Corewell Health Rehabilitation & Nursing Center -
4368 Cleveland Ave, Stevensville, MI 49127 · Non profit - Corporation · 111 certified beds · (269) 983-6501 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0605), cited Oct 2025
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,827 in federal fines (most recent 2024-10-01)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 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, and staffing on its payroll (PBJ) submissions — 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 fell from 3 to 1 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 | 17.4% | 10.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.1% | 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 | 1.1% | 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 | 2.8% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 27.5% | 12.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 8.6% | 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 | 4.6% | 5.1% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 23.8% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.5% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.3% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.9% | 24.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 2.8% | 11.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.10 | 1.84 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.53 | 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.
60.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 307 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 34.6% 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 153 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 0.44 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% 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 | 60.6%CMS range 55.7–65.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.2%CMS range 6.6–12.2 | 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 | 34.6% | 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 | 36.6% | 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 | 27.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.8% | 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 | 94.4% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 73.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.3% | 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 | 7.2%CMS range 4.7–9.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 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 111 beds and averages 97.5 residents a day — about 88% occupied, or roughly 14 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 4.15 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.28 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.34 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 3.59 hrs/resident/day on weekends vs 4.38 on weekdays — 18% thinner on weekends. RN hours go from 1.47 to 0.80 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%. 1 administrator has left in the past year.
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.
33 citations, most serious first. The 13 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · J2025-10-01 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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: 2568667.Based on interview and record review, the facility failed to prevent the use of unnecessary psychotropic medications without adequate indication for use and without resident monitoring in 1 of 1 resident (Resident #101) reviewed for psychotropic medications, resulting in an Immediate Jeopardy when on [DATE] Resident #101 was prescribed a psychotropic medication, who then sustained a fall with a impacted acetabulum (hip socket) and pelvic fracture on [DATE] and subsequent death. Findings include: Resident #101 was prescribed lorazepam daily beginning [DATE]. Resident #101 had falls on 5/12, 5/20, and 5/28 with no major injury after no falls since February admission. No monitoring for or recognition of adverse consequences from psychotropic medications occurred after these falls. On [DATE], Resident #101 fell while ambulating and sustained impacted acetabulum and pelvic fractures, was hospitalized , and died as a result of the fall per the medical examiner.The Immediate…
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.
- Actual harm · G2025-10-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: 2614764Based on interview and record review, the facility failed to ensure residents maintained their right to self-determination in 1 of 1 resident (Resident #100) reviewed for choices, resulting in frustration with not being able to go to sleep at a preferred bedtime, an altercation with staff and a left fractured humerus. Findings include: Resident #100: Review of an admission Record revealed Resident #100 was a female with pertinent diagnoses which included chronic pain, contracture of the left upper arm, debility, stroke, paralysis affecting left side, and dementia. Review of current Care Plan for Resident #100, revised on 3/24/25, revealed the focus, .(Resident #100) may refuse to return to her room for incontinence care or go to bed at a reasonable time. with the intervention .Assess decision making ability.Provide a consistent daily routine.Environmental precautions (confusion).Assess for mood changes.Reality orientation as needed. Review of Event Summary Report dated…
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.
