ShorePointe Nursing Center
26001 East Jefferson Avenue, St. Clair Shores, MI 48081 · For profit - Limited Liability company · 200 certified beds · (586) 779-7000 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has abuse, neglect, or exploitation citations (F0602, F0607) — most recent Feb 2025
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (63%) runs well above the national median (45%)
- about 22% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.8% | 10.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.4% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 4.1% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 4.5% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.8% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 20.5% | 12.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.3% | 19.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.2% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.5% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.1% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.3% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.5% | 1.1% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 91.2% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.7% | 24.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 5.5% | 11.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.20 | 1.84 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.16 | 1.64 | 1.80 | better |
§ 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.
54.5% 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 556 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.0% 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 256 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 0.45 therapist hours per resident per day in 2026Q1 — more than 76% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 24% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 54.5%CMS range 48.2–59.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.8%CMS range 9.9–13.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 52.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 57.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 57.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.7% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 95.5% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.9%CMS range 4.6–9.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 200 beds and averages 157.7 residents a day — about 79% occupied, or roughly 42 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 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 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 3.52 hrs/resident/day on weekends vs 4.18 on weekdays — 16% thinner on weekends. RN hours go from 0.79 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2025-02-26 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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: MI00150544. Based on interview, and record review, the facility failed to protect one resident (R901) during an abuse investigation out of four residents reviewed for abuse resulting in fear of retaliation and feeling scared. Findings include: A review of a facility reported incident (FRI) submitted 2/13/25 to the State Agency revealed, It was alleged the facility staff misappropriated resident funds. On 2/25/25 at 10:00 AM, R901 explained back in October (2024) they wanted to open a bank account to deposit their check from social security. They had asked their family to assist but they were taking too long. R901 said they had shared they're frustration to Staff A, and the staff member suggested they (the resident) try to open an account over the phone at Staff A's bank. R901 expressed they did not think this would work because it was over the phone, and they only had a picture of their ID on their phone. R901 reported the bank allowed the account to be opened with R901 as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake: 2695258Based on observation, interview, and record review, the facility failed to prevent a fall for one resident (R901) of two residents reviewed for falls. Findings include:A review of information submitted to the State Agency (SA) revealed the following, On or around November 18, 2025, [R901] was being moved .The staff member, a CNA (certified nursing assistant), dropped [R901] . [R901] was transported to the hospital for care .A review of R901's medical record revealed they were initially admitted into the facility on [DATE] with diagnoses which included, Quadriplegia, Anxiety, and Muscle Wasting and Atrophy. Further review revealed the resident was moderately cognitively impaired and required 2-person assistance for bed mobility and transfers.On 12/22/25 at 9:45 AM, R901 was observed lying in bed and asked about the fall they sustained in November. R901 explained they fell out of bed and was sent to the hospital after complaining of pain. R901 explained there was one staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-16 · tag F0800 — widespreadProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure meal portion sizes met the nutritional needs of the residents, resulting in the potential for inadequate protein intake, weight loss, and decreased meal enjoyment. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 4/14/25 at 11:15 AM, Dietary [NAME] O was observed serving food at the steam table. Dietary [NAME] O was observed ladling chili into bowls with a 6 ounce ladle. When queried about the portion size for the chili, Dietary [NAME] O stated Is this not right? On 4/14/25 at 11:20 AM, review of the production sheet for the lunch meal, noted that the portion size for the chili was supposed to be 8 ounces. When queried at that time, Certified Food Manager D confirmed that Dietary [NAME] O was using the wrong size ladle. On 4/15/25 at 10:30 AM, a group meeting was conducted with eight confidential group residents and they were asked about the food at the facility. All group members indicated that food portions could be larger.