MyMichigan Medical Center Sault
500 Osborn Boulevard, Sault Ste. Marie, MI 49783 · Non profit - Corporation · 51 certified beds · (906) 635-4460 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)
- 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 Mar 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $2,797 in federal fines (most recent 2023-08-28)
- it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 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 | 19.2% | 10.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.4% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.1% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 9.8% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 5.7% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.9% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 23.1% | 12.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 18.5% | 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 | 9.6% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.5% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.7% | 14.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.5% | 1.1% | 1.4% | worse |
§ 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.
Staffing
No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.
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.
30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · G2026-01-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to effectively monitor for progression of a Stage IV pressure injury (full-thickness tissue loss with exposed muscle, bone, tendon or cartilage exposed) for one Resident (#21) of two residents reviewed for pressure injuries. This deficient practice resulted in unidentified worsening of the wound with infection requiring debridement and intravenous (IV) drug therapy.Findings include:Resident #21 (R21)An observation on 1/12/2026 at 12:49 p.m. revealed R21 seated in bed, reading. A wound vac (vacuum-assisted wound closure device) was observed with tubing leading from the device toward the resident, disappearing under the Resident's blanket near the area of her buttocks. When asked about her wound, R21 stated, it's been there for some time, and could offer no further details. Further observation revealed an IV access line in R21's right upper arm.On 1/14/2026 at 1:30 p.m. an observation of R21's wound care was completed as conducted by Registered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2025-02-19 · 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 MI00150095. Based on observation, interview and record review, the facility failed to follow care planned interventions to ensure staff performed safe transfers for two Residents (#1 and #3) of four residents reviewed. This deficient practice resulted in actual harm when Resident #1 experienced a fall resulting in a right femur fracture and subsequently required surgical intervention and pain. Findings include: Resident #1 (R1) Review of a Witnessed Fall, report, provided by the Director of Nursing (DON) and dated 1/29/2025 at 5:41 p.m., revealed the following: Resident [R1] was ambulating x 1 CNA [Certified Nursing Assistant] assist to toilet when legs became weak, and the resident was lowered to the ground with a gait-belt . Immediately post lowering the resident complained of right leg pain. RLE [right lower extremity] appeared to be shortened and foot inverted . did [complain of] right leg/thigh pain .The resident was assisted with a transfer sheet onto a stretcher and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-01-14 · 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 store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by:Failing to ensure labeling of food.Failing to ensure expired food was discarded.Failing to ensure proper hand sanitization when preparing food.This deficient practice had the potential to result in food borne illness among any or all 35 residents in the facility who receive meals.Findings include:During an observation of the kitchen on 1/12/26 at 11:54 a.m., Dietary Staff C and Dietary Staff D were not wearing beard restraints while they were preparing food.During an interview on 1/12/26 at 11:55 a.m., Registered Dietitian B reported the Dietary Staff that have long facial hair are to wear beard restraints when working in the kitchen.During an interview on 1/12/26 at 11:56 a.m., Dietary Staff C reported that He does not normally wear a beard restraint while working in the kitchen.Review of policy titled Food Safety Management System last revised 5/31/25, read in part .Food employees must wear hair…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-01-14 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 COVID 19 vaccinations were offered to five Residents (#1, #3, #7, #21, & #25) of five residents reviewed for COVID 19 vaccinations resulting in the potential for serious respiratory illness.Resident #1 (R1)Review of the Minimum Data Set (MDS) assessment, dated 12/10/2025, revealed R1 was admitted to the facility on [DATE]. Review of R1's electronic medical record (EMR) revealed no documentation indicating the