- Actual harm · Gcited before2024-10-01 · 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 #: MI00147147 Based on interview and record review the facility failed to ensure the safety and provide monitoring and/or supervision while eating in of 4 residents (Resident #1), reviewed for safety and supervision, resulting in Resident #1 choking on food and subsequent death. Findings: Resident #1 (R1) Review of an admission Record revealed R1 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Dementia with behavioral disturbances, oropharyngeal dysphagia (difficulty swallowing), and a history of larynx cancer. R1 was his own responsible party (able to make his own decisions). Review of a Minimum Data Set (MDS) assessment for R1, with a reference date of 6/3/24 revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated R1 was cognitively impaired. The medical record revealed R1 was a full code (resuscitation and all life saving measure in the event of a medical…
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 before2026-04-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure the kitchen/kitchenettes' food contact and/or non-food contact surfaces were consistently maintained in a clean and sanitary manner and failed to consistently date, label, and discard food items appropriately with the potential to effect any resident out of the census of 98 who consumed food/beverages from the kitchen resulting in the potential for foodborne illness, physical food contamination, and/or pest issues.Findings include:Food Contact and/or Non-Food Contact Surfaces Not Maintained in a Clean and Sanitary Manner by Area:Ice Machines-During an observation and interview on 04/14/2026 at 9:29 AM, the ice machine in the kitchen had unknown black, orange, and pink material accumulated on the exterior of the white ice chute. Maintenance Staff F reported the ice machines of the kitchen were cleaned by a third-party vendor, he thought cleaning was done approximately bi-annually (twice a year), and ice machines were last cleaned approximately around the time of late January/early February (2026).During…
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 · D2026-04-16 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 honor food preferences for 1 (Resident #121) of 20 sampled residents reviewed for food preferences resulting in feelings of frustration and anger.Findings include:Resident #121Review of a Face Sheet revealed Resident #121 was a female who was admitted to the facility on [DATE] and had pertinent diagnoses which included: amyotrophic lateral sclerosis (ALS; a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord leading to a loss of muscle control, including muscle weakness, difficulty speaking, swallowing and eventually breathing), unspecified protein-calorie malnutrition, dysphagia (difficulty swallowing), and vegetarian (a person who does not eat meat).In an interview on 4/14/26 at 10:32 AM, Resident #121 reported she requested yogurt to be served at every meal, and she was not getting it. Resident #121 reported she and Family Member (FM) TT had both spoken to Registered Dietitian (RD) I regarding her…
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 · D2025-10-01 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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: 2568667Based on interview, and record review, the facility failed to obtain informed consent for psychotropic medications for 1 of 7 (Resident #101) residents reviewed for psychotropic medications, resulting in the resident/resident representative's inability to make decisions on risk vs benefit of medication use and alternative treatment options. Findings include: Resident #101:Review of an admission Record revealed Resident #101 was a female who was admitted on [DATE] with pertinent diagnoses which included severe late onset Alzheimer's dementia with agitation, ground level fall, insomnia, and depression.Review of all Care Plans for Resident #101, revealed no focus or interventions for the use of psychotropic medications with monitoring for adverse consequences. Review of Order dated 5/9/25 for Resident #101, revealed, .Lorazepam (Ativan) tablet 0.5 mg Oral, nightly, Associated Diagnosis: Other insomnia. Review of Order dated 5/29/25 for Resident #101, revealed, .Lorazepam…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-10-01 · 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 record review and interview, the facility failed to implement care plan interventions and the facility policy to prevent falls in 1 of 7 residents (Resident #102) reviewed for fall prevention, resulting in the potential for falls and injury. Findings includeResident #102:Review of an admission Record revealed Resident #102 was a male with pertinent diagnoses which included dementia, confusion, incontinence, reduced mobility, fall risk, and end stage Alzheimer's disease. Review of current Care Plan for Resident #102, revised on 9/5/2025, revealed the focus, .