dumb bells 2# 2x15 BI/TRI-2.5 # A.W 2x25 kicks, knee lifts, hip Abd/add and ankle pumps. Static standing x3 to tolerance performing task. Start: 7/31/2025 End: 8/28/25. NURSING REHAB/RESTORATIVE: Walking Program 3 x week CGA FWW 150x2 no WC to follow: Start: 7/31/25 End 8/28/25 A review of the The resident has limited physical mobility r/t (related to) weakness Date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-21 · 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
Based on observation, interview and record review, the facility failed to ensure that an indwelling urinary catheter bag and tubing were not in contact with the floor during transport of the Resident through the dining area and hallway and when the Resident was seated in their wheelchair in their room, for one Resident (#2), of two reviewed for indwelling urinary catheters. Findings include:A review of Resident #2's medical record revealed an admission into the facility on 4/30/25 with diagnoses that included diabetes, pressure ulcer of sacral region Stage IV, need for assistance with personal care, and dementia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 8/15 that indicated moderately impaired cognition, and the Resident was dependent on helper for activities of daily living, transfers and mobility. Further review of the medical record revealed the Resident had an indwelling urinary catheter. On 8/19/25 at 12:56 PM, an observation was made of Resident #2 in the dining room for the lunchtime meal. The Resident was seated in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-01 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains to Intake MI00142721 Based on observation, interview and record review, the facility failed to administer a nebulizer treatment according to professional standards for Resident #35, administer medications as prescribed by the physician for Resident #224 and Resident #322, and ensure standards of practice for appropriate diagnosis and use of multiple psychotropic and antipsychotic medications for Resident #377, of seven residents reviewed for medication administration and five residents reviewed for medication regimen review, resulting in Resident #35 not assessed prior to administration or monitored during the duration of a nebulizer treatment with the potential for complications to go unnoticed, untreated or not receive the prescribed amount of medication used to treat lung disease, the potential for exacerbation of medical conditions for Resident #35, Resident #224 and Resident #322, and inappropriate diagnosis and treatment for Resident #377. Findings include: Resident #35: On 6/27/24…
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.
Show the remaining 21 citations
- Potential for harm · Ecited before2024-07-01 · tag F0880 — failed to prevent and control infections — patternProvide 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 implement and operationalize a comprehensive infection control program encompassing outcome and process surveillance and failed to ensure readily available hand hygiene supplies, hand hygiene performance and catheter care per professional standards of practice, resulting in a lack of tracking of potential infections, a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the likelihood for the spread of microorganisms and illness to all 71 facility residents. Findings include: On 6/26/24 at 1:50 PM, a tour of the 400-hall of the facility was completed. No hand sanitizer dispensers were observed in the hallway and/or in the resident rooms in the hallway. On 6/26/24 at 2:03 PM, Certified Nursing Assistant (CNA) X and another facility staff member were observed in Resident #41's room. Resident #41 was sitting in a recliner chair. The staff member was observed touching items in the room…
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 · D2024-07-01 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to obtain informed consent prior to initiating antipsychotic medication for two residents (Resident #25 and Resident #32) of three residents sampled for antipsychotic medication use, resulting in the resident and/or responsible party not being informed of the risk versus benefit of antipsychotic medication use prior to initiation. Findings include: Resident #25 (R25): Resident #25 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, dementia with agitation, anxiety and major depressive disorder. R25 has a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. On 06/25/24 at 04:30 PM, R25 was observed wandering in and out of multiple resident rooms in their wheelchair. R25 was yelling hello as they entered each room and they were looking for someone named [NAME]. This surveyor approached R25 and asked them who [NAME] was and if I could help them find…
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 · D2024-07-01 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 accommodate resident choice in Guardianship for 1 resident (#16) of 27 residents reviewed for resident choice, resulting in Resident #16 becoming upset and worried that she would not have someone to look out for her when her wishes were not considered. Findings Include, Resident #16 Choices On [DATE] at 9:30 AM, during a tour of the facility, Resident #16 was observed getting ready for the day. She was sitting in her wheelchair, dressed and preparing to attend an activity in the dining room. She said she spent most of her day in the facilities activities and that is what she enjoyed doing. She said she had some issues to discuss. Resident #16 said she was upset because the facility was suing her to remove her Guardian, who is her sister and replace her with a public guardian. The resident said they had to go to court twice and there is another hearing with an attorney over the resident losing her Medicaid eligibility and not having her bill…