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-04-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: On 4/14/25 during an initial observation of the kitchen between 8:45 AM-9:15 AM, the following items were observed: The ice scoop holder was observed with black debris on the inside bottom surface. The tip of the ice scoop was resting in the black debris. When queried, Certified Food Manager (CFM) D stated she would clean it right away. According to the Food & Drug administration (FDA) 2017 Model Food Code, Section 3-304.12 In-Use Utensils, Between-Use Storage, During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not potentially hazardous (time/temperature control for safety food) . The ice machine filter was observed to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 person centered care plans for two sampled residents (R78 and R46) of three whose care plans were reviewed. Findings include: R78 A review of R78's medical record revealed an initial admission into the facility on 9/16/20, and a readmission date of 5/11/23 with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Diabetes, Vascular Dementia, and Post-Traumatic Stress Disorder (PTSD). Further review revealed the resident was cognitively intact and required 1-2 person assist for activities of daily living. A review of R78's care plan did not reveal a care plan for the resident's diagnoses of Post-Traumatic Stress Disorder or Vascular Dementia. On 4/16/25 at 12:01 PM, Social Worker A was asked about R78's missing care plan related to their PTSD and Vascular Dementia and explained she would investigate and get back with the surveyor. At 1:14 PM, Social Worker A followed-up with surveyor and acknowledged…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00151407 and MI00151269. Based on observation, interview, and record review, the facility failed to respond to call lights and provide activities of daily living care (ADLs) in a timely manner for one resident (R152) and eight confidential group residents, of thirteen residents reviewed for ADLs. Findings include: R152 On 4/14/25 at 9:40 AM, R152 was met in their room and interviewed regarding the care they received at the facility. R152 indicated they frequently wait a long time for assistance with care. R152 indicated they had been waiting for over an hour to have their brief changed this morning. R152's call light was observed to be on the floor by the bed out of reach of the resident. At 9:50 AM, an observation was made of staff entering R152's room with a breakfast tray, setting the breakfast tray on the resident's bedside table and exiting the room. On 4/15/25 at 9:38 AM, a follow-up visit was conducted with R152. R152 indicated they had a wet brief and proceeded to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the appropriate amount of water flush was provided between administration of individual medications via a percutaneous endoscopic gastrostomy (PEG) tube (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications), for one resident (R73) of four observed during medication administration. Findings include: On 04/15/25 at 9:09 AM, a medication administration via a PEG tube for R73 was observed with Licensed Practical Nurse (LPN) E. LPN E was observed to prepare medications for R73, nine were crushed for administration via R73's PEG tube. The PEG tube was uncapped and the tip of an open graduated 50 milliliter (ml) syringe was placed into the opening. An initial water flush of between 30 and 40 milliliters (mls) was observed to be completed via gravity. (The orders indicated a flush amount of 20-30 ml.) Each of the nine medications had been placed into plastic 30 ml medication cup. The initial medication cup was filled with 20 -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a medication error of less than five percent for one resident (R73) of five residents reviewed for medication observation, resulting in a medication error rate of 12.82%. Findings include: On 04/15/25 at 9:09 AM, a medication administration for R73 via a percutaneous endoscopic gastrostomy (PEG) tube (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) was observed with Licensed Practical Nurse (LPN) E. LPN E was observed to prepare medications for R73, nine were crushed for administration via R73's PEG tube. The PEG tube was uncapped and the tip of an open graduated syringe was placed into the opening. An initial water flush of between 30 and 40 milliliters (mls) was observed to be completed via gravity. The next four medications were followed with an additional 20-30 mls of water. R73 then reported they were feeling full and may need to throw up. LPN E then paused and added the last five crushed medications all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-16 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 MI00152118. Based on observation, interview, and record review, the facility failed to ensure the blood pressure medication (Clonidine) for one resident (R73) of one resident reviewed was administered as needed per physician order Findings include: On 04/15/25 at 9:09 AM, a medication pass observation for R73 was conducted with Licensed Practical Nurse (LPN) E. Prior to the pass of medication LPN E checked the blood pressure of R73. The blood pressure (BP)was documented as 197/96 and a heart rate of 71. LPN E reported they would need to report this to the physician and upon review observed the active physician order dated 04/09/25, Clonidine .1 mg (milligram), give one tablet via a percutaneous endoscopic gastrostomy (PEG) tube (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) every six hours, PRN (as needed) for hypertension (high BP). Administer for SBP (systolic BP) greater than 160 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-16 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to discard expired, label with resident identifier and date when opened biologicals in three of four medications carts and one of four medication rooms reviewed. Findings include: On [DATE] at 8:50 AM, the three [NAME] high medication cart was observed with Licensed Practical Nurse (LPN) P. A dorzolamide eye drop vial was not labeled with a resident identifier nor date opened; glucose strips were not dated when opened; two insulin aspart vials were dated 3/10 and 3/05 and expired; A Basalgar insulin pen was not dated when opened; Two Trelegy inhalers were not dated when opened; and a Arnuity inhaler was not dated when opened on the inhaler and did not have an identifier on the inhaler. On [DATE] at 4:46 PM, the two [NAME] medication room was observed with LPN Q. A tuberculin vial was open, but not dated. On [DATE] at 9:44 AM an observation of the medication cart for revealed Latanoprost Eye drops laying outside of the box, without an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-16 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain a tube feeding (TF) pole in a sanitary manner for one sampled resident (R128) of one reviewed for tube feeding sanitation. Findings Include: On 4/14/25 at 2:10 PM, R128 was observed lying in bed with their tube feeding in place noting a bag of Isosource 1.5 cal missing the resident's name, date, time, or order. The tube feeding pole and base were observed to have a very thick layer of brown dried tube feed stuck to it. Also noted were a pair of used gloves on the floor. A review of R128's medical record revealed they were admitted into the facility on 6/7/24 with diagnoses of Hemiplegia and Hemiparesis following a Cerebral Infarction, Dysphagia, and Diabetes. Further review revealed the resident was severely cognitively impaired and was dependent on enteral feed for nutrition. On 4/15/25 at 8:59 AM, R128's tube feeding pole was observed to have a thick layer of brown tube feeding fluid stuck to it. In addition, there was a pool of wet fluid observed on the floor. On 4/16/25 at 10:50 AM, R128's tube…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · D2025-04-16 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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 that call lights were in reach for three residents (R57, R106, R152) of four residents reviewed for call light accessibility. Findings include: R57 On 4/14/25 at 9:15 AM, an observation was made of R57's call light being on the floor by the side of the bed, out of reach of the resident. On 4/15/25 at 9:27 AM, an observation was made of R57's call light being on the floor, by the bed, out of reach of the resident. R57 was interviewed regarding the location of their call light and stated, I don't know. A record review was completed of R57's electronic medical record (EMR) and revealed that R57 was admitted to the facility on [DATE] with diagnoses that included Atrial fibrillation (Irregular heart rate) and Heart disease. R57's most recent minimum data set assessment (MDS) dated [DATE] revealed that R57 had an intact cognition and required substantial assistance to being dependent for all activities of daily living (ADLs) other than…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-26 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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: MI00150544. Based on interview, and record review, the facility failed to prevent staff misappropriation of resident funds (linking a gambling app and making withdrawals without resident consent from a joint bank account), for one sampled resident (R901) of four reviewed for abuse, resulting in an unauthorized withdrawal totaling $18,368.14. Findings include: A review of a facility reported incident (FRI) submitted 2/13/25 to the State Agency revealed, It was alleged the facility staff misappropriated resident funds. On 2/25/25 at 10:00 AM, R901 explained back in October (2024) they wanted to open a bank account to deposit their check from social security. They had asked their family to assist but they were taking too long. R901 said they had shared they're frustration to Staff A, and the staff member suggested they (the resident) try to open an account over the phone at Staff A's bank. R901 expressed they did not think this would work because it was over the phone, and they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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 MI00149892. Based on interview and record review, the facility failed to ensure notification of a room change was provided for two residents (R906, R908) of three reviewed for room changes. Findings include: On 01/30/25 at 9:22 AM, a review of a complaint related to R906 revealed an allegation R906 responsible party (RP) or family was not notified of R906's room change. A phone call was made to the first emergency contact and financially RP designated in the medical record. An advocate designation dated 09/08/21 documented the RP as the advocate for healthcare. The RP reported they had not been notified until two days after R906 was moved and had to ask