(Resident #102) does not want to experience a fall resulting in major injury. with the intervention .Bed in low position.Accompany resident (ex. 1:1, stand by assist, dayroom monitoring, 15 min checks, line of sight).Visual checks per facility policy. Review of Resident Care Summary dated 9/8/25, revealed, .Safety: Bed by all for increased floor space.Fall mattress next to open side of bed for increased protection from injury.Review of Event Summary Report dated 9/5/25, revealed, .Safety: Bed by wall for increased floor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-10-01 · 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 prevent the risk of urinary tract infection and ensure urinary catheter tubing and drainage bag were not resting on the floor in 2 of 2 residents (Resident #102, #105) reviewed for urinary catheter use, resulting in the potential of a urinary tract infection.Findings include: .A CAUTI (Catheter associated urinary tract infection), or a UTI associated with a catheter, is common if you have an indwelling catheter inside your urethra.Symptoms are similar to a general UTI and include bloody or cloudy urine, gritty particles or mucus in your urine, urine with a strong odor, pain in your lower back, chills and fever. (https://www.healthline.com/health/sediment-in-urine)Resident #103: Review of an admission Record revealed Resident #103 was a male with pertinent diagnoses which included stroke and gross hematuria (blood in urine). During an observation on 09/24/25 at 2:32 PM, Resident #103 was observed lying in his bed, bed was low to the ground, and his catheter bag was on the floor without a barrier under it.…
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 before2025-03-05 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During an initial tour of the kitchen, at 10:32 AM on 3/3/25, an interview with Certified Dietary Manager (CDM) Z found that the maintenance staff takes care of the ice machine cleanings and has a vendor that comes and deep cleans the machines. Observation of the dispensing spout of the ice machine found an increase accumulation of black and brown debris on the surface of the inside spout. During a tour of the main kitchen, at 10:35 AM on 3/3/25, observation of the microwave found increase accumulation of debris on the inside top portion of the unit. Further review of the unit found chipping and degrading surfaces on the inside. During a tour of the main kitchen, at 10:39 AM on 3/3/25, an interview with CDM Z found that staff clean the utensil drawer weekly. Observation of the three…
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 before2025-03-05 · 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 This citation has two Deficient Practice Statements DPS A Based on observation, interview, and record review, the facility failed to 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 water borne 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. Findings include: During a tour of the facility with, Maintenance K and Regional Maintenance HHH, starting at 9:50 AM on 3/4/25, it was found that Maintenance K is newer to the facility and has not been involved much in the water management plan. When asked if he was aware of regular flushing the facility is doing on minimum use or unused domestic water fixtures, Maintenance K was unaware. Regional Maintenance HHH stated some facilities do a wasting water Wednesday, but he is not sure what's done here. During a tour 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 · D2025-03-05 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to complete advance directives completely and accurately for 3 residents (Resident #37, Resident #312, Resident #60) of 22 residents reviewed for advance directives resulting in the potential for resident preferences for medical care to not be followed by the facility staff. Findings include: Resident #37 (R37) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R37 admitted to the facility on [DATE] with diagnoses including chronic pain, paraplegia (loss or impairment of voluntary movement and sensation in the lower half of the body including both legs due to damage to the spinal cord), left lower extremity amputation and a pressure injury (wound) to right buttocks. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R15 was cognitively intact (13 to 15 cognitively intact). Review of R37's physician orders revealed Do not resuscitate (DNR) with a start date of 1/1/2025. Review of R37'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 · D2025-03-05 · 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
Based on observation, interview, and record review the facility failed to maintain a clean comfortable environment with clean, sanitized medical equipment for 1 resident (Resident #75) of 2 residents, resulting in the potential for cross contamination and bacterial harborage. Findings include: Review of Facesheet revealed Resident #75 was a male with pertinent diagnoses which included macular degeneration (loss of in the center of the field of vision), legal blindness, dementia, diabetes, anxiety, kidney disease stage 3, neuropathy (weakness, numbness, and pain from nerve damage), anemia, and stroke. Review of Resident Care Summary dated 3/5/25, revealed, .Safety: Dated 1/24/25 .Low bed, bed by wall for increased floor space, bedside mat .Lay down between meals so he doesn't slid (sic) out of w/c (wheelchair) .Dependent for transfers, bed mobility . During an observation on 03/03/25 at 09:52 AM, Resident #75 was observed lying in bed with a mattress on the floor placed next to the right side of his bed. The mattress was covered with spotted dried liquid stains, dried food, and had…
