Medilodge of Shoreline
14900 Shore Line Drive, Sterling Heights, MI 48313 · For profit - Corporation · 112 certified beds · (586) 247-4700 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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
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 | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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 | 7.8% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.4% | 5.4% | 5.4% | worse |
| 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 | 2.0% | 1.5% | 2.0% | typical |
| 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 | 2.3% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.5% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 25.3% | 19.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.9% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.6% | 5.1% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 17.4% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.9% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.1% | 1.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 61.0% | 79.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 21.9% | 24.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 2.5% | 11.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.98 | 1.84 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.29 | 1.64 | 1.80 | 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.
45.8% 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 89 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 43.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 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 0.32 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 45.8%CMS range 36.8–55.5 | 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 | 11.1%CMS range 7.7–15.6 | 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 | 43.3% | 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 | 46.7% | 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 | 36.7% | 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 | 89.7% | 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 | 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 | 87.5% | 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 | 0.0% | 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 | 0.0% | 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 | 7.3%CMS range 4.0–13.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 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 112 beds and averages 104.0 residents a day — about 93% occupied, or roughly 8 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 3.58 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 2.08 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 2.96 hrs/resident/day on weekends vs 3.84 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.79 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Dcited before2026-05-07 · 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 This citation pertains to Intakes 2999148 and 2996472.Based on observation, interview, and record review, the facility failed to transcribe and administer medications as ordered during a change in condition for one resident (R701) of three reviewed for change in condition, resulting in a delay in treatment and subsequent transfer to the hospital. Findings include:A summary of a complaint called into the State Agency revealed, [R701] was throwing up and having abdominal pain from hernia. The nursing home waited six hours to call EMS (Emergency Medical Services) . It was discovered [R701] had a perforated bowel. suffered for several hours crying out in pain and nothing was done at the nursing home other than giving [R701] Tylenol.A review of R701's medical record revealed, R701 was admitted to the facility on [DATE] readmitted [DATE] and discharged [DATE] with diagnoses of Ventral hernia without obstruction or gangrene, Morbid (severe) obesity, and Type II diabetes.A review of R701's progress note authored by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete annual PASARR (Pre-admission Screening and Annual Resident Review/3877) assessments for four residents (R6, R28, R32 and R61) of four residents reviewed for PASARR assessments.Findings include:Resident 6On 1/06/26 at 10:15 AM, R6 was observed sitting in a chair in their room. When asked about their care, R6 was not able to answer questions.On 1/06/26 the medical record for R6 was reviewed and revealed the following: R6 was initially admitted to the facility on [DATE] and after a brief hospitalization was readmitted [DATE] with diagnoses including Vascular Dementia, Mood Affective Disorder and Adjust Disorder with Disturbance of Conduct. A review of R6's MDS (Minimum Data Set) assessment revealed a BIMS (Brief Interview for Mental Status) assessment score of 3/15 indicating severely impaired cognition.On 1/07/26 further review of R6's medical record revealed a PASARR assessment dated [DATE] for a 30-day hospital exempted discharge.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · 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 Based on observation, interview, and record review, the facility failed to ensure one (R8) of three residents reviewed for medication administration received the correct dose of a medication and consumed all medications provided. Findings include:Review of the medical record revealed a physician's order dated 9/25/25 for Potassium Chloride ER Tablet Extended Release 20 MEQ (milliequivalents), Give 3 tablet by mouth three times a day for supplement.Further review of the medical record revealed R8 was admitted to the facility on [DATE] with the following relevant diagnoses: Essential Hypertension, Lymphedema, Chronic Venous insufficiency and Peripheral Vascular Disease and was cognitively intact. On 1/7/26 at 7:56 AM, during an observation with Licensed Practical Nurse (LPN) A, the nurse was observed to prepare and administer medications to R8. While preparing the medication for administration, LPN A revealed R8 usually only takes one of three prescribed Potassium 20 MEQ tablets and proceeded to put one tablet…
