Roubal Care and Rehabilitation Center
N 306 Maple Street, Stephenson, MI 49887 · For profit - Individual · 39 certified beds · (906) 753-4981 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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 | 5 of 5 |
| Long-stay residentspeople who live here | 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 improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.5% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.8% | 5.4% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 4.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.7% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 5.8% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.8% | 19.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.1% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 32.7% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.7% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.1% | 1.4% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 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 39 beds and averages 36.8 residents a day — about 94% occupied, or roughly 2 beds typically open. It runs fairly full. 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 3.47 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.14 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 3.09 hrs/resident/day on weekends vs 3.62 on weekdays — 14% thinner on weekends. RN hours go from 0.68 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below 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.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · Gcited before2025-06-26 · 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
Based on interview and record review, the facility failed to ensure adequate supervision and proper use of assistive devices (gait belt and wheelchair) to prevent a fall with major injury (fractured femur) for one Resident #37 (R37) out of one resident reviewed for falls. This deficient practice resulted in harm when R37 fell while ambulating with staff and subsequently fractured his femur requiring a surgical hip repair. Findings include:All times noted are in Eastern Daylight-Saving Time (EDST), unless otherwise noted. Resident #37 (R37) Review of R37's Progress Notes revealed the following, in part: 1/12/2025 15:44 ([:44 Central Standard Time (CST)]: Resident ambulating in hall with staff assistance, utilizing walker, wheelchair to follow. Stopped to sit in WC (wheelchair) lost balance and fell from standing position into wall on right side of body head hitting cement wall .Resident complains of right hip pain, unable to lift right leg. Appears misaligned .1/12/25 16:01 (4:01 p.m. CST); Resident left with paramedics at this time .1/12/25 18:35 (6:35 p.m. CST); .resident is being…
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 before2025-06-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain best practices in 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: During a tour of the walk-in cooler, at 7:58 AM on 6/25/25, it was observed that storage racks in the walk-in cooler were found with an accumulation of debris on the open wire rack shelving. Observation of the floor in the walk-in cooler found a dried yellow spill on the floor as well as an accumulation of debris and paper trash under racks and alongside the perimeter of the floor. During a tour of the walk-in freezer, at 8:00 AM on 6/25/25, it was observed that the floor of the walk-in cooler was full of paper trash debris from date marking stickers. During a tour of the clean utensil drawer, at 8:38 AM on 6/25/25, it was observed that an accumulation of crumbs were found along the back wall of the drawer. When asked how often this area gets cleaned out, Dietary Manager (DM)…
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 before2025-06-26 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to:Ensure the use of infection control measures were practiced according to current guidelines and professional standards of practice for three Residents (#31 and #13) of 11 residents reviewed for infection control practices.Have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Resident #31 (R31)Review of the Minimum Data Set (MDS) assessment, dated 5/22/2025, revealed R31 was admitted to facility on 8/14/2024 and had diagnoses including obstructive uropathy, peripheral vascular disease, morbid obesity, and depression. Further review of the MDS assessment revealed R31 had an indwelling urinary catheter, was always incontinent of bowel,…
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 · D2025-06-26 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide a dignified care experience for two Residents (#31 and #14) of two residents reviewed for dignity, resulting in R31 expressing feelings of humiliation and helplessness.Findings include:All times recorded in Eastern Daylight Time (EDT), unless otherwise noted.Resident #31 (R31)Review of the Minimum Data Set (MDS) assessment, dated 5/22/2025, revealed R31 was admitted to facility on 8/14/2024 and had diagnoses including obstructive uropathy, peripheral vascular disease, morbid obesity, and depression. Further review of the MDS assessment revealed R31 had an indwelling urinary catheter, was always incontinent of bowel, required substantial/maximal staff assistance for toileting hygiene and bathing, and was dependent on staff for all transfers and mobility. R31 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he was cognitively intact. On 6/25/25 at 8:59 a.m., an observation in the 300 Hall revealed the door to R31's room was closed. Upon entering, R31 was observed lying in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 interview and record review, the facility failed to maintain facility living areas odor free and with comfortable temperatures for two Residents #7 and #31 (R7 and R31) of 16 residents reviewed for a safe, clean, comfortable environment. This deficient practice resulted in resident dissatisfaction with unbearably hot living conditions and the smell of urine in R7's room.Findings include: All times noted are Eastern Daylight Savings Time, unless otherwise noted. Resident #7 (R7) Review of R7's Minimum Data Set (MDS) assessment, dated 4/1/25, revealed R7 was admitted to the facility on [DATE], with diagnoses that included the following, in part: hypertension, end-stage renal disease, diabetes mellitus, dementia, and chronic obstructive pulmonary disease (COPD). R7 did not complete the Brief Interview for Mental Status (BIMS) but was documented with severely impaired cognition. R7 required Setup or clean-up assistance with upper body dressing, lower body dressing, putting on/taking off footwear (including…