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 · D2025-03-05 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to transmit Minimum Data Set (MDS) discharge assessments timely for 2 residents (Resident #82, Resident #93) of 2 reviewed for MDS transmission resulting in the potential for inaccurate tracking of discharges. Findings include: Resident #82(R82) Review of R82's chart revealed that she discharged from the facility on 9/19/2024. Review of R82's chart revealed a MDS discharge assessment -return not anticipated with an ARD of 9/20/2024 was in progress and incomplete: GG, J, M, N, O, P (sections GG, J, M, N, O, P). The MDS was not transmitted. Resident #93(R93) Review of R93's chart revealed that she discharged from the facility on 9/17/2024. Review of R93's chart revealed a MDS discharge assessment -return not anticipated with an ARD (assessment reference date) of 9/17/2024 was in progress and incomplete: K (section K). The MDS was not transmitted. During an interview on 3/05/2025 at 1:23 PM, MDS nurse D stated that a discharge assessment should be completed whenever a resident discharges from the facility. Then, it should be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · D2025-03-05 · 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 interview and record review the facility failed to ensure that PASARR (Preadmission Screening and Resident Review) Level II (a comprehensive evaluation completed by the local (state mental health aruthority) was completed for 1 (Resident #16) of 4 residents reviewed for PASARR Level II screening resulting in the potential for unmet mental health care needs. Findings include: Resident #16 Review of a Face Sheet revealed Resident #16 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: recurrent major depressive disorder, dementia with behavioral disturbances, and bipolar affective disorder. Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 1/3/2025 revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #16 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment). Review of Resident #16's electronic medical record revealed no noted PASARR Level…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a person-centered care plan related to Hospice care for 1 resident (Resident #58) of 22 reviewed for person centered care plans resulting in the potential for unmet care needs of the resident. Findings include: Resident #58 (R58) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R58 admitted to the facility on [DATE] with diagnoses including dementia and Alzheimer's disease. Brief Interview for Mental Status (BIMS) reflected a score of 3 out of 15 which indicated R58 cognition was severely impaired (0-7 severe impairment). Review of R58's chart revealed he had a significant change MDS (minimum data set) dated 1/21/2025 due to him declining and starting Hospice care. Review of R58's care plans revealed that there wasn't a Hospice care plan. During an interview on 3/05/2025 at 1:13 PM, MDS nurse D revealed that R58 signed onto Hospice on 1/15/2025. MDS D stated that she thought that Social Worker (SW) M 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 · Dcited before2025-03-05 · 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 observations, interview, and record review the facility failed to provide activities of daily living (ADLs) specifically nail care to a dependent resident for 1 (Resident #52) of 5 residents reviewed for activities of daily living, resulting in an unkept appearance and the potential for the spread of infection. Resident #52 Review of a Face Sheet revealed Resident #52 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: cognitive deficits following a non-traumatic intracerebral hemorrhage (bleeding in the brain), hemiparesis (paralysis) on the left non-dominate side, and debility. Review of a Minimum Data Set (MDS) assessment for Resident #52, with a reference date of 12/4/2024 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #52 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment). During an observation and interview on 3/3/25 at 10:24 AM., Resident #52 was lying in her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-05 · 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 residents received care in accordance with physician orders for medications and professional standards in 1 resident (Resident #49) of 22 residents reviewed for quality of care, resulting in a delay in treatment and worsening of a medical condition, and the potential for residents not attaining or maintaining their highest practicable level of wellbeing. Findings include: Resident #49 Review of an admission Record revealed Resident #49 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: CHF (congestive heart failure) (when your heart can't pump blood well enough to give your body a normal supply; over time blood and fluids collect in the lungs and legs causing swelling) and pacemaker (a device placed under the skin that stimulates the heart to beat regularly.) Review of a Minimum Data Set (MDS) assessment for Resident #49, with a reference date of 2/5/25 revealed a Brief Interview for Mental…
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 · D2025-03-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide preventative care, consistent with professional standards of practice for 2 residents (Resident #98 & #65) of 5 residents reviewed for at risk for the development of pressure injuries, resulting in the potential for worsening of pressure wounds, the development of an avoidable pressure ulcer, infection, and overall deterioration in health status. Findings include: Resident #98 Review of Resident #98's Braden Assessment (risk of developing pressure ulcers) dated 12/16/24 revealed, 17 indicating that resident was at a mild risk. Review of Resident $98's Skin Integrity Care Plan revealed, Start 9/18/24 .at risk for compromised skin integrity r/t (related to) impaired mobility and incontinence .History of skin problem: PI (pressure injury) to L (left) and R (right) buttock .Interventions: Assist with repositioning .Utilize appropriate lift or transfer devices .Toileting Plan, Observe and relieve pressure to bony prominences. Review 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 · Dcited before2025-03-05 · 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