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 before2026-01-08 · 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 Intake 2704083. Based on observation, interview, and record review, the facility failed to provide showers for one resident (R66) of three reviewed for activities of daily living (ADLs). Findings include: A review of an Intake allegation noted, It was alleged the resident isn't provided with appropriate showers per preference.A review of R66's shower schedule noted, Bathing: Monday and Thursday dayshift.A review of R66's shower record for the last 30 days revealed, Thursday 12/11/25 documented as response not required (shower did not occur), Thursday 12/18/25 checked as one person assist, Monday 12/22/25 checked as one person assist, Thursday 12/25/25 response not required. Further review of R66's medical record revealed, was admitted to the facility on [DATE] with diagnosis of Paraplegia. A review of R66's Minimum Data Set (MDS) assessment dated [DATE] noted, R66 with an intact cognition and dependent of staff to complete activities of daily. The MDS noted R66's shower ability 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 before2026-01-08 · 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 — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to remove expired medications from two of three medication carts reviewed. Findings include:On 1/7/26 at 1:00 PM, an observation of the Station One, medication cart 2, was a bottle of Midodrine (used to treat low blood pressure), labeled for R17 filled on 11/1/24 with a use by date of 11/1/25. On 1/7/26 at 1:22 PM, an observation of the Station One, medication cart 1, was an over-the-counter brand of sinus severe tablets with an expiration date of 8/2024. An identifying label for a specific resident was not present. On 1/7/26 at 1:54 PM, an interview with Unit Manager (UM) F revealed medication should be in the medication carts secondary to being long past their expiration dates. On 1/8/26 at 2:10 PM, an interview with the Director of Nursing (DON) revealed expired medications are to be removed from the medication carts or medication storage area and returned to pharmacy or discarded.
- Potential for harm · F2024-10-17 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) meetings were held quarterly, for two of four meetings, potentially affecting all of the 103 residents currently residing in facility resulting in delayed identification and resolution of identified issues. Findings include: On 10/17/24 at 12:30 PM, a meeting was held with the Nursing Home Administrator (NHA) regarding Quality Assurance (QA) activities at the facility. A review of the sign in sheets (to confirm at least three staff were present who were knowledgable of facility systems and oversight) revealed there was no sign in sheet for March and June 2024. The NHA confirmed there were no QA meetings held during those two months. A review of the facility's policy titled, QAPI (Quality Assurance Performance Improvement) Plan, dated 10/24/22, indicates: a.The governing body and/or executive leadership is responsible and accountable for the QAPI program. The Governing oversight responsibilities include, but are not limited to: i. Approving the QAPI plan annually, and 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 · F2024-10-17 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 MI00147288. Based on observation, interview, and record review, the facility failed to maintain a pest-free environment, resulting in gnats throughout the common areas of the facility and throughout residents rooms. This deficient practice had the potential to affect all 130 residents who reside in the facility. Findings include: On 10/15/24 at 9:18 AM, during initial tour room [ROOM NUMBER] bed two trash can was observed to gnats laying on and inside of the trash can. The trash can was without a liner/trash bag on the inside of the can. On 10/15/24 at 9:39 AM, during initial tour room [ROOM NUMBER] bed two trash can was observed to gnats laying on and inside of the trash can. The trash can was without a liner/trash bag on the inside of the can. On 10/16/24 at 8:02 AM, during the medication administration observation gnats were observed flying around the medications cart. The Nurse was observed to use their hands to swat the gnats away. On 10/16/24 at 8:18 AM, room [ROOM NUMBER]…
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 before2024-10-17 · 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 care in a dignified manner, for one sample resident (R49) of seven reviewed for dignity. Findings include: On 10/16/24 at 6:50 AM, R49 reported there was an incident with two Certified Nursing Assistants (CNA) while they were receiving care. R49 continued and explained, two CNAs (CNAs F and G) entered their room to assist with care, then CNA G asked R49 about a comment R49 made about the CNAs. R49 reported they felt like CNA G was intimidating them by confronting them about their comment. R49 stated during the conversation CNA G made the comment, because they are not allowed to hit R49, she took a hygiene product and poured in down the bathroom sink. R49 stated it was reported and the CNAs were removed from their room and no longer provide care to them. On 10/16/24 at 11:05 AM, the Unit Manager confirmed that R49 reported CNA G poured out their hygiene product down the bathroom sink and the facility completed an investigation. On 10/16/24 at 11:23 AM, CNA G was called, the phone message stated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-17 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
