Lahser Hills Care Centre

Location & what’s nearby

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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

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.

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.

44.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 58.8% 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 34 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 44% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 127 beds and averages 104.6 residents a day — about 82% occupied, or roughly 22 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.84 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.39 hrs/resident/day on weekends vs 4.02 on weekdays — 16% thinner on weekends. RN hours go from 0.60 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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.

35 citations, most serious first. The 14 most serious are shown; the remaining 21 are one tap away and print in full.

• Immediate jeopardy · Jcited before2023-04-21 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00129778 This citation contains three Deficient Practice Statements (DPS). DPS #1 Based on interview and record review the facility failed to consistently monitor a resident in respiratory distress, notify the physician of ineffective interventions and failed to transfer the resident to a higher level of care for appropriate treatment for one (R312) of three residents reviewed for infection prevention and control, resulting in staff to not have completed and documented consistent respiratory assessments and monitoring once staff identified R312 with a low oxygen saturation rate of 72%, staff failed to inform the physician of the supplemental oxygen to not have been effective, and failed to transfer the resident to a higher level of care for further treatment causing Immediate Jeopardy (IJ), when R312 expired two hours and twenty five minutes after staff identified the change of condition. This continued practice puts other residents at risk for serious harm and/or death.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-06-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent pressure ulcer formation, document accurate skin assessments and implement interventions for one (R80) of three residents reviewed for pressure ulcers resulting in R80 acquiring a Stage 4 (full-thickness skin and tissue loss). Findings include: On 6/3/25 at 9:51 AM, R80 was observed lying in their bed. R80 was asked if they had any wounds or sores. R80 explained they had a couple wounds on their bottom. When asked if they had developed the wound at the facility or if they were present when they were admitted , R80 explained one developed at the facility. Review of the clinical record revealed R80 was admitted into the facility on 1/17/25 and readmitted [DATE] with diagnoses that included: paraplegia, hypertension and stroke. According to the Minimum Data Set (MDS) assessment dated [DATE], R80 was cognitively intact. The MDS assessment also indicated in section M0300 that R80 had one facility acquired Stage 4 pressure ulcer. Review…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-12-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00148859 Based on observation, interview and record review, the facility failed to prevent pressure ulcer formation, document accurate skin assessments, implement interventions and complete pressure ulcer wound care per physician orders for two (R903 and R904) of three residents reviewed for pressure ulcers resulting in R903 acquiring one Stage 4 (full-thickness skin and tissue loss) which became infected and required antibiotics and acquired a Deep Tissue Pressure Injury (DTPI - persistent non-blanchable deep red, maroon or purple discoloration) and R904 who aquired an unstageable wound to their coccyx. Findings include: R903 A complaint was filed with the State Agency (SA) that alleged in part, .the resident . has developed a wound on (their) buttocks . it's the size of a silver dollar . can see deep inside the hole and it smells bad . On 12/30/24 at 10:02 AM, R903 was observed lying in bed. R903 was asked if they had any wounds or sores on their body. R903 indicated they 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-09-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation refers to Intake #MI00137826 Based on interview and record review, the facility failed to ensure a safe and proper transfer from the bed to Geri chair for one resident (R808) of two residents reviewed for falls/accidents, resulting in seven stitches over the left eye, two lumps (hematomas) on the forehead, bruising to the left side of their neck, bruising on the left side of their chest, pain, and a three-day hospital stay. Findings include: A Complaint was filed with the State Agency (SA) that alleged R808 was a two-person transfer in need of a Hoyer lift and was transferred by only one Certified Nursing Assistant (CNA) who used a sit-to-stand (a medical device that assists individuals with limited mobility in standing up from a seated position) and the resident fell during the transfer and sustained injuries requiring hospitalization. A review of R808's clinical record was conducted and revealed that the resident was initially admitted to the facility on [DATE] and readmitted 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-05 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
