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Lakeview Manor Healthcare Center

408 North Fifth Avenue, Tawas City, MI 48763 · For profit - Corporation · 60 certified beds · (989) 362-2211 Medicare & Medicaid certified

Call the home — (989) 362-2211 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (23) — 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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
25 Michigan 55 · (989) 362-2540 · Call to confirm hours
Pharmacy
222-200 Wheeler St · (989) 362-3311 · Call to confirm hours
Grocery
220 W Lake St · (989) 362-9180 · Call to confirm hours
Park
429 W Lake St · (989) 362-8643 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased19.2%10.8%15.4%worse
Long-stay residents who lose too much weight2.1%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection1.6%1.5%2.0%better
Long-stay residents with depressive symptoms0.0%4.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.4%3.0%3.3%worse
Long-stay residents whose ability to walk worsened18.5%12.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.4%19.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers2.9%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control25.2%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.7%14.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.5%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine87.5%79.5%79.4%better
Short-stay residents rehospitalized after admission13.3%24.0%22.6%better
Short-stay residents with an outpatient ER visit9.9%11.7%12.0%better
Long-stay hospitalizations per 1,000 resident days0.881.841.67better
Long-stay outpatient ER visits per 1,000 resident days2.211.641.80worse

* 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.

59.2% 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 119 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.2%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
70.2%U.S. median 56.6%
Met the expected recovery
0.36U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 70.2% 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 47 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 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 24% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF59.2%CMS range 51.7–65.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.5–14.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge70.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge68.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge76.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 4.1–11.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.711.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.57
RN hours/ resident / day
0.72
LPN hours/ resident / day
2.32
Aide hours/ resident / day
3.62
Total nurse hours/ resident / day
0.46
RN hoursweekends
47.5%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 54.0 residents a day — about 90% occupied, or roughly 6 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 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 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 3.11 hrs/resident/day on weekends vs 3.82 on weekdays — 19% thinner on weekends. RN hours go from 0.61 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2026-05-13)
9
at the previous standard inspection (2025-03-27)

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.

