Medilodge of Tawas City
400 North Street West, Tawas City, MI 48763 · For profit - Corporation · 85 certified beds · (989) 362-8645 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- it has 1 actual-harm citation
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- 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 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.9% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 11.5% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.2% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.5% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.1% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.5% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 9.4% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 26.3% | 19.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.5% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 11.6% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.8% | 14.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.8% | 1.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 84.3% | 79.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 22.9% | 24.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 22.4% | 11.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.23 | 1.84 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.71 | 1.64 | 1.80 | worse |
§ 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.
57.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 60 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.7% 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 39 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 64% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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 | 57.7%CMS range 48.1–66.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 6.7–15.1 | 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 | 66.7% | 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 | 53.9% | 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 | 51.3% | 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 | 96.9% | 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 | 100.0% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.4%CMS range 3.4–13.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 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 85 beds and averages 74.1 residents a day — about 87% occupied, or roughly 11 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 3.90 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.03 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.57 is at or above 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 3.24 hrs/resident/day on weekends vs 4.17 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.13 to 0.77 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · G2025-09-12 · 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 interview and record review, the facility failed to ensure that two residents (Resident #9 and Resident #72) were adequately supervised to prevent falls out of 5 residents reviewed for falls, resulting in the likelihood of a fear of falling, skin tears, head injuries with hospitalization and repeated individual falls. Resident #9: Record review of the facility provided CMS-802 'Resident Matrix' identified Resident #9 as had a fall with injury. An observation and interview on 09/10/2025 at 10:19 AM with Resident #9 revealed that she was laying on the top of her bed with the room partition/privacy curtain pulled so that the resident could not be observed from the doorway of the room. Resident #9 stated that she did have a fall at her closet but could not recall when the fall had occurred. Resident #9 stated that she did have a broken arm from the fall and tailbone pain. identified a fall with major injury and resident stated that she had a fall at her closet. In an observation on 09/11/2025 at 10:34 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-09-12 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing accurate outcome and process surveillance, accurate data collection/documentation/analysis, failure to ensure readily accessible hand hygiene supplies/equipment, and appropriate use of Personal Protective Equipment (PPE) for transmission-based isolation precautions, resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis, a lack of hand hygiene completion, PPE use, and the likelihood for the spread of microorganisms and illness to all 73 facility residents.Findings include: Transmission Based Precautions (TBP) Resident #1 On 9/10/25 10:06 AM, a sign was noted outside of Resident #1's room specifying the Resident had Enhanced Barrier Precautions (EBP) in place. CNA T was asked why Resident #1 had EBP and replied, Has tube feeding. CNA T was observed entering the Resident's room. Resident #1 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 · F2025-09-12 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to implement and operationalize a comprehensive Antibiotic Stewardship Program including documentation and treatment for three residents (#31, #35, and #44) of three residents reviewed for antimicrobial treatment and the potential to affect all facility residents by means of unnecessary and inappropriate antibiotic and antimicrobial medication utilization, antibiotic resistance, and ongoing infection.Findings include:An interview and review of facility Infection Control (IC) and antibiotic utilization data was completed on 9/12/25 at 12:24 PM with IC Registered Nurse (RN) C. When queried what criteria the facility utilizes for antibiotic use and infections, IC RN C replied, McGeer (standardized criteria providing guidelines for antibiotic use). A review of the facility lC documentation for October 2024 was completed. The Monthly line listing documentation provided did not specify if the infection being treated with an antimicrobial medication met McGeer…
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 · E2025-09-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 interviews and record reviews, the facility failed to prevent facility-acquired urinary infections for 4 residents' (#31, # 35, #44, #70) of 4 sampled residents, resulting in likelihood for recurrent urinary tract infections with prolonged illness or hospitalization and antibiotic therapy.Findings include: Resident #31:Observation, interview and record on 9/10/2025 at 10:10 AM estimated of Resident #31 during the initial screening process of the annual recertification survey the resident was verbal with confusion and could not recall having a urinary tract infection. Record review of Resident #31's 8/6/2025 Minimum Data Set (MDS) identified the resident with a Brief Interview of Mental status (BIMs) of 4 out of 15, severe cognitively impaired. Record review on 09/10/2025 at 2:34 PM of Resident #31's urology office visit note dated 7/9/2025 noted hematuria (blood in urine) and urinary tract infection. Ordered Macrobid 100mg capsule oral, one tablet twice daily for 30 capsules.Record review on 09/10/2025…
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 before2025-09-12 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe medication storage for 2 residents (Resident #30 and Resident #33) of 18 residents reviewed for medications left in rooms, resulting in the potential for ingestion of medications. Findings include: Resident #30: On 9/10/25 at 10:53 AM, Resident #30 was observed sitting in a chair on the left side of their bed and an interview was completed. During the interview, a clear cup containing medication pills was observed sitting on a bedside dresser table next to a clear plastic cup of water on the right side of the Resident's bed. The medication cup contained several different size and colored pills. The number of pills in the cup was unable to be accurately counted due to the way the pills were in the cup. When queried regarding the medications, Resident #30 revealed the nurse had left them there for them to take. When asked if the nursing staff always leave their medications in their room, Resident #30 replied some nurses do and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · 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