DPS B Based on observation, interview, and record review, the facility failed to ensure resident safety with chair to bed transfers for 2 residents (Resident #98 & #65) of 5 residents reviewed for accident hazards, resulting in the potential for avoidable accidents and serious injury. Findings include: Resident #98 Review of a Minimum Data Set (MDS) assessment for Resident #98, with a reference date of 1/23/25 revealed, under Functional Abilities that Resident #98 required substantial/maximum assistance (helper does more than half of the effort) for transfers from chair to bed. Review of Resident #98's Care Plan revealed, .potential for falls and fall related injuries: .Interventions: .Use gait belt for all transfers . Review of Resident #98's Resident Care Summary (RCS) revealed, .Transfer: substantial/maximal . Review of Resident #98's most recent Physical Therapy Discharge Summary dated 12/23/24 revealed, .Assessment/Plan: .Patient has made no progress .continues to require .dependent with max A of 2 (staff) for bed to/from w/c (wheelchair) t/fs (transfers) and unable to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure foley catheter (a tube inserted into the bladder through the urethra to drain urine) tubing was secured to prevent pulling and perform incontinence care per standards of practice in 2 residents (Resident #98 & #65) of 5 residents, reviewed for bowel and bladder incontinence, resulting in the potential for dislodgement of the catheter tubing with pain and urethral damage, and the potential for skin breakdown, cross-contamination and development/spread of infection. Findings include: Resident #98 Review of Resident $98's Skin Care Plan revealed, Start 9/18/24 .at risk for compromised skin integrity r/t (related to) impaired mobility and incontinence .Toileting Plan . Review of Resident #98's Catheter Care Plan revealed, .Indwelling Catheter Maintenance: .Nursing staff will provide foley catheter care every (sic) twice daily and as needed . During an observation on 03/05/25 at 08:54 AM Resident #98 was seated in her wheelchair in 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 · D2025-03-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure oxygen delivery equipment was monitored for 1 (Resident #16) of 2 residents reviewed for oxygen administration resulting in the potential for ineffective performance of improperly maintained oxygen delivery equipment. Findings include: Resident #16 Review of a Face Sheet revealed Resident #16 was a female who originally admitted to the facility on [DATE] and had pertinent diagnosis which included: COPD (chronic obstructive pulmonary disorder). Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 1/3/2025 revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #16 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment). During an observation on 3/3/25 at 9:29 AM., Resident #16 was in bed, sleeping, with a nasal cannula (tubing that is inserted into the nostrils and delivers supplemental oxygen) in place on her face. The plastic…
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 · D2025-03-05 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician documented review of pharmacy recommendations/follow up occurred for 1 resident (Resident #15) of 5 residents reviewed for unnecessary medications resulting in the potential for medication side effects and/or unnecessary medications for residents. Findings include: Resident #15 (R15) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R15 admitted to the facility on [DATE] with diagnoses including depression, pain and type 2 diabetes {metabolic disease characterized by high blood glucose (sugar) in the bloodstream}. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R15 was cognitively intact (13 to 15 cognitively intact). Review of R15's monthly pharmacy review dated 10/7/2024 revealed Comment: (R15) currently has an order for Lidoderm 4% (percent), 1 patch to the lower back and 1 patch to each shoulder. Per review of the medication administration record, patient…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-07 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to implement infection control practices to provide sanitary conditions for resident shared equipment, and implement enhanced barrier precautions for a resident with an MDRO (multi drug resistant organism) during care for 1 resident (Resident #19) of 4 residents reviewed for catheter care, resulting in the potential for the spread of infection, cross-contamination, and disease transmission for residents residing in the facility. Findings include: In an observation on 3/05/24 at 1:14 PM., noted 2 sit to stand lifts in the alcove of the back hall parked near the bathing room both sit to stand bases (where resident plant their feet to stand) were soiled with dust, debris and food crumbs. On the blue knee pad (where residents place shins to stabilize legs during lift) were noted to be visibly soiled with dried crusted substances. Noted in the alcove on the floor were numerous random pieces of paper, and entire package of paper hand towels opened and scattered around the lifts parked there. Noted clear plastic 8…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to implement a person centered care plan for 2 (Resident #70 and #63) of 20 residents reviewed for care planning, resulting in Resident #70 using a wheelchair without the recommended safety features and aspiration risk for Resident #63. Findings include: Review of a Face Sheet with a reference date of 8/19/22 revealed Resident #70 was admitted to the facility with pertinent diagnoses that included: Alzheimer's Disease (disease causing progressive mental deterioration). Review of a Minimum Data Set (MDS) assessment, with a reference date of 2/10/24, revealed a Brief Interview for Mental Status (BIMS) assessment