which room the resident had been moved to when they arrived to visit. The RP further reported the room to which R906 had been moved had a resident who yelled out often and disturbed R906. The RP further noted R906 had a roommate (R908) who was also moved out of the room. A review of the record for R906 revealed R906 was admitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to Intake M100149834: Based on interview and record review, the facility failed to implement care planned interventions to prevent a fall for one (R902) of three residents reviewed for falls. Findings include: Review of the facility record for R902 revealed a most recent admission date of 10/17/24 with diagnoses that included Spina Bifida with Hydrocephalus, Paraplegia, and Epilepsy. R902's most recent care plan included the Focus item Resident is at risk for falls and potential for injury related to seizure diagnosis, impaired physical mobility, paraplegia, history of falls, medication use. One intervention item associated with this care plan stated Place anti-slip pad in wheelchair seat. Further review of R902's facility record revealed a progress note dated 01/08/25 authored by Licensed Practical Nurse (LPN) J indicating they had been notified by staff that R902 had fallen in their room. LPN J indicated they went to the room and R902 was laying on the floor near the wheelchair and a mechanical lift (device used to transfer residents from one surface to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00146867. Based on observation, interview and record review, the facility failed to perform transfers according to the plan of care for one (Resident #4) of six reviewed. Findings include: Review of the medical record reflected Resident #4 (R4) admitted to the facility on [DATE], with diagnoses that included developmental disorder of scholastic skills and unspecified dislocation of left shoulder joint (8/30/24). The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/30/24, reflected R4 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had upper extremity impairment on one side of the body. On 9/17/24 at 10:56 AM, R4 was observed seated in a wheelchair, near the nurses station. An Incident Report, dated 9/8/24 at 6:18 AM, reflected a Certified Nurse Aide (CNA) observed a lump on R4's left shoulder while dressing her for the morning shift. R4 had mild discomfort with range…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes: MI00145838, MI00146086, and MI00145914. Based on observation, interview, and record review, the facility failed to provide grooming and showers per schedule and preference for two residents (R701 and R714) out of three reviewed for Activities of Daily Living (ADLs). Findings include: R701 A review of Intake MI00145838 revealed the following, [R701] has not been given a shower since being in facility. [R701] has only been given a bed bath twice in the last month. A review of the medical record revealed that R701 admitted into the facility on 6/22/2024 with the following medical diagnoses, Generalized Anxiety Disorder and Depression. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R701 was also dependent on staff for bed mobility and transfers. Further review of the shower documentation for the entirety of R701's stay revealed they only received bed baths while in facility. No showers were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-08 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to Intake MI00145914. Based on observation, interview, and record review, the facility failed to set up a follow up appointment for one resident (R702) out of one reviewed for follow up appointments. Findings Include: A review of Intake MI00145914 noted the following, [R702] has an (indwelling) catheter (tube that goes into the bladder to drain urine) in and was supposed to get that out before coming here, however they only tried taking it out once and never tried to figure out why [they] needed it. On 8/8/2024 at 12:01 PM, R702 was observes sitting in their chair. R702 was noted to have a drainage bag for a catheter hanging on the side of their wheelchair. R702 stated they received the catheter in the hospital and the facility tried to take it out once, but put it back in. A review of the medical record revealed that R702 admitted into the facility on 7/3/2024 with the following medical diagnoses, Depression and Presence of Urogenital Implants. Further review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-08 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to Intake MI00145880. Based on observation, interview, and record review, the facility failed to provide palatable hot meals for four of four residents interviewed. Additionally, meals were not provided according to the provided Tray Delivery Schedule. Findings include: On 8/82024 at 10:00 AM, R703 said the tea water not hot, every day receive cold eggs. On 8/82024 at 10:30 AM, R704 said the food is barely warm when delivered. On 8/8/2024 at 1045 AM, R705 said the food is not very warm when they receive it. On 8/8/2024 at 11:00 AM, R706 said the food is awful, nothing is ever hot when it should be. On 8/8.2024 at 11:15 AM, while observing food service in the Atrium Dining area, a Dietary Aide (AD) was noted to bring two meals to the steam table area. The two covered meals were set on top of the steam table window. The dietary aide removed the covers and the meals (pork medallion, mashed squash, steamed zucchini meal, and a hamburger with lettuce and tomato), remained on top of the steam table window from 12:02 to 12:10 P.M. then were given to two residents. 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.