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 · D2025-06-26 · 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 Based on observation, interview and record review, the facility failed to ensure the timely provision of ADL (Activities of Daily Living) care for two Residents (#31 and #25) of two residents reviewed for ADL care.Findings include:All times recorded in Eastern Daylight Time (EDT), unless otherwise noted.Resident #31 (R31)Review of the Minimum Data Set (MDS) assessment, dated 5/22/2025, revealed R31 was admitted to facility on 8/14/2024 and had diagnoses including diabetes, obstructive uropathy, peripheral vascular disease, morbid obesity, and depression. Further review of the MDS assessment revealed R31 had an indwelling urinary catheter, was always incontinent of bowel, required substantial/maximal staff assistance for toileting hygiene and bathing, and was dependent on staff for all transfers and mobility. R31 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he was cognitively intact. On 6/25/2025 at 8:59 a.m., an observation in the 300 Hall revealed the door to R31's room was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-26 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consistently implement a bowel protocol program for one Resident (R32) of 2 Residents reviewed for bowel function in a total sample of 12 residents. This deficient practice resulted in extended periods of time when R32 had no documented bowel movement, with increased risk for pain and discomfort and/or the risk for medical complications such as bowel impaction. Findings include:All times recorded in Eastern Daylight Time (EDT), unless otherwise noted.A review of the medical record revealed that Resident #32 (R32) was admitted to the facility on [DATE] with diagnoses including chronic systolic congestive heart failure, protein-calorie malnutrition and encounter for palliative care. Review of R32's Minimum Data Set assessment, dated 5/22/25, revealed Section O (Special Treatments and Programs) noted R32 was on hospice care. The physician's orders for R32 included Fentanyl (a pain medication with known side effects of constipation).A review was conducted…
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 · D2025-06-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain sanitary oxygen tubing for three Residents (R6, R32 and R34) of four Residents reviewed for respiratory care.Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted.Resident #6 (R6)A review of R6's electronic medical record (EMR) revealed an initial admission to the facility on 4/24/25 with diagnoses including chronic diastolic congestive heart failure. A review of R6's Minimum Data Set (MDS) assessment, dated 5/5/25, revealed Section O (Special Treatments and Programs) reported while residing in the facility R6 required the use of oxygen. A Physician's order was written for R6 Change oxygen tubing weekly, date and initial tubing with each change.On 6/26/25 at 3:24 PM, R6 was observed in her room with an oxygen concentrator. The oxygen tubing was dated as last changed on 6/16/25.Resident #32 (R32)A review of R32's EMR revealed initial admission to the facility on 2/7/25 with diagnoses including chronic systolic congestive heart failure. A review of R32's MDS…
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 · D2025-06-26 · 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 maintain a medication error rate of less than 5% for three Residents (R6, R7 & R 1) of 9 residents reviewed for medication administration. This deficient practice resulted in a medication administration error rate of 12.00%, based on 3 medication errors in 25 opportunities for error.Findings include:All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. Resident R21On 6/26/25 at 9:18 a.m., Registered Nurse (RN) A was observed preparing and administering medications on the 300 Hall medication cart. When preparing medications for R21, RN A punched out one 88 mcg (microgram) tablet of Levothyroxine that landed on top of the medication cart which had not been disinfected, nor was a barrier in place. RN A donned clean gloves without the performance of hand hygiene, picked up the tablet and placed it into R21's plastic medication cup for administration to the Resident.During an interview on 6/26/25 at 9:31 a.m., when asked if the top of the 300 Hall medication cart was clean or dirty, RN…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-05-15 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for a least 8 consecutive hours a day, 7 days a week. Findings include: During an interview on 5/15/2024 at 1:53 PM, the DON and the Nursing Home Administrator reported that the facility had 2 RNs employed, in addition to the DON until 3/08/2024 when RN F resigned. The NHA reported that despite attempts to recruit more RNs, no RNs had been hired yet. Review of a Facility Assessment dated 4/19/2024 reflected Facility Staffing was to include, RN Supervisor (2 RN's - Full -time, 10-hour shift, 4 days a week and each and every 4th weekend each and on call. RN supervisor coverage 7 days a week. Review of the March 2024 -Nurses master schedule reflected there were 2 RNs in addition to the DON scheduled (RN E and RN F). Per the DON and