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 MI00147323 Based on observation, interview, and record review the facility failed to ensure communication needs were met for one resident (R10) of three residents reviewed for communication. Findings include: A review of the admission record revealed R10 was admitted on [DATE] with the following pertinent diagnoses: Dysphagia, Protein Calorie Malnutrition, Adjustment Disorder with Anxiety, Restlessness and Agitation. R10 spoke Arabic. On 10/15/24 at 9:00 AM, R10 was observed with head of bed elevated and the overbed table was across the bed with food debris visible. When R10 was queried, they were unable to respond verbally, responded with questioning look on face. On 10/15/24 at 11:40 AM, Certified Nursing Assistant (CNA) I was queried on R10's method of communication. CNA I revealed they verbalize what they are doing, use some gestures and if resident says no or becomes upset they stop and return later. CNA I revealed they were not aware of a communication board. On 10/15/24 at 11:50…
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 before2024-10-17 · 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
Based on interview and record review, the facility failed to hold medication per medication parameters for one resident (R102) out of four reviewed for medication administration. Findings include: A review of the medical record revealed R102 admitted into the facility on 7/3/2024 with the following diagnoses, Essential Hypertension and Rheumatoid Arthritis. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) of 14/15 indicating an intact cognition. R102 also required staff assistance with bed mobility and transfers. Further review of the physician orders revealed the following, Amlodipine Besylate Tablet 10 MG (milligram)-Give one tablet by mouth one time a day for HTN (Hypertension) HOLD FOR SBP (Systolic Blood Pressure) <120.Start Date:7/10/2024 A review of the Medication Administration Record (MAR) for July 2024 revealed the Amlodipine was administered with a SBP <120 on the following days with the following blood pressures, 7/10-119/78,7/16-118/78,7/18-114/69,7/21-119/78,7/25-117/73, and 7/26/24-117/67. Further review of 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.
Show the remaining 16 citations
- Potential for harm · D2024-10-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide and document indwelling catheter care (tube inserted into the bladder to drain urine) for one resident (R63) out of two reviewed for an indwelling catheter. Findings include: On 10/16/2024 at 8:30 AM, R63 was observed laying in bed. R63 was noted to have an indwelling catheter. R63 stated they have had a catheter since their last admission into the facility. A review of the medical record revealed R63 admitted into the facility on 8/30/2024 with the following diagnoses, Urinary Tract Infection and Sever Sepsis with Septic Shock. A review of the Minimum Data Set revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R63 also required staff assistance with bed mobility and transfers. A review of the physician orders revealed the indwelling catheter orders for catheter care were not entered until 10/14/2024 and 10/15/2024. On 10/16/2024 at 10:54 AM, an interview was conducted with Unit Manager (UM) B regarding the catheter orders being put in almost two months after…
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 · D2024-10-17 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
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 properly care for and document colostomy care for one (R88) of one resident reviewed for ostomy care. Findings include: On 10/15/24 at 09:15 AM, R88 revealed they have a new ostomy. R88 further revealed the appliance does not stay on, always leaks, and their skin hurts. R88 further revealed they have not been educated on how to put the appliance on because they can only use one hand. Review of the admission record revealed R88 was admitted to the facility on [DATE] with the following relevant diagnoses: Partial Intestinal Obstruction, Colostomy, Mild Cognitive Impairment, Hemiplegia and Hemiparesis affecting Right Dominant Side following Cerebral Infarction, and Aphasia. On 10/16/24 at 9:00 AM, R88 revealed their ostomy was changed by the night shift because it was leaking again. Review of R10's medical record failed to reveal any documentation of the ostomy appliance leaking, of the skin condition of the ostomy site, or that the NP…
