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Arbor Manor Rehabilitation and Nursing Center

151 2nd Street, Spring Arbor, MI 49283 · For profit - Corporation · 122 certified beds · (517) 750-1900 Medicare & Medicaid certified

Call the home — (517) 750-1900 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3333 Spring Arbor Rd · (517) 787-2160 · Call to confirm hours
Pharmacy
8012 Spring Arbor Rd · (517) 750-2550 · Call to confirm hours
Grocery
8025 Spring Arbor Rd · (517) 750-3373 · Call to confirm hours
Park
Spring Arbor Rd · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased25.1%10.8%15.4%worse
Long-stay residents who lose too much weight5.2%5.4%5.4%typical
Long-stay residents with a catheter left in their bladder5.7%0.8%0.9%worse
Long-stay residents with a urinary tract infection2.6%1.5%2.0%worse
Long-stay residents with depressive symptoms0.7%4.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.3%3.0%3.3%better
Long-stay residents whose ability to walk worsened19.5%12.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication25.5%19.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers4.6%5.1%4.7%typical
Long-stay residents with worsening bladder/bowel control34.0%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.7%14.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.8%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine95.0%79.5%79.4%better
Short-stay residents rehospitalized after admission14.9%24.0%22.6%better
Short-stay residents with an outpatient ER visit11.2%11.7%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.181.841.67better
Long-stay outpatient ER visits per 1,000 resident days0.861.641.80better

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

55.4% 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 146 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.4%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
35.3%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 35.3% 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 68 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 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF55.4%CMS range 47.8–63.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 6.6–14.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge35.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge33.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge44.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.2%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened8.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.3%CMS range 4.1–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.891.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.44
RN hours/ resident / day
1.06
LPN hours/ resident / day
3.23
Aide hours/ resident / day
4.73
Total nurse hours/ resident / day
0.27
RN hoursweekends
51.6%
Total nursing turnover
38.5%
RN turnover

How full it usually is: this home is certified for 122 beds and averages 95.5 residents a day — about 78% occupied, or roughly 26 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 4.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.23 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.46 hrs/resident/day on weekends vs 4.83 on weekdays — 8% thinner on weekends. RN hours go from 0.52 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

9
deficiencies at the latest standard inspection (2026-05-07)
9
at the previous standard inspection (2025-03-05)

Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · Gcited before2025-01-08 · 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 pertains to intake number MI00149135. Based on observation, interview, and record review the facility failed to ensure for one out of three residents (Resident #1) proper and safe transfer with an assistive device was conducted resulting in harm to the resident. Findings Included: Review of Resident #1's (R1) electronic medical record (EMR) revealed R1's had resided at the facility since 2013; Diagnosis included multiple sclerosis and muscle weakness. Review of a progress note dated [DATE], revealed R1 had a fall. The note revealed R1 was noted to be on the floor with her back to the bed, and the assistive device (sit to stand-a device that lifts a person from a sitting to a standing position) in front of her. The note revealed that R1 made a statement that her legs gave out. This was noted in the note to have occurred while the sit to stand was in use on R1. Further review of R1's progress notes revealed that on [DATE] at R1 had complained of pain to both lower legs. The note revealed R1's pain…

    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 · Fcited before2026-05-07 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 92 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and toxic chemical residue.Findings include:During an observation and interview on 5/05/2026 at 9:07 a.m., of initial kitchen tour, Food Service Manager (FSM) N reported had worked at facility about 10 months. FSM N directed this surveyor to single hand-washing sink located in kitchen with trash can located next to sink with unfunctional lid. After washing hands, foot pedal on trash can was not functioning properly, and lid had to be handled with clean hands to open, and observe several used paper towels in trash can. FSM N reported would replace trash can. Continued tour with staff observed using dish machine. FSM N reported dish machine was low temperature chemical machine and staff monitor temperatures daily and record on log and monitor chemical level in large buckets…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure accurate advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for two resident (#12, #78) of two residents reviewed for advance directives.Findings Included:Resident #12 (R12)Review of the medical record revealed R12 was admitted to the facility [DATE] with diagnoses that included Alzheimer's disease, vascular dementia, atrial fibrillation, venous insufficiency (when leg veins [NAME] efficiently return blood to the heart), polyosteioarthritis (a form of arthritis affecting five or more joints), asthma, hypertension, anxiety, hypothyroidism (low thyroid hormone), delusional disorders, and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R12 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. During an attempted interview [DATE] at 09:32 a.m.,…