NHA, RN F resigned on 3/08/2024, leaving the facility without an RN for at least 8 hours a day, 7 days a week beginning on 3/16/2024. Review of an April 2024 - Nurses master schedule reflected there was only one RN (RN E) other than the Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-05-15 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation is related to intake # MI00-138390 Based on interview and record review, the facility failed to 1). Implement a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and visitors and 2.) investigate and document the outbreak of gastrointestinal illness and respiratory illness among staff and residents. Findings: Review of the January 2024 Infection Surveillance Monthly Report revealed an outbreak of RSV (Respiratory Syncytial Virus). Review of the February-March 2024 Infection Surveillance Monthly Report revealed an outbreak of Norovirus (gastrointestinal illness). During an interview on 5/15/2024 at 8:07 AM, Director of Regulatory Compliance (DRC) C reported she was the Infection Preventionist and responsible for staff and resident infection surveillance. DRC C reported, when staff called off of work she would review the call-in sheet and determine if the call-in was infectious or not. DRC C reported employee call-ins were tracked in real time. DRC C reported that…
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 15 citations
- Potential for harm · F2024-05-15 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a qualified Infection Preventionist worked at least part-time at the facility, was provided sufficient time to perform the Infection Preventionist role, and was present to properly assess, implement, and manage the Infection Prevention and Control Program resulting in the lack of outbreak surveillance and investigation, antibiotic stewardship, and immunizations. Findings: Review of the Facility Assessment last reviewed 4/19/24 revealed, .Infection Prevention-Facility-The infection Prevention Plan was revised, modified, and approved at QAPI (Quality Assurance Process Improvement) in January 2023. McGeer compliance is tracked to verify all infections are manage appropriately. A line list is maintained for all resident and staff infections .Infection Prevention Control Program (IPCP)-The IPCP will be monitored, and managed by the facility Infection Preventionist. The (facility) Infection Preventionist is the Director of Nursing and/or the Administrator . During an interview on 5/15/2024 at 8:07 AM, Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-15 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 is related to intake # MI00-142770 Based on observation, interview, and record review, the facility failed to make grievance forms readily available to all resident's and family members, and failed to follow up with 1 of 3 resident's (Resident #4) reviewed for grievances. Findings: During an observation on 5/13/24 at 8:20 AM, a plastic tray hung on the wall near the nurses station and was labeled grievance forms. The tray was empty and did not contain any grievance forms. The plastic tray was situated at a height on the wall that would be out of reach for resident's in wheelchairs with limited range of motion. The posting did not indicate expectations once the grievance form was filled out, i.e. who would be following up on the concern and in what kind of time frame follow up could be expected. During an observation on 5/14/24 at 4:54 PM, the grievance form tray that hung on the wall near the nurses station did not have any grievance forms in it for resident's to utilize. 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.
- Potential for harm · D2024-05-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake # MI00138390 Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of an injury of unknown origin for 1 resident (R16) out of 4 residents reviewed for abuse and neglect. Findings include: Review of an admission Record reflected R16 admitted to the facility with diagnoses that included non-traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein in the blood), alcohol induced dementia, high blood pressure, weakness and hearing loss. Review of a General Progress Note dated 1/25/24 at 4:52 AM reflected (R16) very weak and unsteady on her feet. Was helped to the wheelchair and to the bathroom. She is incontinent of B and B (bowel and bladder). Review of a Communication - with Physician progress note dated 1/25/24 at 6:57 AM reflected (R16) is reporting increased right leg pain and has been much more immobile. In her room last several days. Not ambulating…
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 · D2024-05-15 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00138390 and MI00139816 Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 2 of 15 residents (Resident #6 and #36), reviewed for the provision of nursing services, resulting in medications being administered outside of the physician ordered parameters. Findings: Resident #6 (R6) Review of an admission Record revealed R6 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R6's Order Summary dated 3/7/24-5/8/24 revealed, METOPROLOL 25 MG (milligram) TAB Give 0.5 tablet orally two times a day for HYPERTENSION HOLD FOR HR (heart rate) LESS THAN 65, SBP (systolic blood pressure-top number) LESS THAN 110. Review of R6's May Medication Administration Record revealed: *On 5/1/24 R4's blood pressure was 98/60 and the evening dose of metoprolol was administered. *On 5/2/24 R4's blood pressure was 106/76 with a heart…