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 · D2024-10-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to implement nutritional interventions for one resident (R63) out of two reviewed for nutrition. Findings include: On 10/16/2024 at 8:27 AM, R63 was observed eating breakfast. R63 was sitting leaned off to the side with visible tremors in their hand. R63 was noted to have food on the floor, as well as on their clothes. R63 stated they ate by themselves with no assistance for all meals, but they could use a little help. R63 was noted to try and drink some orange juice from a regular cup and stated they needed to put a straw in it. A two handled cup was observed on the meal tray, flipped upside down. A review of the meal ticket on the tray documented R63 was supposed to have 1:1 assistance with eating, and a two handled cup with a lid for beverages. A review of the medical record revealed that R63 admitted into the facility on 8/30/2024 with the following diagnoses, Urinary Tract Infection and Sever Sepsis with Septic Shock. A review of the Minimum Data Set revealed a Brief Interview for Mental Status score 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 · D2024-10-17 · 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
Based on observation, interview, and record review, the facility failed to ensure one resident (R63) out of four reviewed for medication administration were free of any significant medication errors. Findings include: On 10/16/2024 at 9:12 AM, 9:00 AM medication administration was completed with Licensed Practical Nurse (LPN) A for R63. A review of the physician orders revealed the following, Furosemide Oral Tablet 20 MG (Milligrams) (diuretic). Directions: Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10). Time: 0900 (9:00 AM). Famotidine Oral Tablet 20 MG (antacid). Directions: Give 1 tablet by mouth one time a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS (K21.9). Time: 0600. (6:00 AM) LPN A was observed putting medication in the cup and clicking off the medicine as yes on the Medication Administration Record (MAR) as they put the medicine in the cup. LPN A was then observed taking the Famotidine (due at 6:00 am) 20 MG cartridge and checking off the Furosemide (due at 9:00 am) 20 MG on the MAR. LPN A was then asked by…
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 before2024-10-17 · 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 properly store and secure medications for one resident (R48) out of one resident reviewed for medication storage. Findings include: On 11/14/24 at 12:11 PM, R48 was observed lying in bed. Nystatin powder and Hydrocortisone cream were observed on R48's bedside table. R48 explained the facility staff applies the powder and cream and they leave it at R48's bedside. A review of R48's record revealed they were admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease. A review of R48's Brief Interview for Mental Status revealed a score of 13, indicating mild cognitive impairment. Further review of R48's medical record revealed the following active medication order: Apply Hydrocortisone ointment 1% to left forearm and right upper chest and shoulder every day and evening shift for rash for 7 days and every 8 hours as needed for rash/itching. A review of R48's medical record also revealed the following…
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 before2024-10-17 · 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 change an indwelling catheter (tube inserted into the bladder to drain urine) with a urinary tract infection for one resident (R39) out of two reviewed for indwelling catheters. Findings include: On 10/15/2024 at 12:47 PM, R39 was observed to have an indwelling catheter hanging off their wheelchair. R39 stated they recently had a Urinary Tract Infection (UTI) and they were still having symptoms although they were finished with antibiotics. R39 stated they have not had their catheter changed since being admitted into the facility on 8/8/24. A review of the medical record revealed R39 admitted into the facility on 8/8/2024 with the following diagnoses, Sever Sepsis without Septic Shock and Neuromuscular Dysfunction of Bladder. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIM) score of 15/15 indicating an intact cognition. R39 also required staff assistance for bed mobility and transfers. A review of the physician orders revealed the following, Date: 8/9/2024.…
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 before2024-06-26 · 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
This citation pertains to Intake MI00144522. Based on observation, interview, and record review, the facility failed to document and provide showers per resident preference and schedule for three residents (R902, R903, R904) of three residents reviewed for showers. Findings Include: R902 On 6/26/2024 at 10:30 AM, R902 was observed in their bed. R902 stated they do not receive showers as they should and they have only received two showers since being in the facility. R902 stated they do receive bed baths but would much rather have a shower. R902 stated they feel as though staff won't give them showers because they are a bit bigger and the staff do not want to do the extra work. On 6/26/2024 at 10:57 AM, R902 was observed receiving a bed bath from two certified nursing assistants (CNA). One of the CNAs stated they were getting R902 up in the chair for the day and R902's shower days were Monday and Thursday. A review of the medical record revealed that R902 admitted into the facility on 4/16/2024 with the following medical diagnoses, Obesity and Muscle Weakness. A review at the Minimum…
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 before2024-04-24 · 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