Resident was offered and/or received/declined the current 2025-26 Covid-19 vaccination. Further review of the EMR revealed the most recent documentation was a signed declination for the 2024-25 Covid-19 vaccination, dated 10/10/2024.Resident #3 (R3)Review of the MDS assessment, dated 12/02/2025, revealed R3 was admitted to the facility on [DATE]. Review of R3's EMR revealed no documentation regarding the Resident's Covid-19 immunization status. Further review revealed no documentation R3 was offered and/or received/declined the current…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 perform an assessment for self-administration of medication for one Resident (#5) of one resident reviewed for self-administration of medication.Findings include:Resident #5 (R5)A review of R5's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with diagnoses including: anxiety disorder, depression, and diabetes mellitus. R5 scored 12 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of moderate cognitive impairment.During an observation on 1/12/26 at 2:15 p.m., R5 had a tube of antibiotic ointment and a small bottle of [name brand] advanced eye relief drops on her bedside table.During an interview on 1/12/26 at 2:16 p.m., R5 explained she used eye drops to moisten her dry eyes during the day. R5 was queried about the antibiotic ointment, and she pointed to a scratch on her forearm and explained she had the ointment to treat a scratch.Review of R5's Electronic Medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 residents or resident's representatives were provided with written notification of transfer and/or the facility's bed hold policy at the time of transfer out of the facility or anytime thereafter for two Residents (#1 and #3) of three residents reviewed for hospitalization.Findings include:Resident #1 (R1)Review of the Minimum Data Set (MDS) assessment, dated 11/19/2025, revealed R1 was initially admitted to the facility on [DATE] and was transferred to a short-term general hospital on [DATE].Review of R1's census data in the electronic medical record (EMR) revealed a hospitalization on 11/17/2025 and R1 returned to the facility on [DATE].The EMR for R1 revealed the following progress note:11/17/2025 at 7:00 a.m. CNA this morning had this writer come into resident's room to have a listen to her. Upon entering the room this writer could hear resident gargling and a wet cough. Vital signs taken BP-104/51, P-113, O2-84%, T-100.4, R-22. Resident 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 · D2026-01-14 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 meet the needs of a resident coping with verbal and physical abuse, provide emotional support from social services, obtain outside referral services, and develop and implement a comprehensive care plan for one Resident #5 (R5) of one resident reviewed for social services and referral services. This deficient practice resulted in harm which affected R5's psychosocial wellbeing with statements of physical and verbal abuse from her son and a verbalization of feeling scared.Based on observation, interview, and record review, the facility failed to meet the needs of a resident coping with verbal and physical abuse, provide emotional support from social services, obtain outside referral services, and develop and implement a comprehensive care plan for one Resident #5 (R5) of one resident reviewed for social services and referral services. This deficient practice resulted in harm which affected R5's psychosocial wellbeing with statements 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.
- Potential for harm · D2026-01-14 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 timely review and follow-up for pharmacy recommendations for two Residents (#1 and #2) of five residents reviewed for unnecessary medications.Findings include:Resident #1 (R1)Review of the Minimum Data Set (MDS) assessment, dated 12/10/2025, revealed R1 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's Disease, depression and adjustment disorder. Further review of the MDS assessment revealed R1 scored five out of 15 on the Brief Interview for Mental Status (BIMS), indicating the Resident had severe cognitive impairment.Review of the June through December 2025 medication regimen reviews (MRRs) completed by the facility's consultant pharmacist and gleaned from the electronic medical record (EMR), revealed a pharmacist's Consultation Report, with a recommendation date of 6/06/2025. Further review of the Consultation Report, revealed the following: [R1] receives Abilify [antipsychotic medication] 15 mg [milligram] daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-14 · 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 an effective antibiotic stewardship program affecting one Resident (#29) of one resident reviewed for antibiotic use. This deficient practice resulted in the potential for the administration of unnecessary medication and antibiotic resistance.Findings include:Resident #29 (R29)Review of the Minimum Data Set (MDS) assessment, dated 11/11/2025, revealed R29 was admitted to the facility on [DATE] and had diagnoses including dementia and urinary tract infection (UTI).Review of R29's electronic medical record (EMR), accessed 1/12/2026, revealed the following active physician order:Bactrim (sulfamethoxazole-trimethoprim) Oral Tablet 400-80 MG [milligram]. Give one tablet by mouth in the morning for chronic UTI. Starte date: 2/08/2025.Review of R29's pharmacist Consultation Report, dated 7/03/2025, revealed the following: [R29] has received Bactrim 1 tablet daily for UTI prevention since 2-8-25. The order has a stop date of 1-14-26. She recently 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 · D2025-03-13 · 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 ensure the residents right to be free from abuse for two Residents (R10 and R11) of four residents reviewed for sexual abuse, resulting in the potential for psychosocial harm including feelings of humiliation and fear based on a reasonable person standard. Findings include: Review of a facility five-day investigation summary, submitted to the State Agency (SA) on 2/23/2025 at 6:04 p.m., revealed the following: On 2/23/25, [R10] was sitting in the dining room across the table from [R11] when [CNA C] heard [R10] ask [R11] 'come here and come on, you want to touch it. [CNA C] witnessed [R10] with his penis pulled through the bottom of the left leg of his shorts in his hand. Review of the Minimum Data Set (MDS) assessment, dated 3/6/2025, revealed R10 was admitted to the facility on [DATE] and had diagnoses including anxiety, sleep disorder and dementia. Further review of the MDS assessment revealed R10 was independent for transfers and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-31 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to MI00149861 Based on interview and record review, the facility failed to notify the state agency of a resident-to-resident sexual abuse allegation to the state agency for two Residents (#1 and #3) of four Residents reviewed for abuse. This deficient practice resulted in the potential for sexual abuse abuse. Findings include: Resident #1 (R1) Review of R1's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 7/12/22, with active diagnoses that included: dementia and depression. R1 scored a 9 of 15 on the Brief Interview of Mental Status (BIMS) assessment reflective of moderate cognitive impairment. Resident #3 (R3) Review of R3's MDS assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: dementia, anxiety disorder, and depression. R3 scored a 3 of 15 on the BIMS assessment reflective of severe cognitive impairment. Review of R1's behavior note dated 1/18/25 at 15:45 revealed R1 was sitting next to R3 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.
- Potential for harm · D2025-01-31 · 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 This citation pertains to MI00149861 Based on interview and record review, the facility failed to ensure care plans were updated promptly and revised appropriately for two Residents (#1 and #3) of four residents reviewed for care plans. This deficient practice resulted in care plans which did not reflect resident needs. Findings include: Resident #1 (R1) Review of R1's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 7/12/22, with active diagnoses that included: dementia and depression. R1 scored a 9 of 15 on the Brief Interview of Mental Status (BIMS) assessment reflective of moderate cognitive impairment. Resident #3 (R3) Review of R3's MDS assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: dementia, anxiety disorder, and depression. R3 scored a 3 of 15 on the BIMS assessment reflective of severe cognitive impairment. Review of R1's behavior note dated 1/18/25 at 15:45 revealed R1 was sitting next to R3 in the dining…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · D2025-01-16 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
This Citation Pertains to Intake Number MI00149462. Based on interview and record review the facility failed to ensure a complete and thorough investigation was completed on an incident of potential abuse involving two Residents (#30 and #31) out of three Residents reviewed for abuse. This deficient practice resulted in the potential for undetected abuse. Findings include: Resident #30 (R30)/Resident #31 (R31) A Facility Reported Incident (FRI) was received on 1/1/25 at 7:45 PM, which read in part: Incident Summary Registered Nurse (RN E) reported to NHA (Nursing Home Administrator) . witness and Resident Assistant (RA D) reported . she heard (R31) ask (R30) to touch him on the groin. (R30) subsequently placed her hand on (R31's) groin. Residents were immediately separated . On 1/16/25 at 1:25 PM, the NHA and this surveyor viewed the dining room video of the incident between R30 and R31. The residents involved in the FRI were present in the video but were seated at a far distance from the camera. No sound was recorded. R30 does lean in and is visibly closer to R31 several times but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-12-04 · 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 store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failing