ABCDEFGHIJKL

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

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · Gcited before2024-04-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 implement timely interventions to prevent the development of a Stage 3 pressure ulcer for one resident (Resident #18) and an unstageble pressure ulcer for another resident (Resident #30), follow interventions, ensure that physician's treatment orders were followed and documented and prevent the worsening of the Stage 3 pressure ulcer for Resident #18 of three residents reviewed for pressure ulcers, resulting in Resident #18's development and worsening of a Stage 3 pressure ulcer and Resident #30's development of a left heel unstageble pressure ulcer with the likelihood of pain and infection. Findings include: Resident #18: On 4/02/2024, at 2:30 PM, a record review of Resident #18's electronic medical record revealed a readmission on [DATE] after a short hospital stay with diagnoses that included Diabetes, weakness and Dementia. Resident #18 required extensive assistance with Activities of Daily Living (ADL) and had severely impaired…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide 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 proper storage of respiratory equipment (BiPAP, nebulizer treatment mask and nasal cannula) for 3 residents (#14, #25, and #27) of 3 residents reviewed for respiratory equipment. Findings Include: Resident #25 On 5/11/26 at 11:37 AM, Resident #25 was observed in their room, sitting in a wheelchair. A nebulizer machine was present on the dresser beside the Resident's bed. The administration set of the nebulizer was connected and uncontained with visible fluid present in the medication chamber. An interview was completed at this time. When queried regarding the nebulizer machine and treatments, Resident #25 stated, Do daily in the morning. Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), cerebral infarction (stroke) with resulting right sided hemiplegia and hemiparalysis (one-sided paralysis) and aphasia (difficulty communicating).…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-13 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) submission assessment data for one resident (Resident #8) of one resident reviewed. Findings include:Resident #8:Review of the facility provided CMS-802 form indicated Resident #8 was receiving Hospice Services. Record review revealed Resident #8 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included heart failure, dementia, major depressive disorder, and generalized anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment completed, dated 4/10/26, designated Resident #8 was not receiving Hospice services. Review of Resident #8's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #8) is at risk for decline in condition, pain, depression, weight loss and other symptoms R/T (related to) terminal prognosis. Receives Hospice services. The care plan was created, initiated, and revised on 10/23/25. An…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that one resident (Resident #19) of 16 residents reviewed for Activities of Daily Living/ADL care received daily oral care and was shaven as needed. Findings Include:Resident #19: Review of the Face Sheet, care plans dated 4/3/26 through 5/13/26, and nursing notes, dated 4/26 and 5/26, revealed Resident #19 was 62 years-old, alert, admitted to the facility on [DATE], and was totally dependent on staff for all Activities of Daily Living (ADL). The resident's diagnoses included, Cerebral Palsy, other symptoms involving the musculoskeletal system, spastic quadriplegic CP, and required assistance with personal care. Observations made during the survey, revealed Resident #19 had not had any oral care done or had been shaven on the following days and times: Observations made on 5/11/25: -At 9:00 a.m., the resident was in his bed awake and was waiting for his breakfast.-At 12:00 p.m., the resident was in his bed waiting for his noon…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-13 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis 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 interview and record review, the facility failed to implement and operationalize policies and procedures to ensure coordination of care and communication with an external dialysis provider for one resident (Resident #7) of one resident reviewed. Findings include: Resident #7: On 5/11/26 at 3:20 PM, Resident #7 was not in their room. An interview was completed with Registered Nurse (RN) P on 5/11/26 at 3:23 PM. When queried regarding Resident #7's location, RN P responded that Resident #7 had recently returned from dialysis and went straight to the Activities Room when they got back. When asked, RN P revealed they were the Residents assigned nurse. When queried regarding the facility policy/procedure related to communication with the external dialysis provider, RN P responded the facility sends a form with the Resident when they leave, the dialysis nurse completes a portion and sends the form back with the Resident. RN P was asked if they had received a dialysis communication form following 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-13 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, 5 of 17 nursing staff (RN's & LPN's) and 5 Nursing Assistants/CNA's of 34 CNA staff failed to have up-to-date annual competency evaluations, resulting in the protentional for Nursing Assistants to not be able to re-certify certification, and improper nursing techniques and care for the facility's census of 54 residents. Findings Include:During an interview done on 5/13/26 at 11:25 a.m., In Service Nurse Director, RN I revealed she had been at the facility for 2 months, and the Nursing Assistant's/CNA's and Nurse's (Rn and LPN) annual competencies (facility competency check-off's) were not up-to-date, no one had done them for months prior to her. In Service Director I stated Before I came, no one did them; the last In Service Nurse did not keep them up-to-date. On 5/13/26 at 11:30 a.m., the In Service