score of 4/15 which indicated Resident #70 had severe cognitive impairment. Section GG of the MDS revealed Resident #70 used a wheelchair for all mobility and required maximal assistance (helper did more than half the effort) to safely transfer from his bed to the wheelchair. Section J revealed since his last assessment, Resident #70 had 2 or more falls, 1 of which resulted in injury. Review of a Care Plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-07 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update and revise the person centered care plan in a timely manner with appropriate interventions for 2 residents (#63 and #90), with the potential for physical, mental, and psychosocial unmet care needs and harm. Findings include: Resident #63: Review of an admission Record revealed Resident #63 was a male with pertinent diagnoses which included diabetes, dementia, history of falling, ataxia (impaired balance or coordination due to damage to the brain), abnormalities of gait and mobility, paralysis affecting right dominant side, need for assistance with personal care, aphasia (language disorder caused by damage to the brain), lack of coordination, difficulty in walking. Review of current Care Plan for Resident #63, revised on 1/6/24, revealed the focus, .(Resident #63) is currently taking Coumadin and is at risk for complications of anticoagulant therapy . with the intervention .(Resident #63) will remain free of s/sx (signs & symptoms)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-07 · 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 follow professional standards of practice for documentation of medication administration in 2 of 7 residents (Resident #17 & #43) reviewed for medication administration, resulting in the potential for medication errors. Findings include: Resident #17 Review of a Face Sheet revealed Resident #17 was a female, with pertinent diagnoses which included dementia, anxiety, schizoaffective disorder, diabetes, constipation, allergic rhinitis, heartburn, high blood pressure, and restless legs syndrome. Review of the Active Orders for Resident #17 revealed active physician orders for Fluticasone Propionate 50 mcg/actuation two sprays in each nare once a day with a start date of 8/24/22, Aspirin 81 mg chewable one tablet once a day with a start date of 1/26/24, Cetirizine 10 mg one tablet once a day with a start date of 1/26/24, Diltiazem HCl Extended Release 180 mg one capsule once a morning with a start date of 8/24/22, Lamotrigine 25 mg three…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-07 · 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 assistance with activities of daily living (ADL) care was provided for 2 (Resident #13 and #63) of 4 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's dependent on staff for assistance. Findings include: Resident #13: Review of an admission Record revealed Resident #13 was a male with pertinent diagnoses which included Alzheimer's disease, need for assistance for personal care, at risk for malnutrition, debility, demenita, unable to ambulate, stroke, and protein calorie malnutrition. Review of Minimum Data Set (MDS) dated [DATE], revealed, .Functional limitations: lower extremities impairment both sides .A. Eating: Supervision or touching assistance .E. Shower/bathe Dependent- helper does ALL the effort .Mobility: A. Roll left & right - Substantial/maximal assistance . Review of Resident Care Notes dated 3/6/24, revealed, .Reposition every 2-3 hours.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-07 · 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
Based on observation, interview, and record review the facility failed to ensure residents who were not to receive straws with fluids, did not receive them in 2 of 2 residents (Resident #63 and #28) reviewed for quality of care, resulting in the potential for aspiration and potential pneumonia. Findings include: Resident #63: Review of a Facesheet revealed Resident #63 was a male with pertinent diagnoses which included diabetes, dementia, paralysis affecting right dominant side, need for assistance with personal care, aphasia (language disorder caused by damage to the brain), lack of coordination, difficulty in walking, dysphagia (difficulty swallowing). Review of current Care Plan dated 1/6/24, revealed, .(Resident #63) is here for long term basic care following a CVA (cerebralvascular accident - stroke) with right hemiplegia resulting in impaired strength, balance, mobility, right side flaccid; has expressive and receptive aphasia which impacts communication . with the intervention .DIET TYPE AND CONSISTENCY .(NO STRAWS) . Review of Resident Care Notes revealed no indication 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 · D2024-03-07 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure interventions were in place to prevent the worsening of contractures for 1 of 4 residents (Resident #63) reviewed for position and mobility, resulting in the potential for decreased range of motion, skin breakdown, pain and worsening of contractures (hardening of the muscles, tendons, and other tissues). Findings include: Review of an admission Record revealed Resident #63 was a male with pertinent diagnoses which included diabetes, dementia, stiffness of right hand, weakness, abnormalities of gait and mobility, paralysis affecting right dominant side, need for assistance with personal care, aphasia (language disorder caused by damage to the brain), and lack of coordination. Review of current Care Plan for Resident #63, revised on 10/7/2020, revealed the focus, .