to ensure that food items were kept free from contamination due to improper storage or due to potential thawing and refreezing. B. Failing to properly clean and sanitize dishes and utensils. C. Failing to ensure food preparation surfaces in the dietary department were properly sanitized. D. Failing to ensure that food items were dated and discarded on or before the expiration date. This deficient practice had the potential to result in food borne illness among any or all 35 residents in the facility. Findings include: During a tour of the kitchen with Registered Dietitian (RD) A on 12/2/24 at 10:00 AM, a walk-in freezer (#2) had no internal thermometer and large chunks of ice had formed on the floor of the freezer under the condenser. RD A stated there was a work order to look at this problem. There was evidence of ice cascades on food product under the condenser. RD A stated this…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-12-04 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that a Quality Assurance and Performance Improvement (QAPI) program committee was composed of the required committee members. This deficient practice resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues placing all 35 residents of the facility at risk for quality care concerns. Findings include: During an interview on 12/4/24 at 3:10 PM, the Nursing Home Administrator (NHA) stated the QAPI committee previously met quarterly and now met monthly. The NHA reviewed the Long Term Care (LTC) QAPI Sign In or meeting attendance records for the required members and identified the following: - On 2/15/24 the QAPI meeting included the NHA, the Director of Nursing (DON), the Medical Director, the Infection Preventionist (IP), plus 3 other members. - The next record of a QAPI meeting was not until 6/20/24 which included the NHA, the DON, the IP, plus 5 other members. The Medical Director was not in attendance. - On 7/18/24 the QAPI meeting was held and included, 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 · Ecited before2024-12-04 · tag F0810 — patternProvide 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
Based on observation, interview, and record review, the facility failed to provide dining adaptive equipment for four Residents (#26, #23, #3, and #24) of 6 residents reviewed for dining assistive devices. This deficient practice resulted in increased difficulty with food consumption and independent eating, as well as the potential for decreased food/fluid intake and risk for weight loss. Findings include: Resident #26 (R26) On 12/2/24 at 12:21 PM, R26 was eating lunch in the facility dining room and was observed with regular utensils including a knife, fork, and spoon. R26's meal tray card included Adaptive Equip: No Knives/cut food as needed for resident. Certified Nurse Aide (CNA) K approached the resident and removed the knife without explanation. When questioned CNA K was not sure why the resident could not have knives. A review of the electronic medical record (EMR) for R26 revealed a care plan including a focus of: The resident has potential nutritional problem r/t (related to): Medical/Physical conditions -Dementia dx (diagnosis); has confusion/memory deficits. May have…
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 · D2024-12-04 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Resident #1 (R1) Review of R1's EMR progress notes revealed R1 was transferred to the emergency department on 7/29/2024 and admitted to the hospital with discharge back to the facility on 8/01/2024. Further review of R1's EMR revealed no documentation of notification of transfer or discharge was provided to R1 or their representative. Review of the July 2024 transfer and discharge list provided to the Long-Term Care Ombudsman revealed R1's transfer and hospitalization was not included on the list. Review of the facility policy titled, Transfer (Internal and External) and Discharge, last revised 9/2023, revealed the following: Purpose: To ensure residents are appropriately transferred or discharged from the LTC [Long Term Care] . During review of the policy, it was noted the policy included no language or instruction on the provision of notification of transfer or discharge to the resident, the resident's representative or the facility's assigned Long-Term Care Ombudsman. Based on interview and record review, the facility failed to notify, in writing, the resident, resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-04 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide written notification of the bed-hold policy to residents or their representatives prior to a hospital transfer for two Residents (#16 and #1) of two residents reviewed for hospital transfers. Findings include: Resident #16 (R16) A review of the electronic medical record (EMR) revealed on 9/13/24, R16 was transferred to the hospital and returned 9/16/24. The EMR revealed no documentation indicating R16 or their representative was provided information on the facility bed hold policy or agreement at the time of transfer or after hospitalization. During an interview on 12/4/24 at 11:20 AM, the Nursing Home Administrator (NHA) stated the bed hold policy was not reviewed with the resident or the responsible party at the time of transfer. Resident #1 (R1) Review of R1's EMR progress notes revealed R1 was transferred to the emergency department on 7/29/2024 and admitted to the hospital with discharge back to the facility on 8/1/2024. Further review of R1's EMR revealed no documentation indicating R1 or their representative…