- Potential for harm · Fcited before2024-03-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 3/12/24 between 8:45 AM-9:15 AM, during an initial tour of the kitchen with Dietary Manager (DM) I, the following items were observed: The door handles on the [NAME] warmer were observed to be heavily soiled with a buildup of grease and an accumulation of food debris. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. A shelf near the grill, where bins of salt and pepper packets were stored, was observed to be soiled with black grease. DM I stated it was from the grill-brick grill cleaner. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surface,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-14 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure appropriate infection control practices were used for hand hygiene and equipment cleaning for five (R7, R30, R53, R127, R143) of five residents observed. Findings include: On 3/13/24 at 8:30 AM, LPN G was observed administering an injectable medication to R7. When injecting the medication, Nurse G did not wear gloves. On 3/13/24 at 8:40 AM, LPN F was observed dispensing oral medication to R7. Prior to administration LPN F completed a blood pressure and pulse using a multi-resident, electronic sphygmomanometer (blood pressure cuff) without cleaning it before or after taking the blood pressure. On 3/13/24 at 8:53 AM, LPN F was observed dispensing oral medication to R30. A blood pressure without cleaning it before or after taking the blood pressure. On 3/14/24 at 2:07 PM, LPN E was observed administering injectable medication to R143, and did not complete hand hygiene after removing gloves. On 3/13/24 at 1:30 PM, during an interview with the Infection Control Preventionist (ICP) the identified concerns…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-14 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a preadmission screening (PAS) and resident review (ARR) evaluation for one resident (R96) of three residents reviewed for PASARR, resulting in the potential for unmet mental health services. Findings include: A review of the medical record revealed no Preadmission Screening (PAS) 3877 from hospital for (R96). There was no additional PASARR forms nor was a Level II screening requested due to R96 having diagnoses of mental illness. A review of the medical record revealed that R96 admitted into the facility on 2/11/24 with the following diagnoses of depression and generalized anxiety disorder. A review of the most recent Minimum Data Set assessment dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. On 03/14/2024 at 10:45 AM, an interview was conducted with Social Worker (SW) regarding R96's 3877 PAS screening not being completed. The SW stated, We are down a social worker, so the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 develop, implement and update care planned pressure ulcer prevention interventions for two (R510 and R143) of four residents reviewed for care planning. Findings include: Review of the facility record for R510 revealed an admission date of 03/04/24 with diagnoses that included Myocardial Infarction, Diabetes Mellitus and Congestive Heart Failure. The Minimum Data Set (MDS) assessment dated [DATE] indicated R510 required moderate assistance with lower body dressing which indicated a similar level of required assistance for management of heel float boots and elevating or floating the resident's heels. The MDS included a Brief Interview of Mental Status (BIMS) score of 15/15 which indicated intact cognition. On 03/12/24 at 11:10 AM, during an initial interview R510 was laying in bed and a heel float boot was observed to be on the nightstand. When asked if the boots were for their use R510 stated Yes, they only wanted to put it on one time.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications and biologicals were labeled with a date opened and a resident identifier in three of five medications carts. Findings include: On 03/13/24 at 8:57 AM, in the two Lakeland low medication cart the glucose test strips were not dated when opened. On 03/13/24 at 9:38 AM, in the two Lakeland low medication cart six Incruse inhalers, for four different residents, were not dated when opened on the inhaler; An Anoro inhaler did not have the date opened nor a resident identifier on the inhaler nor the box and the glucose test strips were not dated when opened. On 03/13/24 on 11:25 AM, the St [NAME], medication cart had two fluticasone inhalers without a resident identifier on the inhalers. On 03/14/24 at 3:04 PM, the Director of