This citation pertains to Intake MI00143567. Based on observation, interview, and record review, the facility failed to get residents out of bed per their preference for two residents (R803 and R806) out of two reviewed for resident rights. Findings include: R803 On 4/23/2024 at 9:30 AM, R803 was observed laying in bed. R803 was interviewed regarding their care in the facility. R803 stated that they enjoy being at the facility, however they (facililty staff) do not get them up like they should R803 stated they prefer to get up before breakfast and be up for all meals. R803 stated they do not like eating their meals in the bed. R803 stated that they also don't like to miss bingo. On 4/24/2024 at 10:15 AM, R803 was observed still in bed. R803 stated they asked to get up before breakfast, but no one got them up. R803 stated they hope they are up by lunch. On 4/24/2024 at 11:51AM, R803 was observed eating lunch in their bed. R803 stated they were informed they would be getting up after lunch. On 4/24/2024 at 12:06 PM, an interview was conducted with Certified Nursing Assistant (CNA) D.…
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 · D2024-04-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to Intakes MI00143495 and MI00143567. Based on observation, interview, and record review, the facility failed to float heels per physician orders for two residents (R802 and R803) out of two reviewed for skin conditions. Findings include: R802 On 4/23/2024 at 9:28 AM, R802 was observed laying in bed. R802 heels were noted to be resting on the mattress. No pillow was observed under their legs to float their heels. On 4/23/2024 at 11:23 AM, R802's heels were observed resting on the mattress. On 4/24/2024 at 9:45 AM, 10:10 AM, and 12:08 PM, R802's heels were observed resting on the mattress. A review of the medical record revealed that R802 admitted into the facility on 3/22/2023 with the following diagnoses, Diabetes and Dysphagia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. R802 also required assistance with bed mobility and transfers. Further review of the physician orders revealed the following, Start: 10/23/2023. Status: Active .Cleanse bilateral heels with Normal…
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 · D2024-04-24 · 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
This citation pertains to Intake MI00142973. Based on observation, interview, and record review, the facility failed to answer a call light and provide needs in a timely manner for one resident (R805) out of three reviewed for call lights. Findings Include: On 4/23/2024 at 1:50 PM, R805's call light was observed activated. At 2:09 PM, R805 call light was observed still activated. Multiple people were noted in the hallway and walking past the light. R805 was interviewed regarding what assistance they were waiting for Certified Nursing Assistant (CNA) B. R805 stated that they were waiting to be changed and that they had been waiting for an hour and a half. On 4/23/2024 at 2:10 PM, CNA B was observed going into the room with R805 and turning off their call light. CNA B stated that R805 was a two person assist and they had to go find someone to help. On 4/23/2024 at 2:20 PM, CNA B was observed going into R805's room with another staff member and stated they were about to perform care. A review of the medical record revealed that R805 admitted into the facility on 1/11/2024 with 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 · F2023-08-23 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the repair of damaged walls, doors, ceiling tiles, and vinyl floors, and failed to clean and empty trash in rooms in a timely manner, resulting in an unsafe and unhomelike environment. Findings include: On 08/21/23 at 9:30 AM until 2 PM, during the initial tour of the facility: The bathroom door in room [ROOM NUMBER] was observed with horizontal marring and gouges which revealed the unpainted surfaces as compared the white of the door; The wall behind the bed in room [ROOM NUMBER] had six vertical gouges which revealed the unpainted surfaces; The door and frame to the fire extinguisher box by the business office drop box appeared rusty; The door to the 200 bathing room had black and gray horizontal marring; Inside the bathing room an approximate four foot by one and half foot hole was observed in the wall of the rear bathing stall; The door to the bathing room on the 100 hall was observed with notches out of the edges of the door;…
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 · E2023-08-23 · 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 MI00138545. Based on observation interview and record review the facility failed to ensure fall and skin management care plan interventions were consistently implemented for four residents (R7, R44, R27, R10) of 5 whose fall and skin management care plans were reviewed, resulting in the potential for unmet care needs, falls and skin breakdown. Findings include: R7 On 08/21/23 at 9:01 AM, R7 was observed to be in bed. The aide came in with the breakfast tray and set it before the resident, The roommate talked to the aide then to ensure resident was sitting up and the food was cut up and positioned where R7 could reach it as R7 could not use their right side. A knife was not included on the tray and the sausage patty appeared difficult to cut up with the edge of the fork. On 08/21/23 at 10:14 AM, R7 was observed to be on their back in bed with the head of the bed up around 30-45 degrees. On 08/21/23 at 12:31 PM, R7 was observed to be in bed, laying on their back. The head of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-23 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 R7 On 08/21/23 at 9:01 AM, R7 was observed to be in bed. The aide came in with the breakfast tray and set it on the tray table in front the resident. The roommate talked to the aide and told the aide to ensure R7 was sitting up and the food was cut up and positioned where R7 could reach it as R7 could not use their right side. A knife was not included on the tray and the sausage patty appeared difficult to cut up with the edge of the fork. The aide did not remain to assist R7. On 08/21/23 at 10:14 AM, R7 was observed to be on their back in bed, a pillow under the left side and with the head of the bed up around 30-45 degrees. On 08/21/23 at 12:31 PM, R7 was observed to be in bed, laying on their back, dressed in T-shirt and brief. The left leg was flexed up and a right hand contracture was observed. The pointer finger was straight out and the other fingers were curled toward the palm, The head of the bed was up around 30-45 degrees. On 08/21/23 at 12:50 PM, staff entered R7's room with their lunch tray. A knife…