Director I and this surveyor went through all nursing and CNA's annual competencies for 2025 through 5/2026. There was a total of 5 Nurse's ana total of d 5 CNA's that were found to not be up-to-date with their facility annual competencies. Review…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-13 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure a sanitary environment in the kitchen (Soiled equipment, rust on freezer shelves), water in clean and ready for use dishes, and no use-by dates on open and partly used foods, for a census of 57 residents who eat from the kitchen. Findings include:On 5/11/26 starting at 8:15 a.m., the initial kitchen walkthrough was done with Dietary Manager B on 5/11/26 at 8:15 a.m., and the following concerns were noted: -At 8:17 a.m., observation of x 6 clean and ready for use plastic cups with water inside of all of them were in the dry cup container and ready for use. During an interview done on 5/11/26 at 8:19 a.m., Dietary Manager B stated yes, they (cups) are dry. According to the FDA 2022 Food Code, clean equipment and utensils were to be air dried in a manner in which allows them to circulate air in order to dry; no water should be left inside. -At 8:20 a.m., 1 open and partly used bag of chips (Bangles), 1 open package of hamburger buns, 1 open half loaf of bread, and 1 package of hot dog buns, were all…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure timely implementation of Transmission Based Precautions (TBP) and ensure appropriate hand hygiene for one resident (Resident #58) of two residents reviewed for Infection Control (IC) resulting in a lack of immediate implementation of TBP for a resident with known positive Clostridioides difficile (C. diff- highly contagious bacterium which effects the colon, can be life threatening, and becomes a spore when outside of the body). Findings include:Resident #58: On 5/11/26 at 10:59 AM, a contact isolation sign was observed on Resident #58's room door. Certified Nursing Assistant (CNA) S was observed approaching Resident #58's room and began donning Personal Protective Equipment (PPE) without performing hand hygiene first. Family Member T approached the room while CNA S was donning PPE and asked CNA S if they needed to wear PPE to go into the room. CNA S told Family Member T they were unsure and would need to ask other staff. CNA S left…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-03-27 · tag F0880 — failed to prevent and control infections — widespread
    Provide 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 and operationalize an infection control program including ensuring safe and sanitary conditions in the beauty parlor, comprehensive outcome surveillance, evaluation and analysis of data for potential trends, and identification and monitoring of potential infections for all 57 residents residing in the facility. Findings include: An interview and review of facility Infection Control (IC) data was completed with IC Registered Nurse (RN) C on 3/27/25 at 2:09 PM. Upon request to review IC data for February 2025, RN C provided a written line listing tool, a typed line listing Surveillance Monthly Report, a mapping tool, and a summary form. When queried why there were both written and typed line listing forms, RN C revealed the written form is not an official tracking tool but stated they use it to make notes regarding infections when not in their office. RN C stated they enter the appropriate information into the system and the computer program generates the official typed Infection Surveillance Monthly…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-27 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide 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 ensure that weights were done accurately for two residents (Resident #11 & Resident #16). Findings include: Resident #11: Observation on 03/25/25 at 10:38 AM during the survey screening process the surveyor observed Resident #11 to be lying in bed and thin in appearance. Observation and interview on 03/25/25 at 01:06 PM with Resident #11 revealed that she did get lunch (while still lying in bed), she had Lost some weight, but that she was not hungry. Observation on 03/25/25 at 01:08 PM of Resident #11's meal tray in the meal tray brown box revealed 3/4 of tray was eaten. Record review of Resident #11's documented weights revealed that on 2/10/2025 at 12:49 PM weight was 129.0. Weight on 2/25/2025 at 3:09 PM was 123.5. The weight loss of 5.5 pounds was not reweighed again until 3/4/2025 at 2;01 PM of 123.5. Record review on 03/25/25 at 02:47 PM of Resident #11's weight log documentation revealed: On 1/21/2025 resident #11's weight was 136.2 pounds and on 2/25/2025 weight of 123.5 equaled a 12.7-pound weight…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-27 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to: 1) Ensure proper labeling of open dates and expiration dates of multi-dose medications in 2 of 2 medication carts and 2) Ensure proper labeling of glucose monitor strips for expiration date after opening, resulting in the opened and undated medications and inaccurate blood glucose monitoring. Findings include: Observation and interview on 03/25/25 at 09:28 AM with Registered Nurse (RN) D of the 200/400 medication cart revealed that she was a unit manager and staff education director, but was working the 200/300 hallway medication cart because of a staff nurse call-in. RN D unlocked the medication cart to review with the state surveyor: Resident #41's had Lantus insulin pen open date with no expiration date, and Novolog insulin pen with open date, with no expiration date. Resident #28 had Humulin 70/30 insulin pen with open date and no expiration date. Novolin 70/30 insulin pen with an open date with no expiration date. Resident #17 had Lantus insulin 100unit/ml bottle with an open date that was unreadable…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2025-03-27 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement a care plan related to supplemental oxygen use for one resident (Resident #44) of two residents