    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 · D2026-05-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide Activities of Daily Living care (showering and shaving) for one dependent resident (#61) of two residents reviewed.Findings Included: Resident #61 (R61)Review of the medical record revealed R61 was admitted to the facility 08/26/20222 with diagnoses that included Alzheimer's Disease, dementia, polyarthritis (arthritis in five or more joints), insomnia, kidney disease, peripheral neuropathy (nerve damage in nerves), gout (high uric acid in joints), urinary retention, sleep apnea, gastro-esophageal reflux, and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/09/2026, revealed R61 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. Section GG- Functional Abilities of MDS, with the same ARD, revealed R61 was dependent for shower/bathe self and dependent for personal hygiene.On 05/05/2026 at 09:12 a.m. during observation and interview, R61 was observed sitting in chair at the side of his bed. R61 was observed to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure proper positioning was in place for one resident (resident #28) of two residents reviewed for positioning. Findings include: Review of the clinical record revealed Resident #28 (R28) was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included heart failure. Review of the Minimum Data Set (MDS) dated [DATE] revealed R28 scored 7 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and was receiving hospice care. On 05/05/2026 at 9:56 AM, R28 was observed sitting in her room in high back wheelchair. The footrests were on the wheelchair but R28's feet do not touch and were observed dangling. R28 was observed to be sitting on a wheelchair pad, a pillow and the sling to a mechanical lift. R28 was observed in the dining room at the noon meal with her feet dangling from the wheelchair. Observations of R28 were made on 05/06/2026 at 9:35 AM in her room watching television,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide range of motion (ROM) to one (R11) of two reviewed. Findings include:Review of the medical record revealed R11 was admitted to the facility on [DATE] with diagnoses that included heart failure and polyarthritis (arthritis affecting multiple joints). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/28/26 revealed R11 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had functional limitation in range of motion impairments both sides of the lower extremities. On 05/05/2026 at 1:57 PM, R11 was observed lying in bed. R11 reported she had previously received therapy services, but her insurance no longer covered therapy services. R11 reported during therapy, she did exercises with her arms and legs. R11 reported she knew what exercises she should perform, but reported since therapy services ended, staff did not assist her with any exercises or…

    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 before2026-05-07 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 that the attending physician documented his/her rationale for not changing medication as requested by the pharmacist for one resident (#6) of five residents pharmacy reviews. Findings Included:Resident #6 (R6)Review of the medical record revealed R6 was admitted [DATE] with diagnoses that included congestive heart failure (CHF), epilepsy (neurological disorder causing seizures), type 2 diabetes, morbid obesity, bladder dysfunction, heart disease, hypothyroidism (low thyroid hormone) atrial fibrillation, restless leg syndrome, insomnia, depression, gout (build-up of uric acid in bone joints), hypertension, and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/27/2026, revealed R6 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) of 15.Review of R6's medial record revealed a Consultant Pharmacist Medication Regimen Review, dated 02/07/2026,…