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 · D2024-12-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to physically assess an acute change in condition and failed to timely identify and treat constipation for one Resident (#18) of one resident reviewed for change in condition, resulting in abdominal discomfort, nausea, and the potential for worsening of medical condition and complications of constipation. Findings include: Resident #18 (R18) Review of R18's Minimum Data Set (MDS) assessment, dated 10/23/2024, revealed admission to the facility on [DATE] with diagnoses including peripheral vascular disease, Type 2 diabetes mellitus with hyperglycemia, left above the knee amputation and gangrene (tissue death from infection or lack of blood flow) of the right foot. Further review of the MDS assessment revealed R18 was cognitively intact and required extensive/maximal assistance with transfers and toileting. On 12/2/2024 at 10:13 a.m., R18 was observed seated in bed, holding a tissue to her mouth. Further observation revealed a green emesis bag…
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 before2024-12-04 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 appropriate feeding assistance for one Resident (#20) of one resident reviewed for nutrition, resulting in the potential for decreased intake and weight loss. Findings include: Resident #20 (R20) A review of R20's Minimum Data Set (MDS) assessment, dated 11/6/2024 revealed R20 was admitted to the facility on [DATE] and had diagnoses including dementia and arthritis. Further review of the MDS assessment revealed R20 had severe cognitive impairment. Review of R20's, Medical Nutrition Therapy Assessment, completed by Certified Dietary Manager (CDM) C on 11/11/2024 at 2:49 p.m. revealed R20 had a history of weight loss/underweight BMI [body mass index]. Further review of the Assessment reviewed the following: . verbal reports from CNA [certified nursing assistant] and NSG [nursing] indicate signs resident may need increased cueing and assistance [related to] gradual cognitive decline and increased dexterity/pain [related to] rheumatoid…
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 · D2024-12-04 · 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 less than five percent for 1 Resident of 4 residents reviewed for medication administration, resulting in 2 observed medication errors out of 25 opportunities, and a medication error rate of eight percent. Findings include: Resident #26 (R26) On 12/4/2024 at 8:37 a.m., Licensed Practical Nurse (LPN) J was observed preparing a dose of insulin from a Humalog Kwikpen (rapid-acting insulin pen) for administration to R26. Prior to dialing the prescribed dosage in the pen, LPN J primed the pen needle by dialing two units, holding the pen horizontally with the needle pointed sideways, and depressing the dose knob to release the insulin into the needle. LPN J then dialed the pen to deliver 13 units for administration, as prescribed. LPN J reported R26 was also due to receive 25 units of long-acting insulin. After attaching the needle to R26's Lantus Solostar (long-acting insulin pen), LPN J dialed two units and proceeded to prime the needle by depressing the dose knob to release 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 · D2024-12-04 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 therapeutic diets were served as prescribed for three Residents (#14, #26, and #34) of six residents reviewed for therapeutic diets. This deficient practice resulted in the potential for health complications and contributed to an inability for residents to meet their goals. Findings include: Resident #14 (R14) On 12/2/24 at 12:46 PM, R14 was observed in the facility dining room eating lunch. The meal tray card for R14 read: Special Diets: Low Sugar ~Thin Liquids and Standing (order): ½ (one half) portion desserts. R14 had received two oatmeal raisin cookies. The Certified Dietary Manager (CDM) C observed the meal. When CDM C observed two cookies were served to R14 (the standard portion size), and the meal tray card instructions indicated 1/2 portion dessert, CDM C stated, That is incorrect. The resident should have received one cookie. The resident was observed eating both cookies. A review of the Electronic Medical Record (EMR) for R14 revealed Diet order: Low Sugar diet, IDDSI (International…