(Resident #63) is here for long term basic care following a CVA (stroke) with right hemiplegia (paralysis) resulting in impaired strength, balance, mobility, right side is flaccid (hanging loosely or limply) .requires extensive to total assist…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-07 · 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 1. provide adequate supervision and monitoring of a resident at risk for accidents for 1 resident (Resident #13) and 2. utilize wheelchair footrests for safe wheelchair transport for 1 resident (#92) of 2 resident reviewed for accidents and hazards, resulting in the potential for falls and injury. Findings include: Resident #13: Review of an admission Record revealed Resident #13 was a male with pertinent diagnoses which included Alzheimer's disease, post right [NAME] hole for drainage of subdermal hematoma, need for assistance for personal care, at risk for malnutrition, debility, dementia, unable to ambulate, stroke, pike's disease (rare form of dementia similar to Parkinson's disease, abnormal substances inside nerve cells in the damaged areas of the brain) and protein calorie malnutrition. Review of Minimum Data Set (MDS) dated [DATE], revealed, .Section GG: Functional Abilities and Goals: Lower extremities: Impairment on both sides…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure physician orders were in place and followed for a resident with a Foley catheter (a tube inserted through the urethra to drain urine out of the body from the bladder) in 1 (Resident #42) of 3 residents reviewed for catheter care, resulting in the failure to provide care and services to prevent blockage and infection, and the potential for serious complications and urinary tract infection (UTI). Findings include: Resident #42 Review of an admission Record revealed Resident #42, was originally admitted to the facility on [DATE] with pertinent diagnoses which included urinary tract infection. Review of Resident #42's Skilled Nursing Facility admission H &P (History and Physical) note dated 3/4/24 revealed, .(Resident #42) is a .male with past medical history of .urinary and bowel incontinence . Assessment and Plan: 4. Chronic indwelling foley catheter. Urinary catheter in situ (in place) . Review of Resident #42's Orders on 3/6/24 did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-07 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 residents who were trauma survivors received care and services that addressed their psychosocial needs for 3 of 3 residents (Resident #68, Resident #13, and Resident #63) reviewed for trauma informed care, resulting in Resident #68 experiencing feelings of frustration, Resident #13 experiencing nightmares with no interventions to minimize his distress, and a potential for unmet care needs. Findings include: Resident #68 Review of a Face Sheet with a reference date of 1/31/24 revealed Resident #68 was admitted to the facility with pertinent diagnoses that included: metabolic encephalopathy (acute condition of brain dysfunction caused by alteration in brain chemistry), and osteomyelitis of right ankle and foot (infection in the bone). Review of a Minimum Data Set (MDS) assessment with a reference date of 2/6/24 revealed a Brief Interview for Mental Status (BIMS) assessment score of 9/15 which indicated Resident #68 had a moderate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-07 · 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 track and offer the pneumococcal vaccine for 5 (Resident #63, #363, #90, #11, #74) of 5 residents reviewed for immunizations, resulting in a delay in being given the opportunity to receive or decline the pneumococcal vaccination. Findings include: According to the Centers for Disease Control and Prevention (CDC) PCV20 Vaccination for Adults 65 Years and Older dated 02/09/23, revealed, .Routine vaccination: Adults 65 years or older who have- Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose . www.cdc.gov/vaccines/hcp/admin/downloads/job-aid- SCDM-PCV20-508.pdf According to the Centers for Disease Control and Prevention (CDC) PCV20 Vaccination for Adults 65 Years and Older dated 02/09/23, revealed, .Routine vaccination: Adults 19 years or older: Ages 27-49: Previously received both PCV13 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$8,827 in federal fines across 1 penalty.
- $8,827 — penalty dated 2024-10-01
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to COREWELL HEALTH — 6 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 | 4.7 | -1.7 vs chain |
| Health inspection | 2 of 5 | 4.3 | -2.3 vs chain |
| Staffing | 5 of 5 | 4.8 | +0.2 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 5 homes this chain runs (chain average 4.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LAKELAND REGIONAL HEALTH SYSTEM | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 10/30/2014 |
| COREWELL HEALTH | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 10/01/2018 |
| GRUBER, MELINDA | Individual | CORPORATE DIRECTOR | — | since 10/01/2017 |
| JOHNSON, DEBRA | Individual | CORPORATE DIRECTOR | — | since 10/01/2017 |
| LALLO, HEATHER | Individual | CORPORATE DIRECTOR | — | since 10/01/2017 |
| COX, MATTHEW | Individual | CORPORATE OFFICER | — | since 11/02/2022 |
| FREESE DECKER, CHRISTINA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2022 |
| KEITH, ANGIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/26/2023 |
| MARLOW, TAMILA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2020 |
| SEAGLE, RONALD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/28/2024 |
CMS files one row per role, so the 16 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $326K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
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 235164. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.