  Provide 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 weights were taken appropriately and verified as accurate per professional standards of nutritional practice for one Resident (R21) of two residents reviewed for nutritional status, with multiple facility residents affected who were weighed. Findings include: On 6/03/25 at 9:46 a.m., R21 was observed dressed, seated on the edge of their bed. R21 was thin in stature. Their breakfast tray was observed in front of them on a tray table, which included scrambled eggs, biscuits and gravy and two bowls of cereal, with juice, milk, and coffee. R21 showed this Surveyor their meal ticket. It was noted the word Oatmeal was scratched out with a black marker. R21 was observed feeding themselves breakfast. The ticket showed R21 was on a regular diet with thin liquids. On 6/03/25 at 9:48 a.m., R21 reported they wanted Oatmeal every day, and their dentures were loose, which they wanted addressed to help them chew food more easily. Review of R21'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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · E2025-06-05 · tag F0881 — failed to use antibiotics responsibly — pattern
  Implement a program that monitors antibiotic use.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to consistently maintain a system that consistently met criteria for antibiotic use, this had the ability to affect any resident prescribed an antibiotic of the 107 residents that resided in the facility. Findings include: Review of the facility's Infection Surveillance books revealed multiple incidents of antibiotics prescribed that did not meet antibiotic use criteria, including residents treated for Urinary Tract Infections (UTI's) with no signs and symptoms of infection and no lab results to confirm an infection. On 6/4/25 at 3:00 PM, the facility's Infection Control Preventionist (ICP) C was interviewed and asked what criteria was used for antibiotic use. ICP C confirmed the facility used McGeer's Criteria. ICP C was asked about antibiotics prescribed for UTI's with no culture and sensitivity (C&S - to indicate if an infection was actually present and what antibiotic the bacteria was sensitive to). ICP C explained she was trying to educate the nurses' to ask for a C&S when calling the doctor, and to not just get 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-05 · tag F0561 — failed to honor residents' choices — isolated
  Honor 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 provide a working clock for one (R67) of one resident reviewed for choices. Findings include: On 6/3/25 at 9:42 AM, R67 was observed lying in their bed. R67's bed was positioned so that R67 had a clear, direct view of the door. A clock was observed directly above the door. The time on the clock was 1:05, and the second hand was not moving. R67 was asked how long the clock had been broken. R67 explained it had never worked since they had been in that room, someone would put a new battery in the clock and it would work for 45 minutes then stop again. R67 was asked how they knew what time it was. R67 explained they had a cellular phone they could use for the time, but since the clock was above the door, every time they looked at the door they saw the broken clock and it was an annoyance. Review of the clinical record revealed R67 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: Parkinson's disease,…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe homelike environment for two Residents (R15 and R99) of two residents reviewed for equipment safety, when their toilet durable medical equipment was found in disrepair. Findings include: On 6/03/25 at 1:30 p.m., R99's bathroom was observed in room [ROOM NUMBER]-1. There was a gray metal toilet safety frame (bedside commode) over their toilet. The left plastic armrest (when seated on the commode) was observed with an opening where the occupant's hand would push from to stand up. The opening was cracked, with sharp, jagged edges, placing R99 and any occupants at risk for skin tears. On 6/03/25 at 1:33 p.m., R99 observed their bathroom, and stated, Oh, that needs to be fixed, as that could cut people (sitting) on it. On 6/03/25 at 3:03 p.m., R99 was observed dressed, seated in a manual wheelchair. On 6/03/25 at 3:04 p.m., R99 confirmed they used their bathroom for toileting occasionally. Review of R99's most recent skin…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-05 · tag F0646 — isolated
  Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
  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 notify the local state mental health authority of Preadmission Screening and Resident Review (PASARR) changes for one (R60) of two residents reviewed for PASARR. Findings include: Review of the clinical record revealed R60 was admitted into the facility on 3/3/25 with diagnoses that included schizophrenia, unspecified. According to the survey software, R60 was identified as having no PASARR II with a mental illness diagnosis. (PASARR Level II is a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has MD (Mental Disorder), ID (Intellectual Disorder) or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs.) Further review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented R60 scored a 14/15 on the Brief Interview for Mental Status Exam (BIMS) which…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure that wound care was completed according to physician's orders for two residents (R13 and R6) of three reviewed for impaired skin conditions (non pressure related). Findings include: R6 On 6/3/25 at 9:40 AM, R6 was observed in their room sitting in their chair located near the bed. R6 appeared to be dressed and ready for the day. With further observation of R6, there were two kerlex bandages around the resident's ankles that were dirty and unkempt with a date of 5/27 with initials that appeared to be a CN. R6 was asked if they knew why their legs were wrapped up and how often did the facility change the bandages but R6 could not recall or answer for either question. A review of the record revealed that R6 was admitted to the facility on [DATE] with a medical diagnosis of dementia, type two diabetes, and varicose veins. A further review of the record revealed that R6's dressings to the legs were to be changed daily. On 6/4/25 at…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-05 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure 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