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 before2024-12-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the use of enhanced barrier precautions (EBP) during wound care according to the physician's order and current standards of practice for one Resident (#15) of two residents reviewed for wound care, resulting in the potential for the spread of multidrug-resistant organisms (MDROs). Findings include: Resident #15 (R15) Review of the Minimum Data Set (MDS) assessment, dated 10/30/2024, revealed R15 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, diabetes, bullous pemphigoid (an autoimmune disease causing large, fluid-filled blisters), and a stage two pressure injury (partial thickness loss of tissue) to the right buttock. On 12/2/2024 at 9:37 a.m. a sign indicating the use of enhanced barrier precautions (EBP) for all high-contact care activities, was observed attached to the left side of R15's doorway. The sign stated, Everyone Must: . Wear gloves and a gown for the following high-contact resident…
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 before2023-10-20 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
During an interview on 10/17/23 at 4:10 PM, R33 stated he got a cold but I'm almost over it. R33 remarked his roommate also was sick and was sleeping during the day which was unusual. R33 stated many residents seemed to be sick. This Citation will have two deficient practice statements: A and B. A. Based on observation, interview, and record review, the facility failed to establish and maintain a complete infection control program to prevent, identify, report, investigate, and control the spread of infections and communicable diseases based on accepted national standards. This deficient practice resulted in an unidentified facility-wide outbreak of COVID-19 that affected 25 of 34 facility residents. Findings include: On 10/17/23 at 2:30 p.m., upon entrance to the facility the Nursing Home Administrator (NHA) was asked if the facility had any active COVID-19 cases in-house. The NHA reported there were no cases of COVID-19 in the resident or staff population, and none had been reported in the recent past. Staff were observed without facial masks, and the survey team was notified…
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 · F2023-10-20 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
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 consistently employ the services of an Infection Preventionist (IP) who completed specialized training in infection prevention and control and was responsible for the facility's infection control program. This deficient practice resulted in an unidentified outbreak of COVID-19 with the potential to affect all 34 vulnerable residents. Findings include: During an interview on 10/18/23 at 9:15 a.m., when asked about the lack of Infection Control Monthly Summaries the Nursing Home Administrator (NHA) stated, That is my fault. I was trying to make sure it (Infection Control documentation) was done for when you got here. The NHA said the specially trained IP, Registered Nurse (RN) J was out on leave, and the fill-in IP [Director of Nursing (DON)] was taking the course but had not completed the specialized infection control training and was also on leave. When asked who would review the facility infection control during the recertification survey, the NHA said she was not a nurse, and not trained in IC. The NHA said…
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 · E2023-10-20 · tag F0806 — failed to honor food preferences — patternEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 honor resident food preferences for 5 of 6 residents (R6, R13, R15, R18 and R26) reviewed for nutritional services. This deficient practice resulted in decreased meal enjoyment and the potential for weight loss and nutritional decline. Findings include: Resident #6 (R6) During the breakfast meal in the main dining room on 10/18/23 at 9:27 AM, R6 was observed sleeping in front of her breakfast. The meal ticket indicated preferences of Coffee, encourage protein and bananas . R6 did not receive coffee or bananas. R6 was observed to only eat her yogurt. R6 did not touch other food or fluid served. The Care Plan for R6 listed a problem of Risk of Nutritional Deficit including history of weight loss which was initiated 11/16/21. Interventions for this problem included: - Request and honor meal selections while adhering to/encouraging ordered diet. - Food preferences included: Coffee . bananas . - See Special Nutrition lists and meal tickets for scheduled supplements, fortified foods, and/or additional preferences.…
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 · D2023-10-20 · 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 appropriate catheter care to prevent urinary tract infections for two Residents (R12 and R27) out of two residents reviewed for catheter care. This deficient practice resulted in the potential for urinary tract infections. Findings include: Resident R12 During an observation on 10/18/23 at 3:01 p.m., peri care and catheter care was completed for R12 by Certified Nurse Aide (CNA) E. When asked about any history of urinary tract infections (UTI's), R12 said he was currently on antibiotics for a UTI. CNA E used one cloth to cleanse R12's right groin crease, left groin crease, and the penis. The same dirty cloth was used to clean the tubing. A clean fold of the washcloth was not used on the tubing, but rather areas of the cloth that had already come into contact with the residents' unclean skin. CNA E removed her dirty gloves and without the performance of hand hygiene donned clean gloves and removed the dirty linens from the bed. CNA E removed the dirty gloves and again donned clean gloves without hand…