    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 · D2026-05-07 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% when 2 of 26 medications for two residents (R7 and R31) were not administered in accordance with physician's orders resulting in a medication error rate of 7.69%.Findings include:R7 Review of the medical record revealed R7 admitted to the facility on [DATE] with diagnoses that included dementia and congestive heart failure. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/27/26 revealed R7 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). During an observation on 5/6/26 at 8:35 AM, Licensed Practical Nurse (LPN) I prepared medications for R7. LPN I reported R7 took his medications crushed. LPN I separated a few medications that were not allowed to be crushed. Amongst those medications was ferrous gluconate 324 milligrams (mg). LPN I then used a pill cutter to cut those medications in half,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-07 · 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 maintain infection prevention and control practices during medication administration for one (R31) of two reviewed. Findings include: Review of the medical record revealed R31 admitted to the facility on [DATE] with diagnoses that included congestive heart failure and hypertension. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/3/26 revealed R31 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). During an observation on 05/06/2026 at 8:14 AM, Licensed Practical Nurse (LPN) S prepared medications for R31. LPN S dispensed 11 of R31's 14 medications into her bare hand and then placed each medication in the pill cup. The medications included hydralazine, metformin, bumetanide, colchicine, diltiazem, tamsulosin, duloxetine, eliquis, metolazone, metoprolol, and potassium chloride. LPN S then administered the medications to R31. In an interview…

    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 · Dcited before2026-05-07 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 maintain documentation that pneumococcal immunization education was provided and whether consent or declination was received for one (R11) of five reviewed. Findings include: Review of the medical record revealed R11 admitted to the facility on [DATE] with diagnoses that included heart failure and atrial fibrillation. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/28/26 revealed R11 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was offered and declined the pneumococcal immunization. Review of R11's medical revealed no documentation of pneumococcal immunization education, consent or declination. On 05/07/2026 at 10:56 AM, Nursing Home Administrator (NHA) A reported the facility was not able to locate a consent or declination for R11's pneumococcal immunization. In an interview on 05/07/2026 at 11:21 AM, Director of Nursing (DON) B reported she was 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-03-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 84 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 03/03/25 at 07:30 A.M., An initial tour of the food service was conducted with Dietary Aide C. The following items were noted: Ice [NAME] were observed protruding from the Walk-In Freezer Freon refrigerant inlet supply lines. The Walk-In Freezer ceiling surface was also observed with accumulated ice droplets, adjacent to the refrigeration fan unit. The Can Opener Assembly was observed soiled with accumulated and encrusted food residue. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · E2025-03-05 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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 provide a homelike environment for up to 84 residents residing at the facility, resulting in residents being subjected to numerous loud overhead paging throughout the day. Findings: During an observation on 3/3/25 at 8:31 AM on North 2 unit, during initial resident screening heard very loud overhead speaker announcement made through facility, [named staff] to dietary. During an observation on 3/3/25 at 8:41 AM, overheard very loud overhead announcement, Maintenance to back hall for delivery. During an observation on 3/03/25 at 9:12 AM, overheard very loud overhead announcement throughout facility. During an observation on 3/03/25 9:at 21 AM , overheard very loud overhead announcement throughout facility, Wander risk front lobby. During an observation on 3/03/25 at 9:34 AM, resident # 35 granted permission to enter room and reported door was closed because overhead paging was so loud and was annoying to her. During an observation on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-05 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based observation, interview, and record review the facility failed to ensure proper storage of medication in one of three medication carts and one medication room of three reviewed for medication storage. Findings include: During an observation and interview on 3/04/25 at 12:32 PM, Licensed Practical Nurse(LPN) R unlocked the South 1 medication cart. Located in the medication cart was an open resident Albuterol 90mcg, dated on box 2/21/24. LPN R verified date and inhaler was open and reported should have been discarded 12 months after open date. LPN R verified the LOT#(batch number) on the inhaler and the box were not the same and reported should match. Observed open bottle of Timolol Mateate eye drops with no open date. LPN R verified eye drops open and should have been labeled with open date. Observed Glucose Gel in cart with manufacturer expiration date of 7/2024. LPN R reported planned to discard. During an interview on 3/05/25 at 11:45 AM, Director of Nursing (DON) B reported would expect nursing staff to date medications when opened. DON B reported Pharmacy and Unit Managers…