Nursing (DON) was asked about the need for a date opened and resident identifier on inhalers and noted they should be dated when opened. A review of the undated facility policy titled, Ordering and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-23 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake: MI00142122. Based on interview and record review, the facility failed to revise interventions on the care plan following a fall for one resident (R901) of two residents reviewed for falls. Findings include: A review of R901's medical record revealed that they were admitted into the facility on [DATE] and discharged on with diagnoses that included End Stage Renal Disease, Peripheral Vascular Disease, and Encounter for orthopedic aftercare following surgical amputation. Further review of the medical record revealed that R901 had a moderately impaired cognition, and required total dependent on staff for transfers and toileting. A review of R901's progress notes revealed the following: 12/28/2023 17:26 (5:26pm) Nursing - Transfer to Hospital Summary Note Text: .writer observed resident in room lying flat and face down on floor in front of dialysis chair calling out for assistance, turned patient over to a sitting position, called for assistance from another nurse, assisted resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-12-09 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to display current nurse staffing information daily, affecting all residents and visitors in the facility, resulting in the likelihood of necessary staffing information not being readily available to residents and visitors. Findings include: On 12/8/22 at 10:36 AM, 18 months of daily staffing sheets were requested from the facility. On 12/8/22 at 4:09 PM, the Nursing Home Administrator (NHA) provided a small stack of requested daily staffing sheets and explained that they couldn't locate more than what was being provided. A review of the provided staffing sheets revealed the following dates were missing: 7/25/21, 7/26/21, the entire month of August 2021, and September 2021 except for 9/29/21. For the months of October 2021, 10/14/21 and 10/24/21, and for the month of November 2021, 11/1/21, 11/15/21 through 11/30/21. There were no staffing sheets for the entire month of December 2021, January 2022, February 2022, the entire month of March. There were no staffing sheets for April 2022, May 2022, June 2022, July 2022, August…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-12-09 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure food items were dated when opened, failed to maintain fans in the kitchen in a sanitary manner, failed to maintain kitchen equipment, and failed to maintain the exterior refuse area. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: In the walk-in cooler, there were (2) 5 pound containers of cottage cheese that were opened and undated, and an opened, undated package of deli ham. Dietary Director A confirmed that the food items should have been dated when opened. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-12-09 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 MI00131242. Based on observation, interview and record review the facility failed to implement interventions and/ or provide person centered interventions and care plans for four sampled residents (R79, R100, R236, R285) of 30 whose care plans were reviewed resulting in, and the potential for, unmet care needs. Findings include: Resident #79 On 12/07/22 at 10:36 AM, R79 was observed to be dressed and seated in a wheelchair in their room. R79 was queried about the care provided by the facility and reported a recent fall where their leg gave out and the temperature and taste of the food was not always so great though they did not have much of an appetite anyway. A review of the record for R79 revealed R79 was admitted into the facility on [DATE] and had diagnoses that included Diabetes, Heart Disease and Dementia. The Minimum Data Set (MDS) assessment dated [DATE] documented moderately impaired cognition and the need for extensive assistance of two persons for transfer and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-09 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to offer and provide bedtime snacks on a consistent basis for four (R30, R43, R56, R58) of 30 sampled residents and seven (R1, R12, R16, R56, R73, R76, R94, R117) residents participating in the resident group meeting, resulting in resident dissatisfaction and potential for diabetic residents to experience hypoglycemic episodes and unmet