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 before2023-10-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 recognize, address, and evaluate the fluid needs of one resident (R15) out of six residents reviewed for nutritional status. This deficient practice resulted in the potential for fluid overload and medical complications. Findings include: During the lunch meal on 10/19/23 at 12:55 PM, R15 was observed to receive two 12-ounce cups containing beverages. The meal ticket indicated R15 was to receive a diet of ground meat and included FLUID RESTRICTION and indicated an amount of 330 ml (milliliters) for this tray. During an interview on 10/19/23 at 1:10 PM, Certified Nurse Aide (CNA) E confirmed R15 had received two 12-ounce cups or two 360 ml containers (totaling 720 ml) containing beverages for lunch. This amount served exceeded the 330 ml fluid planned for R15. The Electronic Medical Record (EMR) of R15 revealed a current diet order of General Diet with Total Fluid Intake per Day (ml/day): 1800. The Nutritional assessment dated [DATE] also…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-20 · tag F0810 — isolatedProvide 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
Based on observation, interview, and record review, the facility failed to provide dining adaptive equipment for two Residents (R15 and R17) of three residents reviewed for dining assistive devices. This deficient practice resulted in increased difficulty with food consumption and independent eating, as well as the potential for decreased food/fluid intake and risk for weight loss. Findings include: Resident #15 (R15) During the breakfast meal in the main dining room on 10/18/23 at 9:02 AM. R15 was observed with her eyes closed and an untouched breakfast meal of scrambled eggs, corned beef and yogurt. The beverage was a pink juice in a Styrofoam cup with a straw and no lid. The meal ticket for R15 indicated Adaptive Equipment all beverages in cup with lid . The Nutritional Assessments dated 5/2/23 and 8/1/23 indicated Additional Adaptive Equipment: All beverages in cups with lids. The Care Plan for R15 listed a problem of Risk of Nutritional Deficit which included Self-feeding difficulty due to shakiness/weakness/cognitive impairment, initiated 11/14/22. Interventions for this…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-10-20 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to complete and post the daily nurse staffing information at the beginning of each shift. This deficient practice resulted in the inability of residents and visitors to determine the number of staff available to provide resident care and had the potential to affect all 34 residents in the facility. Findings include: During an observation on 10/17/2023 at 2:28 PM, a review of the daily nursing staffing sheet posted at the main nurses' station revealed the most current staff posting was dated 10/13/2023. During an interview on 10/18/2023 the Nursing Home Administration stated the staffing posting was kept at the main nurses' station and was completed at the end of each day, but on observation the most current posting was from 10/13/2023. The NHA stated the postings were not current and indicated the Director of Nursing completed the postings, but she was on vacation, and they had not been completed. The NHA stated the postings were done after the fact. During an interview on 10/19/23 at approximately 9:00 AM, 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.
“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
$2,797 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $2,797 — penalty dated 2023-08-28
- Medicare payment denial — starting 2025-03-03 for 32 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 | Since |
|---|---|---|---|
| ANDERSON, MAXINE | Individual | CORPORATE DIRECTOR | since 01/01/2014 |
| COATES, THOMAS | Individual | CORPORATE DIRECTOR | since 01/01/2019 |
| GORDE, TRICIA | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/20/2025 |
| PALMER, CHARLES | Individual | CORPORATE DIRECTOR | since 01/01/2019 |
| SAVOIE, MARK | Individual | CORPORATE DIRECTOR | since 01/01/2019 |
| KALCHIK, KEVIN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 04/27/2010 |
| GARLINGHOUSE, JOSEPH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| HUNTER, SAMANTHA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 06/26/2025 |
| LABELL, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/29/2024 |
| MYMICHIGAN HEALTH | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | since 07/01/2023 |
CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
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 235381. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.