    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 · Ecited before2025-03-05 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure appropriate use of Personal Protective Equipment (PPE-protective garments or equipment designed to protect the wearer from injury or infection) and hand hygiene for Transmission-Based Precautions (TBP-used for patients known or suspected to be infected or colonized with infectious agents) for one (Resident #4) of two reviewed. Findings include: Review of the medical record reflected Resident #4 (R4) admitted to the facility on [DATE], with diagnoses that included congestive heart failure and carrier of Carbapenem-resistant Acinetobacter baumannii (a multi-drug resistant bacteria). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/9/24, reflected R4 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). A Physician's Order, dated 12/5/24, reflected R4 was on Contact Precautions (a type of TBP) for a multi-drug resistant organism (MDRO).…

    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 · Dcited before2025-03-05 · tag F0623 — isolated
    Provide 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 — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice of transfer/discharge for one (R92) of two reviewed. Findings include: Review of the medical record revealed R92 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, and multiple rib fractures. Review of the Health Status Note dated 12/31/24 revealed R92 was transferred to the emergency room for evaluation due to behaviors and refusals of care. R92 did not return to the facility. Review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/24 revealed R92 had an unplanned discharge with return not anticipated. The medical record did not indicate a written notice of transfer/discharge was provided. In an interview on 03/05/25 at 10:20 AM, Director of Nursing (DON) B reported they were not able to locate a written notice of transfer/discharge for R92.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-05 · tag F0625 — isolated
    Notify 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 — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice of bed hold policy upon transfer for one (R92) of two reviewed. Findings include: Review of the medical record revealed R92 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, and multiple rib fractures. Review of the Health Status Note dated 12/31/24 revealed R92 was transferred to the emergency room for evaluation due to behaviors and refusals of care. R92 did not return to the facility. Review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/24 revealed R92 had an unplanned discharge with return not anticipated. The medical record did not indicate a written notice of bed hold policy was provided upon transfer. In an interview on 03/05/25 at 10:20 AM, Director of Nursing (DON) B reported they were not able to locate a written notice of bed hold policy upon transfer for R92.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-05 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    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 enteral nutrition was administered as ordered and weights were monitored for two (R33 and R41) of four reviewed. Findings include Resident #33 (R33) Review of the medical record revealed R33 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/3/24 revealed R33 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of Physician's Order dated 11/27/24 revealed an order for Jevity 1.5 cal (tube feeding formula) run at 55 milliliters (mL) per hour continuous via PEG tube (percutaneous endoscopic gastrostomy/feeding tube) for total of 1320 mL of formula per day. On 03/03/25 at 09:27 AM, R33 was observed lying in bed. An empty bottle of Jevity 1.5 cal was hanging from the tube feeding pump. The pump was off. At 9:43 AM, a new…

    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 · D2025-03-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure monitoring of psychotropic medications was completed as ordered for one (Resident #74) of five reviewed. Findings include: Review of the medical record reflected Resident #74 (R74) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included bipolar disorder, schizophrenia, anxiety disorder, other recurrent depressive disorders and bipolar type schizoaffective disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/9/25, reflected R74 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). A Physician's Order, dated 4/10/24, reflected orthostatic blood pressures (monitoring for blood pressure changes that occur when transitioning from lying down to standing) were to be obtained monthly for psychotropic medication monitoring. Further review of Physician's Orders reflected R74 routinely received Buspirone…