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 · D2024-07-01 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to update/revise individualized, person-centered care plans to reflect changing care needs for three residents (Resident #2, Resident #6, and Resident #32), of 30 residents reviewed for care plans, resulting in the potential for unmet care needs. Findings Include: Resident #2: Accidents On 6/25/2024 at 12:56 PM, Resident #2 was observed sitting in a wheelchair in his room. He was alert but did not answer any questions. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #2 was admitted to the facility on [DATE] and had multiple discharges and readmissions with the most recent readmission on [DATE] with diagnoses: history of traumatic brain injury, paraplegia, chronic kidney disease, kidney stones, urinary catheter, history of seizures, gastrostomy tube, hypothyroidism, and anxiety. The MDS assessment dated [DATE] revealed the resident had severe cognitive dysfunction and needed assistance with all care.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-01 · 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 Intake Number MI00140471. Based on observation, interview and record review the facility failed to ensure nail care was routinely provided for one resident (Resident #68) of 4 residents reviewed for Activities of Daily Living (ADL), resulting in Resident #68 having long, soiled, fingernails and long, cracked toenails. Findings Include, Resident #68 Activities of Daily Living On 6/25/24 at 12:51 PM, during a tour of the facility, Resident #68 was observed to have her left foot with long, cracked toenails. Her fingernails were extremely long and soiled. The resident said she couldn't trim them herself, but her granddaughter helped trim a couple of her toenails, although she couldn't trim 2 of them because the toenails were too long and difficult to cut. When asked if the staff assisted her, she said they had not trimmed them in a while. A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #68, indicated the resident was admitted to the facility on [DATE] 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.
- Potential for harm · D2024-07-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 provide oxygen per physician's order and store nebulizer equipment sanitarily for one resident (Resident #35) of three residents reviewed for respiratory needs, resulting in oxygen administration provided of improper dosage with the likelihood of decreased oxygenation and infection. Findings include: Resident #35: On 6/25/24, at 10:54 AM, Resident #35 was resting in bed. Their oxygen concentrator was dialed to 5 liters of oxygen and was on via a nasal cannula. Their nebulizer mask was lying on top of their nightstand face down. On 6/25/24, at 2:44 PM, a record review of Resident #35 electronic medical record revealed an admission on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Stroke and Congestive Heart Failure. Resident #35 required assistance with all Activities of Daily Living and had intact cognition. A review of the physician orders revealed Apply Oxygen at 6 liters/min per nasal cannula with humidified…
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 · D2024-07-01 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure coordination of dialysis care for one resident (Resident #26) of 1 resident reviewed for dialysis services, resulting in a lack of assessment for the left arm Dialysis fistula, dressing and site, resulting in the potential for unidentified complications. Findings Include: Resident #26: Dialysis A record review Face sheet and Minimum Data Set (MDS) assessment for Resident #26 indicated the resident was admitted to the facility on [DATE] with several discharges to the hospital and readmissions. The latest readmission was 2/6/2024 with diagnoses: history of a stroke, right side weakness, kidney stones, respiratory failure, COPD, diabetes, chronic kidney disease, renal dialysis dependence, morbid obesity, and heart failure. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15 and the resident needed assistance with all care. On 6/25/24 at 11:20…