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 before2024-05-15 · 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 #MI00138390 Based on observation, interview, and record review, the facility failed to implement their policy for post-fall assessments for 2 of 4 resident's (Resident #6 and Resident #14) reviewed for accidents and hazards. Findings: Resident #6 (R6) Review of an admission Record for R6 revealed a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnoses of dementia, bilateral hearing loss, insomnia, and history of falling. Review of a BIMS (brief interview for mental status), dated 3/14/24, revealed a score of 12/15 indicating R6 was mentally intact. During an observation on 5/13/24 at 9:13 AM, R6 sat in a chair in her room, resting with eyes closed. R6 awoke to her name and allowed the surveyor to visualize the back of her head. R6 stated that she fell hard. R6 had an approximately 3 centimeter long laceration at the base of her skull, approximated with sutures. Review of a Nursing Progress Note for R6, dated 5/8/24 at 3:30 AM, revealed…
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 · D2024-05-15 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement the antibiotic stewardship program and ensure that residents who required an antibiotic were prescribed the appropriate antibiotic for 3 of 7 Residents (#14, #18, and #6) reviewed for antibiotic use, resulting in inappropriate antibiotic utilization and the potential for antibiotic resistance. Findings: Resident #14 (R14) Review of an admission Record revealed R14 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R14's Health Status Note dated 3/16/24 at 1:35 PM revealed, Resident has been requesting to go to the bathroom frequent per wife, she has been here with him today and the times he has been to the bathroom only has been urinating small amounts also has been holding himself down below. Did urine dip positive for leukocytes and blood. Not enough urine to send out at this time. On call Dr notified. Review of R14's Physician Order Note dated 3/16/24 at 4:19 PM revealed, writer received a T/O (telephone order) from…
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 · D2024-05-15 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop 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 provide the pneumococcal immunization per consent and the recommendation by the Centers for Disease Control and Prevention (CDC) for 2 of 5 residents (Resident #37 and #191) reviewed for immunizations, resulting in residents not receiving the pneumococcal immunization. Findings: Resident #37 (R37) Review of an admission Record revealed R37 was an [AGE] year-old female, admitted to the facility on [DATE]. Review of R37's Electronic Health Record revealed R37 had not received a pneumococcal vaccine since 9/9/2016. Review of R37's Universal Vaccine Consent dated 4/1/24 revealed R37 and/or Power of Attorney provided signed consent for the influenza and pneumococcal vaccines. Review of R37's Order Details dated 4/25/24 revealed, May administer pneumovax (pneumonia) vaccine every 5 years unless contraindicated. Resident #191 (R191) Review of an admission Record revealed R191 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R191's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-06-16 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 employ qualified staff with the appropriate competencies, skill sets, and credentials to supervise and carry out the functions of the food and nutrition service department. This deficient practice resulted in the potential for clinical and operational dietary needs to be compromised or unmet for all 39 residents living at the facility. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. During an interview on 6/13/23 at 11:56 AM, Dietary Manager (DM) G stated she had been employed as a cook at the facility since 12/2020 but had recently been promoted to the Dietary Manager position (3/15/2023). DM G stated she had attempted to pass a dietary manager course but was not certain of the title. DM G presented an email and flyer for a Certified Food Manager test which did not cover clinical nutritional aspects of resident care, but focused on managing the kitchen. DM G stated she had failed 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 · Fcited before2023-06-16 · 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 store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failing to properly clean areas with a potential to contaminate food during preparation. B. Failing to ensure food preparation surfaces in the dietary department were properly disinfected. C. Failing to ensure that refrigerated potentially hazardous foods brought in by visitors were dated and discarded on or before the expiration date. This deficient practice had the potential to result in food borne illness among any or all 39 residents in the facility. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. During the initial tour of the kitchen with Dietary Manager (Staff) G on 6/13/23 at 11:56 AM, the hood over the cooking equipment providing the ventilation was observed to have a thick grease build up. Under the hood there were light covers with dust observed directly over the stove top/grill area. The hood grease catch pan had a thick layer of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-16 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store drugs and biologicals in locked compartments, with keys accessible only to authorized personnel, on three halls out of three halls reviewed for medication storage. This deficient practice resulted in the potential diversion of medication, and uncontrolled access by facility staff to physician prescribed and over-the-counter medications. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. On 6/14/23 at 8:12 a.m., during observation of medication administration with Licensed Practical Nurse (LPN) U, two unsecured plastic divided storage containers with 100 Hall AM (morning) and PM (afternoon) skin treatments including ointment, creams, anti-infective agents, and suppositories were in an unlocked Clean Linen room on the 100 Hall. When asked about the uncontrolled access to the resident treatment and skin cremes, etc., LPN U stated, The (medication) cart is locked and they (CNAs) can't get to them, so they are in the clean linen room, so the CNAs have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-16 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual 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 provide food prepared in the prescribed texture to meet individual needs for four Residents (R16, R20, R27, and R36) of 5 residents reviewed for food served in the proper form. This deficient practice resulted in the delivery of food of inappropriate consistency for the prescribed diet with the potential for choking, aspiration (accidental breathing of food or fluid into the lungs) and complications including aspiration pneumonia. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. Resident #16 (R16) The Electronic Medical Record (EMR) for R16 revealed an original admission date of 10/16/19 with medical diagnoses including Alzheimer's disease, age-related physical debility, hypertensive heart disease, and major depressive disorder. The Minimum Data Set (MDS) assessment of 4/4/23 contained a Brief Interview of Mental Status (BIMS) score of 3/15 indicating severe cognitive impairment. The current Physician Orders for R16 as printed on 6/14/23 at 11:24 AM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-16 · 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 Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards including access to the electronic bed and recliner chair remote controls and a potentially hazardous, inedible denture cleanser tablet for one Resident (R92) out of five residents reviewed for accidents and hazards. This deficient practice resulted in the potential for unsafe bed and chair repositioning, partial ingestion of a denture cleanser tablet, poison control notification, and additional physical monitoring for R92. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. Review of R92's Minimum Data Set (MDS) assessment, dated 5/23/23, revealed R92 was admitted to the facility on [DATE] with active diagnoses that included, in part: Alzheimer's disease and cerebrovascular accident (stroke). R92 scored 4 of 15 on the Brief Interview for Mental Status (BIMS), reflective of severe cognitive impairment. R92 required extensive, two-person…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-16 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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: attempt alternatives prior to the use of a bedrail, appropriately assess resident risk of entrapment prior to use of a bedrail, and obtain a physician order for the bed rail prior to use of a restraint for one Resident (R92) out of one resident reviewed for safe bedrail usage. This deficient practice resulted in the potential for bedrail entrapment of a cognitively impaired resident, and the potential for unnecessary use of bedrails. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. During an observation on 6/14/2023 at 4:45 p.m., R92's bed was found with a mobility bedrail installed on the upper, right side of R92's bed. Review of R92's Minimum Data Set (MDS) assessment, dated 5/23/23, revealed R92 was admitted to the facility on [DATE] with active diagnoses that included, in part: Alzheimer's disease and cerebrovascular accident (stroke). R92 scored 4 of 15 on the Brief Interview for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-06-26 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to honor the residents' rights to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect. This deficient practice affected all 36 residents residing in the facility.Findings include:All times recorded in Eastern Daylight Time (EDT), unless otherwise noted.On 6/25/25 at 11:00 AM, a confidential group meeting was held with six interested residents in attendance. The annual survey process was explained whereby a report would be sent to the facility with issues and concerns discovered by the State Agency. The facility would then respond in writing with a plan to correct the noted concerns. The entire report of both concerns and corrections would be public knowledge and must be posted in an easily accessible place in the building where the residents and others have the opportunity to read and review it. The residents in attendance did not know of this procedure and were unaware of the report's availability.The resident council…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-06-26 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to post the actual hours worked by licensed and unlicensed nursing staff on the daily Staff Posting Information.Findings include:All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. On 6/24/25 at 12:37 p.m., the Nurse Staffing Sheet was observed posted on the wall outside of the Social Workers office and across from the main nurses' station. A copy of the Nurse Staffing Sheet was requested and received from Activity Director O on 6/24/25 at 12:39 p.m. Review of Nurse Staffing Sheets dated 6/24, 6/25, and 6/26/25 revealed all columns for RN (Registered Nurse) Hours Actually Worked, LPN (Licensed Practical Nurse) Hours Actually Worked, and CNA (Certified Nurse Aide) Hours Actually Worked were blank: absent any documentation for all shifts.During an interview on 6/26/25 at approximately 3:30 p.m., the Nursing Home Administrator (NHA) was asked if she understood this Surveyor's concerns related to completion and posting of the Nurse Staffing Sheets. The Director of Nursing (DON) who 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2025-07-25 for 14 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FRIEDMAN, BENJAMIN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER | 100% | since 03/01/2023 |
CMS files one row per role, so the 4 rows in the source record cover these 1 parties — each is shown once here with every role it holds. Nothing is omitted.
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 $362K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 235591. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-26, 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 →
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