    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 · D2025-03-05 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain complete and accurate medical records for one (Resident #90) of 18 reviewed. Findings include: Review of the medical record reflected Resident #90 (R90) was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation, retention of urine and urinary tract infection. R90's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/4/25, was in progress (not complete). On 03/03/25 at 9:56 AM, R90 was observed seated in a recliner, in their room. R90 reported they had open areas on their buttocks, since admitting to the facility. R90 believed cream and a bandage were being applied to the open areas. A Progress Note for 2/26/25 at 5:54 PM reflected R90 admitted from the hospital following a urinary tract infection and atrial fibrillation. Open areas were noted to R90's bilateral (both sides) buttocks, according to the note. The admission skin assessment for 2/26/25 reflected R90 had pressure…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 pertains to MI00147519 Based on observation, interview and record review, the facility failed to initiate new interventions to prevent falls for one resident (Resident #4) of two reviewed for falls, from a total sample of 5, resulting in continued falls and hospitalization for major injury. Findings include: Resident #4 (R4) Review of the medical record reflected R4 was an initial admission to the facility on [DATE]. Diagnoses of [NAME] Matter Disease, Dementia with behavioral disturbance, Anxiety, Delusional Disorder, Restlessness and Agitation, Muscle Weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/09/2024, revealed R4 had a Brief Interview of Mental Status (BIMS) of 06 (severe cognitive impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R4 requires substantial assistance with personal care. During an interview and observation on 10/18/24 at 11:46 AM, R4 was sleeping in his bed fully dressed, hair 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-23 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 MI00147519 Based on observation, interview and record review the facility failed to implement, revise and evaluate effectiveness of the care plan for one of two sampled residents (Residents #4) reviewed for falls resulting in unnecessary falls and hospitalization with major injury. Findings include: Resident #4 (R4) Review of the medical record reflected R4 was an initial admission to the facility on [DATE]. Diagnoses of [NAME] Matter Disease, Dementia with behavioral disturbance, Anxiety, Delusional Disorder, Restlessness and Agitation, Muscle Weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/09/2024, revealed R4 had a Brief Interview of Mental Status (BIMS) of 06 (severe cognitive impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R4 requires substantial assistance with personal care. During an interview on 10/22/24 at 1:08PM, Social Worker (SW) L stated with R4's falls, they met every week to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-03-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 83 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and toxic chemical residue. Findings include: On 03/26/24 at 08:53 A.M., An initial tour of the food service was conducted with Director of Food Services E. The following items were noted: The three-compartment sink sanitizer concentration was observed slightly excessive. The sanitizing product ((Manufacturer's Name) Sink & Surface Cleaner Sanitizer) test strip was also observed to read approximately 800 parts-per-million (ppm) instead of the manufacturer's recommended concentration of 272-700 parts-per-million (ppm). Director of Food Services E indicated he would contact Contractual Vendor Company Name as soon as possible for adjustments. The 2017 FDA Model Food Code section 4-501.114 states: A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-28 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #27 (R27): Review of the medical record reflected R27 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included generalized atherosclerosis and hypertension (high blood pressure). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/12/24, reflected R27 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R27's medical record reflected medicaid hospice was effective 7/7/23. The significant change in status MDS, with an ARD of 7/14/23, did not reflect coding for hospice services. During an interview on 03/27/24 at 01:36 PM, MDS Nurse C reported hospice should have been coded on R27's significant change in status MDS, with an ARD of 7/14/23. Resident #59 (R59): Review of the medical record reflected R59 admitted to the facility on [DATE], with diagnoses that included cerebral infarction, pseudobulbar affect, major depressive disorder, unspecified psychosis not due to 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-28 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 83 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 03/26/24 at 01:40 P.M., An environmental tour of the facility Laundry Service was conducted with Director of Housekeeping and Laundry Services G. The following item was noted: Clean Laundry Room: The drywall surface was observed (etched, scored, particulate), adjacent to the exterior window. The damaged drywall surface measured approximately 12-inches-wide by 36-inches-long. On 03/27/24 at 09:40 A.M., A common area environmental tour was conducted with Director of Maintenance H and Director of Housekeeping and Laundry Services G. The following items were noted: West Unit (South) Occupational/Physical Therapy: Restroom: Two 24-inch-wide by 48-inch-long acoustical ceiling tiles were observed stained from a previous moisture leak.…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-28 · tag F0623 — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice of transfer for one resident (Resident #20) of two reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the reason for the transfer. Findings include: Resident #20(R20) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R20's admission date was 1/12/2024. Brief Interview for Mental Status (BIMS) score was a 14, which indicated her cognition was intact. Resident was discharged to the hospital on 2/26/2024 and returned to the facility on 3/2/2024 with a diagnosis of pulmonary embolism. During an interview on 3/26/2024 in the afternoon, R20 stated that she went to the hospital recently and she was very scared because she thought she was going to die. R20 said she was feeling better and would be discharging from the facility on 3/28/2024. R20 couldn't remember if she received a written transfer notice when she went to the hospital. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-28 · tag F0625 — isolated
    Notify 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident of the facility bed hold policy and provide a written copy upon hospital transfer for one resident (Resident #20) of two reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the bed hold policy. Findings include: Resident #20(R20) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R20's admission date was 1/12/2024. Brief Interview for Mental Status (BIMS) score was a 14 which indicated her cognition. Resident was discharged to the hospital on 2/26/2024 and returned to the facility on 3/2/2024 with a diagnosis of pulmonary embolism. During an interview on 3/26/2024 in the afternoon, R20 stated that she went to the hospital recently and she was very scared because she thought she was going to die. R20 said she was feeling better and would be discharging from the facility on 3/28/2024. R20 couldn't remember if she received a written bed hold…