reviewed for respiratory care. Findings include: Resident #44: On 3/25/25 at 11:06 AM, Resident #44 was observed in their room in bed. The Resident was receiving supplement oxygen via Nasal Cannula (NC) at a rate of 2 liters (L) per minute. At 3:42 PM on 3/26/25, Resident #44 was observed in their room. The Resident was in bed and receiving supplemental oxygen at 2L/minute via NC. Record review revealed Resident #44 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included bladder cancer, depression, bipolar disorder, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to total assistance for toileting, transferring, and hygiene. The MDS further detailed the Resident 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to timely update/revise individualized, person-centered care plans to reflect changing care needs for 3 residents (Residents #11, Resident #16 and Resident #111). Findings include: Resident #11: Observation on 03/25/25 at 10:38 AM during the survey screening process the surveyor observed Resident #11 to be lying in bed and thin in appearance. Observation and interview on 03/25/25 at 01:06 PM with Resident #11 revealed that she did get lunch (while still lying in bed), she had Lost some weight, but that she was not hungry. Observation on 03/25/25 at 01:08 PM of Resident #11's meal tray in the meal tray brown box revealed 3/4 of tray was eaten. Record review on 03/25/25 at 02:47 PM of Resident #11's weight log documentation revealed: On 1/21/2025 resident #11's weight was 136.2 pounds and on 2/25/2025 weight of 123.5 equaled a 12.7-pound weight loss in 35 days of 9.32% loss. Record review of Resident #11's care plans pages 1-56 revealed…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 implement planned interventions for pressure ulcer (wounds caused by pressure) prevention for one resident (Resident #23) of six residents reviewed. Findings include: Resident #23: On 3/25/25 at 9:52 AM, Resident #23 was observed in their room in bed. The Resident was in bed, positioned on their back and covered in a blue blanket. The blue blanket was visibly soiled with scattered areas of an unknown brown colored substance. Their left knee was bent, and their right leg was straight. A heel boot (soft boot to refuse pressure) was in place on the Resident's right lower extremity only. When spoke to, Resident #23 made eye contact but did not provide meaningful, verbal responses. A second heel boot was observed on the top and back corner of the Resident's armoire/closet behind their room door. Record review revealed Resident #23 Electronic Medical Record (EMR) revealed the Resident was admitted to the facility on [DATE] with diagnoses which…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 to complete urinary catheter care per professional standards of practice for one resident (Resident #41). Findings include: Resident #41: Record review of Resident #41's Minimum Data Set (MDS) dated [DATE] revealed a male resident with Brief Interview of Mental Status (BIMS) score of 15 out of 15, cognitively intact. Medical diagnosis included anemia, coronary artery disease, hypertension, neurogenic bladder, diabetes and depression. Section H: Bladder & Bowel identified indwelling urinary catheter. Observation made on 03/25/25 at 09:24 AM of Resident #41, who was lying in bed with the room door open to the hallway. State surveyor observed urine catheter bag off the floor hanging out of a blue bag with the spout hanging down on the floor visible from the doorway. Observation of Resident #41's wound vac and tubing visible from doorway with dark fluid noted in tubing hanging down from the bed frame railing. Resident #41 stated that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure informed consent including risks and benefits of psychotropic medications were provided for one resident (Resident #44) of five residents reviewed for unnecessary medications. Findings include: Resident #44: On 3/25/25 at 11:05 AM, Resident #44 was observed in their room. The Resident was in bed wearing a hospital style gown. An interview was completed at this time. When asked how they were feeling, Resident #44 stated, I'm real depressed. When asked if they were taking any medications for depression, Resident #44 replied, They keep switching my meds around without telling me and it makes me feel like I don't matter. Record review revealed Resident #44 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included bladder cancer, depression, bipolar disorder, adjustment disorder, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-27 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to 1) Maintain food kitchen equipment in a sanitary and good working condition, and 2) Date prepared foods with made date and use-by date, resulting in an increased likelihood for food borne illness with hospitalization, and cross contamination affecting 57 residents who consumed oral nutrition from the facility kitchen of a total census of 57 residents. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. On 3/25/25 at 9:50 a.m., during the tour of the kitchen accompanied by Dietary Manager G the following concerns were observed: -At 9:51 a.m., observation of the food processor that was cleaned and ready for use was found to have a thin layer of dark brown dried on food particles near the blade. -At 10:00 a.m., there was 1 clean silver metal pan (1/3rd size) found with dried…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-04 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 administer one resident's (Resident #57) morning medications on their scheduled dialysis days, resulting in Resident #57 not being administered approximately 62 doses of scheduled medication on the days that the resident received dialysis. Findings Include: Resident ##57: On 4/2/2024 at 12:47 PM, Resident #57 was observed in his room after finishing lunch. He reported he is currently on restrictions for food and liquids. He has dialysis three times a week on Monday, Wednesday and Friday and the facility transport him to/from about 6:30 AM for his 7:00 AM chair time. On 4/3/2023 at approximately 10:30 AM, a review was completed of Resident #57's medical records and it indicated he was admitted the facility on 3/11/2024 with diagnoses that included, End Stage Renal Disease, Atrial Fibrillation, Acute Cholecystitis, Heart Failure and Anxiety. Further review of Resident #57's records revealed the following: Care Plan: Administer medications as ordered. Observe for side effects and ineffectiveness, report abnormal…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-04 · tag F0710 — isolated
    Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
    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 record review, the facility failed to provide timely physician's visits for one resident (Resident #15), resulting in a lack of a physician's 60-day follow-up visit, with the likelihood of decreased quality of care and missed assessments of health changes. Findings include: Resident #15: On 4/02/24, at 11:35 AM, a record review of Resident #15's electronic medical record revealed an admission on [DATE] with diagnoses that included Chronic Pulmonary Obstructive Disease, Hypertension and Anxiety. A review of the physician visits revealed the last visit was documented on Date of Service: 1/19/24 Visit Type: Acute'. There were no documented physician visits from 1/19/2024 thru survey exit 4/4/24. A review of the facility provided Physician Services Last Revised 2/22/2022 Policy revealed . Each guest/resident must be seen by their physician at least every 30 days for the first 90 days after admission, and then every 60 days thereafter . A physician visit is considered timely if it occurs not later than 10…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-04 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a that Pharmacy Regimen Review was acted upon for one resident (Resident #15), resulting in a delay of the pharmacy recommendation of a fasting (nothing to eat or drink for 8 to 12 hours beforehand) lab test with the likelihood of unwanted side effects and/or ineffectiveness of the medication going unmonitored. Findings include: Resident #15: On 4/02/24, at 11:35 AM, a record review of Resident #15's electronic medical record revealed an admission on [DATE] with diagnoses that included Chronic Pulmonary Obstructive Disease, Hypertension and Anxiety. A review of the Medication Regimen Review - Pharmacy Date: 2/5/2024 revealed the box was check marked for See report for noted irregularities and/or recommendations. A review of the Consultation Report . Recommendation date: 02/05/2024 . Comment: (Resident #15) receives Atorvastatin Calcium and does not have a fasting lipid panel documented in the medical record in the previous 12 months. Periodic…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-04 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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 document clinical rationale for the usage of duplicate drug therapy for one resident (Resident #40) of four residents reviewed for unnecessary medications, resulting in Resident #40 being prescribed dual antipsychotic and antidepressant medications in the absence of appropriate documentation that clarified the rationale for and benefits of duplicate therapy. Findings Include: Resident #40: During initial tour on 4/2/2024, Resident #40 was observed ambulating through the hallway and speaking with facility staff. He was not able to be interviewed due to his disease process but appeared to be in good spirits. On 4/2/2024 at approximately 3:30 PM, a review was conducted of Resident #40's medical records and it indicated he admitted to the facility on [DATE] with diagnoses that included Alcohol Dependence with Alcohol Induced persisting dementia, Bipolar Disorder, Major Depressive disorder, Anxiety Disorder, Alcoholic Cirrhosis of the liver,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to reconcile narcotics during medication/narcotic key exchanges and ensure that narcotic reconciliation was completed accurately for two of two medication carts reviewed, resulting in scribbled over narcotic totals/numbers with the likelihood of narcotic diversion going unnoticed. Findings include: On 4/03/24, at 10:22 AM, the Director of Nursing (DON) was asked to explain the narcotic reconciliation process for the facility. The DON explained that two nurses sing for the narcotic delivery, place the narcotics in the locked drawer in the medication carts. The DON was asked when the narcotics are reconciled and the DON stated, when placing them in the medication cart and at shift change. A record review of the CONTROLLED SUBSTANCE SHIFT INVENTORY 200/300 narcotic reconciliation document revealed on 4-1-24 0700 . TOTAL # of Rx's at Start of Shift there was a total of 71. The column labeled Received from Pharmacy has a +1 with two sets of initials in the box. The column labeled Empty or to DON revealed -1 with two…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-04 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to alert staff and visitors of Enhanced Barrier Precautions in a timely manner and follow Enhanced Barrier Precautions during a medical treatment for one resident (Resident #18), resulting in wound care being completed with no gown and the likelihood of cross contamination and spread of infections causing bacteria. Findings include: Resident #18: On 4/02/2024, at 9:30 AM, Resident #18 was resting in their bed. There was no isolation caddy nor sign on the door. On 4/02/2024, at 2:30 PM, a record review of Resident #18's electronic medical record revealed a readmission on [DATE] after a short hospital stay with diagnoses that included Diabetes, weakness and Dementia. Resident #18 required extensive assistance with Activities of Daily Living (ADL's) and had severely impaired cognition. A review of the Physician orders revealed an order for Enhanced Barrier Precautions Start Date: 03/26/2024. A review of the care plan (the resident) is on…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CIENA HEALTHCARE/LAUREL HEALTH CARE — 81 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 →