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 · D2023-08-23 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to accommodate resident/resident representative's choices and preference for bed rails for one sampled resident (R46) of one reviewed for self-determination resulting in feelings of frustration and loss of control. Findings include: On 8/21/23 at 10:45 AM, R46 was observed in bed with bruising noted below their right eye, and a laceration above their right eye, one fall mat on the floor, and bilateral foam boots on feet. Resident's power of attorney, Family Member A was asked about the care R46 has been receiving in the facility, and explained that R46 had fallen twice at the facility. They explained that the facility staff implemented a fall mat following the fall however, less than one month later, R46 sustained a second fall in which they landed on the mat, hit they're head on the floor resulting in a laceration above their right eyebrow and a facial fractures on the right side of their face. Family Member A explained that after the second fall, they provided R46 a perimeter mattress, which Family Member A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a pacemaker check for one sampled residents (R32), of one reviewed for pacemakers. Findings include: On 8/21/23 at 9:37 AM, R32 was asked about the stay at the facility and stated, I haven't had my pacemaker checked since being here for over a year. On 8/21/23 at 3:35 PM, an email request was made to ask if R32's Phyisican was aware of R32's pacemaker and if there was documentation of the pacemaker being checked. The Nursing Home Administrator (NHA) replied, Physician is aware of [R32's] pacemaker and has not provided order for checks. A request was made for R32's pacemaker check documentation. The facility did not provide any documentation in regards to R32's pacemaker. Further review of R32's medical record noted, Care planning: 7/6/23 .Nursing: Resident complaining of pain in [R32] right breast, Dr. notified new order to obtain an Ultrasound. Ultrasound ordered and has not been completed at this time. Working on getting the Dr.…
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 before2023-08-23 · 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 ensure proper hand hygiene and maintain appropriate infection control practices during patient care for three residents (R7, R33, R72, Resident L) of six reviewed for infection control practices, resulting in the potential for the spread of infection. Findings include: On 08/22/23 at 04:24 PM, R7 was observed with Certified Nurse Assistant (CNA) G. R7 was soiled with mushy/unformed stool and it was up between the legs and over the vaginal area. Disposable wipes were used to clean R7. CNA G was observed to clean up the stool from R7. During care CNA G removed their gloves and placed on a new pair without hand hygiene between the change. Additional spots of stool were cleaned up and a new brief was applied and the gown changed. CNA G noted they did not have a new gown in the room and doffed their gloves and exited the room without hand hygiene being done. CNA G retrieved a new gown, returned to the room and placed on the new gown. CNA G was assisted by the second CNA to pull R7 up in bed and a pillow placed under…
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 MEDILODGE — 53 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 | 3.1 | -0.1 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 3 of 5 | 3.7 | -0.7 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 52 homes this chain runs (chain average 3.1★, per CMS)
Showing 40 of 52; lowest-rated first.
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 | Share | Since |
|---|---|---|---|---|
| B&Y HEALTHCARE S CORP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 48% | since 03/01/2018 |
| CODY HEALTHCARE S CORP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 48% | since 03/01/2018 |
| B&Y TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 48% | since 03/01/2018 |
| CRAIG FLASHNER 2007 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 48% | since 03/01/2018 |
| NORCROSS, ROBERT | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 03/01/2018 |
| ROGERS, STACEY | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 03/01/2018 |
| KIRK, KRISTINE | Individual | W-2 MANAGING EMPLOYEE | — | since 03/01/2018 |
| CENTURY HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2018 |
| FLASHNER, CRAIG | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2018 |
| PERLSTEIN, YITZCHOK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2018 |
5 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 $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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 235473. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, 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 →
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