  Based on interview and record review, the facility failed to ensure freedom from unnecessary antibiotic therapy for three (R40, R85, and R86) of three residents reviewed for unnecessary antibiotic (ABT) use, resulting in the potential for the development of antimicrobial resistance. Findings include: On 6/4/25 at 3:00 PM, review of the facility's infection control program with Infection Control Preventionist (ICP) C revealed the following: R40 was documented in March 2025 as having a facility acquired infection listed as Urinary, the signs and symptoms were Fever-Low grade, Altered mental status, the comments included Criteria Not Met .No culture results . R40's March 2025 Medication Administration Record (MAR) included an order for Cipro Oral Tablet 500 MG (milligrams) .Give 1 tablet by mouth two times a day for UTI (urinary tract infection) for 3 Days, and documented as given from 3/24/25-3/26/25. ICP C was asked if R40 had a culture and sensitivity (C&S) done to see if there was an infection and what was the low grade fever. ICP C explained no C&S was ordered, and she had found…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake(s): MI00151185 Based on observation, interview and record review, the facility failed to ensure an oxygen dependent resident was provided continuous physician ordered respiratory care for one (R601) of two residents reviewed for respiratory care, resulting in R601's SPO2 (blood oxygen saturation level) to have dropped to an abnormal range level and the resident being transferred to the hospital for a higher level of care. Findings include: A Complaint was filed with the State Agency (SA) that alleged that on 3/12/25, R601 was observed in the dining room unattended. R601 was found to be lethargic and slumped over the table with a puddle of urine underneath them. R601's oxygen tank was determined to be empty. In addition, the humidity bottle for the concentrator in their room was also empty. The Complainant noted that R601 was sent to the hospital as their 02 levels were not stable. On 3/26/25 at approximately 10:00 AM, R601 was observed sleeping in bed. The resident was alert 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-26 · tag F0745 — failed to provide medically-related social services — isolated
  Provide 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 This citation pertains to Intake #MI00151195 Based on observation, interview and record review the facility failed to timely evaluate the competency of a resident and obtain legal guardianship for a resident with impaired cognition for one (R601) of three residents reviewed for Hospice Services. Findings include: A Complaint was filed with the State Agency (SA) that alleged R601 does not have a guardian, power of attorney, or conservator and they are receiving Hospice Services. On [DATE] at approximately 10:00 AM, R601 was observed sleeping in bed. The resident was alert but not able to answer any questions asked. A review of R601's clinical record revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: chronic kidney disease, Chronic Obstructive Pulmonary Disease (COPD), altered mental state, type II diabetes and alcohol abuse. A review of R601's Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-12-30 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices related to enhanced barrier precautions (EBP) for two residents (R903 and R904) of three residents reviewed for wounds, resulting in the potential for the spread of infection. Findings include: Review of a facility policy titled, Enhanced Barrier Precaution (EBP) Policy and Procedure dated 9/23/22 read in part, .Enhanced Barrier Precautions expand the use of PPE (personal protective equipment) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multi-drug resistant organisms) to staff hands and clothing. High-Contact Resident Care Activities include: Dressing; Bathing/showering; Transferring; Providing hygiene; Changing linens; Changing briefs or assisting with toileting; Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator; Wound care: any skin opening requiring a dressing…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$14,898 in federal fines across 1 penalty. 2 Medicare payment denials on record.

• $14,898 — penalty dated 2023-09-07
• Medicare payment denial — starting 2025-01-25 for 6 days
• Medicare payment denial — starting 2023-10-03 for 16 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.

Part of a chain

This home belongs to NEXCARE HEALTH SYSTEMS — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

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

Follow the money — this home’s finances

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

About 84% 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 $1.2M 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