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 · D2024-07-01 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 a medication error rate of less than 5% when two medications were omitted for Resident #224 and nine medications were not administered timely for Resident #224 and Resident #322, from a total of 42 opportunities, resulting in a medication administration error rate of 26.19% with the potential for adverse reactions or exacerbation of conditions related to the omission of the medications or medications not given timely. Findings include: Resident #224: On 6/27/24 at 9:11 AM, during observation of medication administration task, Nurse L was observed to prepare medication for Resident #224. The Nurse prepared the Residents medication and put them in a cup. The Protonix 40mg delayed release was not available. When asked why the medication was not available, Nurse L indicated that it had to be ordered and they did not have it available in the facility. The Nurse retrieved the Resident's inhaler from the box with the Residents name on the inhaler and box. The Nurse had to retrieve medication from 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 before2024-07-01 · 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 store medications, including a narcotic medication, properly during the medication administration task of the survey, resulting in improper medication storage with the potential of drug diversion. Findings include: On 6/27/24 at 9:12 AM, during observation of medication administration task, Nurse L was observed to prepare medication for a resident. The Nurse prepared the Residents medication and put them in a cup. The Nurse retrieved the Resident's inhaler from the box with the Residents name on the inhaler and box. The Nurse had to retrieve medication from the medication storage room refrigerator. Prior to retrieving the refrigerated medication, the Nurse wrote the Resident's name on the cup of medications and placed the cup and the inhaler in a top drawer of the medication cart. Inside the top drawer was another cup of medications with a Resident's name written on the cup. The Nurse retrieved the medication from the med room refrigerator and took out the cup of medications from the top drawer 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 · Dcited before2024-07-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a comprehensive antibiotic stewardship and monitoring program for two residents (Resident #2 and Resident #21) of two residents reviewed, resulting in inappropriate use of antibiotics. Findings include: Resident #2: On 6/25/2024 at 12:56 PM, Resident #2 was observed sitting in a wheelchair in his room. He was alert, but did not answer any questions. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #2 was admitted to the facility on [DATE] and had multiple discharges and readmissions with the most recent readmission on [DATE] with diagnoses: history of traumatic brain injury, paraplegia, chronic kidney disease, kidney stones, urinary catheter, history of seizures, gastrostomy tube, hypothyroidism, and anxiety. The MDS assessment dated [DATE] revealed the resident had severe cognitive dysfunction and needed assistance with all care. A record review of Resident #2's medical record, indicated he had…
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 before2024-07-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Numbers MI00142202 and MI00144560. Based on interview and record review, the facility failed to assess and monitor hydration status timely and notify family for one resident (Resident #376) of one resident assessed for Intravenous (IV) fluids, resulting in an undocumented amount of IV fluids administered, no family notification and ultimately hospitalization. Findings include: Resident #376: On 6/26/24, at 10:15 AM a review of Resident #376's electronic medical record revealed an admission on [DATE] with diagnoses that included Diabetes Type 2, Dysphagia and Chronic Kidney Disease. A review of a laboratory result verified on 1/10/2024 . Sodium Lvl (level) Value 158 (H) .Ref. Range/Units 135 - 145 . A review of the Medication Administration Record 1/1/2024 - 1/31/2024 revealed no entry for the 1 liter or normal saline intravenous documented. A review of the IV Assessment Effective Date: 01/11/2024 16:48 . Location of IV Right Forearm . Type of IV Solution 0.9 % sodium Chloride .…
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 · D2024-07-01 · 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 Number MI00142721. Based on interview and record review, the facility failed to operationalize policies and procedures to mitigate potential adverse consequences of psychotropic medications for one resident (Resident #377) of two residents reviewed for behaviors, resulting in a lack of baseline laboratory testing prior to the initiation of multiple psychotropic medications, ongoing in facility monitoring, and identification of potential adverse consequences in a timely manner with Resident #377 suffering decreased liver and kidney function, and a decline in overall health. Findings include: Resident #377: Review of Intake documentation dated as received 2/12/24 revealed Resident #377 was 57-years old male with dementia and including the allegations that Resident #377 was over sedated, and their health had rapidly and drastically declined including no longer being able to walk and talk. The intake detailed the facility is giving (Resident #377) Risperdal (antipsychotic medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-06-28 · 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 1) Failed to ensure that food preparation and kitchen equipment were maintained in a sanitary manner and in good working condition, and 2) Failed to ensure that kitchen dish machine temperature logs were completed, resulting in an increased potential for food borne illness with possible hospitalization and with the potential to affect the census of 74 residents who consume nutrition from the facility kitchen. Findings include: During the initial kitchen tour on 6/22/23 at 8:00 a.m., accompanied by [NAME] D, the following was observed: -At 8:15 a.m., a large bag of open whipped cream with no dates at all was found in the cooler. -At 8:17 a.m., the large can opener had chipping silver paint on the blade. -At 8:30 a.m., the produce cooler was observed to have food, excessive crumbs, dirt and pieces of paper on the bottom of it. It had not been cleaned the night prior. During an interview done on 6/22/23 at 8:17 a.m., Dietary Manager F stated The stock person cleans it (the cooler) on Wednesdays and Friday's. They are…