RatingThis homeChain avg
Overall 5 of 52.8+2.2 vs chain
Health inspection 4 of 52.5+1.5 vs chain
Staffing 4 of 53.2+0.8 vs chain
Quality measures 5 of 54.0+1.0 vs chain
The other 80 homes this chain runs (chain average 2.8★, per CMS)
1 of 5Aria Nursing and RehabilitationLansing, MI 1 of 5Autumnwood of McBainMcBain, MI 1 of 5Christian Park Health Care CenterEscanaba, MI 1 of 5Courtney ManorBad Axe, MI 1 of 5Ely ManorAllegan, MI 1 of 5Kith HavenFlint, MI 1 of 5Laurels Of Norworth TheWorthington, OH 1 of 5Laurels Of West Carrollton TheWest Carrollton, OH 1 of 5Laurels Of West Columbus, TheColumbus, OH 1 of 5Notting Hill of West BloomfieldWest Bloomfield, MI 1 of 5Regency at FremontFremont, MI 1 of 5Regency at JacksonJackson, MI 1 of 5Regency at TroyTroy, MI 1 of 5Regency at WaterfordWaterford, MI 1 of 5Regency at Whitmore LakeWhitmore Lake, MI 1 of 5Royalton Manor, LLCSt Joseph, MI 1 of 5The Laurels Of HeathHeath, OH 1 of 5The Laurels Of Walden ParkColumbus, OH 1 of 5The Laurels of GalesburgGalesburg, MI 1 of 5The Laurels of HudsonvilleHudsonville, MI 1 of 5The Manor of NoviNovi, MI 2 of 5Laurels Of Athens, TheAthens, OH 2 of 5Laurels Of Mt Vernon TheMount Vernon, OH 2 of 5Laurels Of Steubenville TheSteubenville, OH 2 of 5Regency At Bluffs ParkAnn Arbor, MI 2 of 5Regency at CheneDetroit, MI 2 of 5The Laurels Of GahannaColumbus, OH 2 of 5The Laurels Of KetteringKettering, OH 2 of 5The Laurels Of University ParkRichmond, VA 2 of 5The Laurels Of Willow CreekMidlothian, VA 2 of 5The Laurels of BedfordBattle Creek, MI 2 of 5The Laurels of ChathamPittsboro, NC 2 of 5The Laurels of ColdwaterColdwater, MI 2 of 5The Laurels of Forest GlennGarner, NC 2 of 5The Manor of Farmington HillsFarmington Hills, MI 2 of 5Willowbrook ManorFlint, MI 3 of 5Autumnwood of DeckervilleDeckerville, MI 3 of 5Boulevard Temple Care Center, LLCDetroit, MI 3 of 5Brittany ManorMidland, MI 3 of 5Hamilton Respiratory and Nursing CenterHamilton, OH

Showing 40 of 80; 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 / managerTypeRoleSince
QAZI, MOHAMMADIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2001
KHAN, ANISIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2001
STOBB, DAVIDIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/03/2003
CIENA HEALTHCARE MANAGEMENT INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/21/2025
GONG, CHRISTOPHERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
KREINER, CHRISTINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/26/2021
MOHAMMAD A QAZI LIVING TRUST DATED 09/26/97OrganizationADP OF THE SNFsince 06/01/2001
DEUTSCH, NEALIndividualADP OF THE SNFsince 09/01/2009
GARDINA, ANNAIndividualADP OF THE SNFsince 09/01/2009

CMS files one row per role, so the 18 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$7.7M
Net patient revenuemost recent cost report
+0.2%
Operating marginrevenue minus expenses
$898K
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 9%Other / private 91%

This home reported $898K paid to related parties — landlords or management companies under common ownership — equal to about 12% 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.

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

$370per resident / day
operating cost
$11,251per month
≈ monthly operating cost
$371per day
avg. revenue, all payers

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

What families pay in MI

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235515. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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