care needs. Findings include: On 12/08/22 at 12:23 PM, R30 reported that they were not being offered bedtime snacks. When asked if a snack cart or tray was brought around during the evening R30 reported that one was not. R30 reported that they discussed this with the dietician due to the potential for hypoglycemic episodes related to R30's diabetes. R30 reported the dietician agreed to have a snack included on the dinner tray so that the resident could save the snack for after dinner. R30 reported that the dietician indicated that the pantry is not kept stocked in the evening due to the snacks being taken by staff. On 12/09/22 at 10:56 AM, all residents present at the resident group meeting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to obtain consent for psychotropic medications from an authorized person (such as medical power of attorney, patient advocate, legal guardianship, or living will) for one resident (R103), of four residents reviewed for unnecessary medications resulting in, the administration of potentially unwanted psychoactive medication and potential adverse side effects. Findings Include: On 12/8/22 at 8:20 AM, R103 was observed sitting in their wheelchair, breakfast tray observed on the floor. R103 was unable to be interviewed due to their cognition as they yelled out in a non-sensical manner. A review of R103's medical record revealed that they were admitted into the facility on 6/18/22 with diagnoses that included Dementia, Adult Failure to Thrive, and Depression. Further review revealed a Minimum Data Set (MDS) assessment dated for 10/2/22 revealing a severely impaired cognition, and required 1-person assistance with Activities of Daily Living (ADL's). A review of R103's care plan revealed the following: Focus: Cognitive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to OPTALIS HEALTH & REHABILITATION — 36 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 1.9 | +1.1 vs chain |
| Staffing | 3 of 5 | 2.4 | +0.6 vs chain |
| Quality measures | 4 of 5 | 4.3 | -0.3 vs chain |
The other 35 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| OM HOLDCO, LLC | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/01/2019 |
| CHARLES FRANKLIN LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/01/2019 |
| CHARLES WESTLAND LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/01/2019 |
| DILIPBHAI & KALAVATI PATEL FAMILY TRUST | Organization | INDIRECT OWNERSHIP INTEREST | since 09/01/2019 |
| HEMANT SHAH 2018 IRREVOCABLE TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/01/2019 |
| OPTALIS LP INVESTORS 1, LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/01/2019 |
| OPTUM MANAGEMENT SOLUTIONS. INC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2019 |
| PAAR 108 LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/01/2019 |
| PINAL R. PATEL 2017 IRREVOCABLE TRUST F/B/O AARNA R. PATEL | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/01/2019 |
| PINAL R. PATEL 2017 IRREVOCABLE TRUST F/B/O ANSH R. PATEL | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/01/2019 |
| PINAL R. PATEL 2020 IRREVOCABLE FAMILY TRUST UAD 10-6-2020 | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/01/2019 |
| RAJAN G PATEL 2020 IRR FAM TR UAD 12-3-2020 | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/01/2019 |
| EAST WEST BANK | Organization | 5% OR GREATER SECURITY INTEREST | since 09/01/2019 |
| PATEL, RAJAN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2019 |
| SHARON, ROBERT | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2024 |
| HOLLADAY, MELANIE JEAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2024 |
| MEDUVSKY, ANGILA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2024 |
| PARKER, SETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| DUNN, CHARLES | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 01/29/2026 |
| SHAH, HEMANT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 01/29/2026 |
| CLIFTONLARSONALLEN LLP | Organization | ADP OF THE SNF | since 01/01/2025 |
| SCHLAUPITZ MADHAVAN | Organization | ADP OF THE SNF | since 01/01/2025 |
| WBH NCC #1, LLC | Organization | ADP OF THE SNF | since 09/01/2019 |
| CONNER, MARIANNE | Individual | ADP OF THE SNF | since 09/01/2019 |
CMS files one row per role, so the 41 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
16 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.
This home reported $4.9M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235443. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-16, 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.