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 · F2023-06-28 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to effectively conduct a Quality Assurance and Performance Improvement program for all residents residing within the facility, resulting in 1) A physician prescribing antibiotics prior to laboratory results, 2) Inconsistent narcotic counts, 3) Resident Council grievances, 4) Infection rate action plans and 5) Call lights within reach for residents' use, all with the likelihood for residents' frustration. Findings include: Record review of the facility 'Quality Assessment and Assurance Committee' policy, dated 9/13/2021, revealed that the governing board of the facility potentates high-quality resident care by requiring and supporting the establishment of the Quality Assessment and Assurance Committee as a permanent committee of the facility. The Quality Assessment and Assurance Committee is advisory to the administration and the governing board of the facility. The Quality Assessment and Assurance Committee has the full authority of the governing board to implement the QAA program of the facility including but not limited to,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-28 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 by not ensuring that 7 residents' (Resident #2, Resident #22, Resident #27, Resident #43, Resident #64, Resident #70, and Resident #128) call lights were within reach, of 24 resident's sampled, resulting in decreased safety while left in the room alone without a way to contact staff in an emergency, and feelings of anger, frustration, decreased dignity and fear of being left alone. Findings Include: Review of the facility Call Button/Activator: Accessibility and Timely Response/Resident Call Pagers (includes call lights), reported This policy is to assure residents to call for assistance. Assess the arrangement of furniture in the resident's room to assure proper call button/activator placement. Determine if the call light is easily accessible, determine if the resident has the call button/activator within reach of his/her bed. During observations made on 6/23/23 from 6:10 a.m., through 6:15 a.m., a total of 5 residents…
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 · Ecited before2023-06-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 properly identify and treat Urinary Tract Infections (UTI) for five residents (Resident #11, Resident #13, Resident #49, Resident #59, and Resident #176), resulting in the likelihood for urinary tract infections to be mistreated with prolonging of illnesses or hospitalizations. Findings include: Record review of the facility 'Infection Control Coordinator' job description (undated) revealed that the infection control coordinator will plan, develop, organize, implement, evaluate, coordinate and direct facility infection control program in accordance with current rules, regulations and guidelines that govern such requirements in long-term care facility. Ensure that the facility is in compliance with current CDC, OSHA, and local regulations concerning infection control . Record review of the facility provided 'McGeers criteria for infection surveillance checklist' dated 2012 revealed constitutional criteria for infection of: fever,…
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 · E2023-06-28 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure each resident’s drug regimen must be free from unnecessary 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 interview and record review, the facility failed to obtain adequate indication for the use of treatment with antibiotics for 5 residents (Resident #11, Resident #13, Resident #49, Resident #59, and Resident #176), resulting in the likelihood for urinary tract infections to be mistreated and prolonged illnesses or hospitalizations. Findings include: Record review of the facility 'Antimicrobial Stewardship' policy, dated 7/20/2021, revealed the facility antibiotic stewardship will implement to improve antibiotic prescribing practices and reduce inappropriate use . Each action implemented to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents. Accountability: Antibiotic stewardship activities will be led by the Infection Control Preventionist (ICP) nurse who will use the medical director, pharmacists, laboratory, health department, infectious disease consultants, Director of Nursing or CDC as supportive resources as needed.…