    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 · D2024-03-28 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to follow pharmacy policy and acceptable clinical practice for maintaining controlled medication for three of four medication carts, record controlled medication for one resident (#24) in a timely manner, and failed to destroy medication for one resident (#77) in an acceptable clinical practice resulting in the potential for controlled medication diversion. Findings Included: Resident #24 (R24) Review of the medical record demonstrated R24 was admitted to the facility 10/15/2021 with diagnoses that included Alzheimer's Disease, dementia, and anxiety. The most recent Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 01/22/2024, demonstrated R24 had a Brief Interview for Mental Status (BIMS) that was not assessed because she rarely/never could be understood. Resident #77 (R77) Review of the medical record demonstrated R77 was admitted to the facility 10/29/2023 with diagnoses that included dementia, anxiety, and hypertension. The most recent Minimum Date Set (MDS), with an Assessment Reference Date…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-28 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 address medication irregularities for one (Resident #37) of five reviewed. Findings include: Review of the medical record revealed Resident #37 (R37) was admitted to the facility on [DATE] with diagnoses that included a history of pulmonary embolism and atrial fibrillation. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/23 revealed R37 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R37's Physician's Order dated 12/21/23 revealed Xarelto 20 milligrams (mg) was ordered daily and scheduled to be administered in the evening between 6:00 PM and 11:00 PM. Review of the pharmacy's Note to Attending Physician/Prescriber dated 10/3/23 revealed Xarelto doses equal to or greater than 15 mg should be administered with the largest meal of the day to increase bioavailability [the extent a substance or drug becomes completely available to its intended…

    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 before2024-03-28 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 offer pneumococcal immunizations per Centers for Disease Control and Prevention (CDC) recommendations for two (Resident #16 and Resident #37) of five reviewed. Findings include: Resident #37 (R37) Review of the medical record revealed R37 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), history of pulmonary embolism, type 2 diabetes mellitus, asthma, congestive heart failure (CHF), and chronic kidney disease. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/23 revealed R37 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was up to date with pneumococcal vaccines. Review of R37's pneumococcal vaccine history revealed they received the PPSV23 on 11/1/16, before the age of 65, and received the PCV14 on 8/16/18. The medical record did not show that any further pneumococcal vaccines were offered.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
BUCHHOLZ, KAROLIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF50%since 11/01/2025
BUCHHOLZ, PAULIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF50%since 11/01/2025
HILER, JEREMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
REES, LORIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2025
YALAVARTHI, JYOTHSNAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
SPRING ARBOR MANOR CARE CENTER, INC.OrganizationADP OF THE SNFsince 11/01/2025

CMS files one row per role, so the 14 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$6.7M
Net patient revenuemost recent cost report
-27.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 66%Medicare 10%Other / private 23%

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

$340per resident / day
operating cost
$10,329per month
≈ monthly operating cost
$267per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MI

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.

Typical monthly cost in Michigan
$11,254/mo
Nursing home (semi-private)
$11,969/mo
Nursing home (private)
$5,818/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235360. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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