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 · Ecited before2023-06-28 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 1) Failed to ensure that controlled medication shift change sheets, dated 06/23, had the correct daily count for 2 medication carts (Cart 300 and Cart 600/800), and 2) Failed to ensure a clean and sanitary medication cart (Cart 600/800), resulting in the likelihood for missing narcotics, residents not receiving pain medications (narcotics) per orders and increased pain for a census of 74 residents. Findings Include: Observation of the 600/800 medication cart accompanied by Nurse, LPN B done on 6/22/23 at 10:19 a.m., revealed crushed medications and papers in the bottom of the second drawer. During an interview done on 6/22/23 at 10:30 a.m., Nurse B stated The night nurse cleans it (medication carts). Observation of the 600/800-medication cart narcotic shift count sheet dated 6/23, done on 6/22/23 at 10:19 a.m., revealed no documentation for shift narcotic sheet (the reconciliation sheet) dated 6/19/23 at 1800; nor was an outgoing nurse signature (Nurse, LPN H) found for the same day. Nurse H had not documented a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to prevent moisture associated skin damage for one resident (Resident #49), resulting in pain and discomfort and the likelihood for the development of a pressure injury to the skin. Findings include: Record review of the facility 'Wound Care' policy dated 8/29/2019 revealed that all new wounds noted will be measure by wound care nurse or designee within one business day. Record review of the facility Treatment Nurse' job description (undated) revealed the primary purpose of the job position is to provide primary skin care to residents un the medical direction and supervision of the resident's attending physician. The wound care and treatment nurse goal: to reduce workload with charge/art nurse, improve wound care, decrease facility acquired pressure ulcers, assist with management of moisture associated skin damage, and assist with the duties of the wound care/infection control department. Resident: #49: In an observation on 06/22/23 at 09:59 AM the state surveyor observed bilateral buttocks with damaged areas…
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 before2023-06-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility 1) Failed to ensure that the Infection Control program analyzed monthly resident and staff infections completely and accurately, and 2) Failed to put complete COVID precautions in place (stopping the use of fans turned on in the hallways of the main unit) on 06/27/23, when 5 residents (Resident #1, Resident #22, Resident #27, Resident #35 and Resident #129) became positive with COVID-19, resulting in the likelihood for cross contamination of medications in the medication cart, cross contamination of COVID from resident-to-resident, and the likelihood of an increase in resident infections with resident illnesses and hospitalizations. Findings Include: On 6/22/23 at 10:53 a.m., the Infection Control program and tracking, graphs, and analysis for the months of 3/23, 4/23, and 5/23 was reviewed accompanied by Infection Control/IC Nurse, RN C. Review of month's 3/23 and 4/23, revealed no analysis of the data collected. Also, no staff illnesses compared to resident infections analysis was found. Review of the month 5/23, revealed data was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility 1) Failed to ensure monitoring and analyzing of resident illnesses and antibiotic usage, and 2) Failed to ensure that resident infections met the accepted McGeer criteria, indicating that signs and symptoms were documented as meeting the criteria, resulting in the likelihood of resident infections not meeting the McGeer definition of infection and not meeting the criteria for antibiotic usage, adverse side effects from antibiotics, and over antibiotic usage with the possibility for antibiotic resistance, and increased resident illnesses. Findings Include: Review of the facility Resident Infections for the Month of March 2023, revealed a total of 17 resident infections with antibiotic usage of 19 (non-COVID) resident infections that did not meet the McGeer criteria for antibiotic usage. No tracking for asymptomatic UTI infections nor reassessment after treatment in 2 to 3 days for appropriateness of antibiotic usage was found. Most of the resident infections did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2024-07-31 for 13 days
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SANILAC COUNTY | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 08/01/1968 |
| BUTTAR, NICK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/02/2024 |
| CARINGI, HEATHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/29/2022 |
| DUNSMORE-GANLEY, RACHEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/23/2024 |
| JOHNSON, TAMMI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2023 |
| LABA, TERI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/26/1998 |
| MILLER, LINDSEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/31/2022 |
| MILLER, NICOLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/15/2024 |
| POWELL, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | NO DATE PROVIDED |
| SHERMAN, CARI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/09/2025 |
CMS files one row per role, so the 19 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $62K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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
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 235157. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-21, 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.