Based on observation, interview and record review, the facility failed to update/revise individualized, person-centered care plans to reflect changing care needs for 1 resident (Resident #9), of 18 residents reviewed for care plans. Findings include: Resident #9: Record review of the facility provided CMS-802 'Resident Matrix' identified Resident #9 as had a fall with injury. In an observation and interview on 09/10/2025 at 10:19 AM with Resident #9 revealed that she was laying on the top of her bed with the room partition/privacy curtain pulled so that the resident could not be observed from the doorway of the room. Resident #9 stated that she did have a fall at her closet but could not recall when the fall had occurred. Resident #9 stated that she did have a broken arm from the fall and tailbone pain. identified a fall with major injury and resident stated that she had a fall at her closet. Observation on 09/11/2025 at 10:34 AM of Resident #9 was noted to be lying in bed with the room partition curtain pulled between beds and the resident was not able to be seen from the hallway.…
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 · D2025-09-12 · 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
Based on observation, interview and record review, the facility failed to identify skin breakdown for three residents (#3, #13, #70) resulting in the lack of implementation of interventions to prevent skin injury, the worsening of skin injuries, pain, discomfort, and the likelihood of prolonged illness or hospitalization.Findings include: Resident #3:An observation and interview on 09/11/2025 at 8:38 AM of Resident 3 revealed that there were sore spots to the resident's buttocks area and the nurses apply a cream to the area and take photos sometimes. During the survey the surveyor observed Resident #3 to be non-ambulatory related to Parkinson's disease and was able to self-propel wheelchair to the dining room. Resident #3 stated that he does use a WC for ambulation and does spend a lot of time in bed. Observed an air mattress in place to the bed. Resident #3 stated that he was the president of the resident council for residents' concerns and that he had no issues or concerns with the facility. Record review of Resident #3's 8/28/2025 Moisture associated Skin Damage (MASD) assessment…
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 · D2025-09-12 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids 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 that Peripherally Inserted Central Catheter (PICC) line care was provided, per professional standards of practice, for one resident (Resident #2) of one resident reviewed, resulting in a lack of sterile technique during dressing change and a lack of accurate measurement of arm circumference. Findings include:Resident #2:On 9/10/25 at 10:14 AM, A Contact Precaution sign was observed on Resident #2's room door. Activity Aide S was observed in the hallway near the Resident's room. When asked if they knew the why Resident #2 had Contact Precautions in place, Activity Aide S stated, No. Certified Nursing Assistant (CNA) T was observed walking down the hall and was asked if they knew why Resident #2 had contact precautions in place and replied, (Resident #2) has a central line (PICC). When asked if the Resident had an infection, CNA T replied, No. Record review revealed Resident #2 was most recently admitted to the facility on [DATE] with…
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 before2025-09-12 · 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 that respiratory care and oxygen therapy administration tubing was changed per Health Care Provider's (HCP) order for one resident (Resident #2) of one resident reviewed.Findings include:Resident #2:On 9/10/25 at 10:14 AM, A Contact Precaution sign was observed on Resident #2's room door. The Resident's door was open and they were laying in bed, on their back with their eyes closed. Resident #2 had supplement oxygen in place via nasal cannula (NC). Activity Aide S and Certified Nursing Assistant (CNA) T were observed in the hallway. When asked the reason Resident #2 had contact precautions in place, Activity Aide S verbalized they did not know and CNA T stated, (Resident #2) has a central line (PICC). When asked if the Resident had an infection, CNA T replied, No. On 9/11/25 at 8:20 AM, Resident #2 was observed in their room, sitting on the edge of their bed. The Resident's NC prongs (part of the tubing that oxygen comes out of and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-12 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that the appropriate backflow prevention was installed on cross connections. This deficient practice increases the likelihood of contamination of the water supply due to a backflow event, potentially affecting all residents, staff, and visitors who consume water at the facility.Findings include: On 09/10/2025 at 10:30AM during the kitchen tour, observed overhead spray nozzle sitting below the flood rim in the garbage disposal. During interview at this time with Certified Dietary Manager G, she stated she was just using it and forgot to put it back on the hook. On 09/10/2025 1:30PM - 2:30PM during interview with Regional Maintenance I, he stated they are in the process of replacing the sink and the overhead spray nozzle in the kitchen and proceeded to show the order for the parts. On 09/10/2025 between 1:30PM - 2:25PM observed a hose with a spray nozzle attached downstream of a hose bib atmospheric vacuum breaker on the outside spigot located near the front of the building. At this time, Regional…
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 before2025-08-12 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number 2580560.Based on interview and record review, the facility failed to ensure that professional standards of care were given (assess, monitor and promptly report to the physician a change of condition regarding surgical wounds) and follow the care plan for one resident (Resident #101) of 3 residents reviewed for professional standards of care resulting in sepsis, 2 surgeries (debridement's of sternum and left leg surgical wounds), antibiotics, and hospitalization stay.Findings Include:Resident #101:Based on Face Sheet, Minimum Data Set (MDS, dated [DATE], revealed Resident #101 was [AGE] years old, fully alert and able to make her own healthcare decisions and required assistance with Activities of Daily Living/ADL's. The resident was admitted to the facility on [DATE] post open heart surgery, for rehabilitation and was discharged to the local hospital for shortness of breath and dehiscence (opening of surgical wound) of 2 post-surgical wounds (sternum and left lower leg) 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.
Show the remaining 20 citations
- Potential for harm · D2025-01-30 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and 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 This Citation Pertains to Intake Number MI00149747. Based on observation, interview and record review, the facility failed to ensure comprehensive assessment and timely implementation of a plan of care and interventions for one resident (Resident #703) of three residents reviewed, resulting in the lack of facility and staff knowledge of the resident's situation, history of inappropriate sexual behaviors, and the potential for unmet care needs and Resident #703 and other facility Residents to experience psychosocial injury. Findings include: Review of intake documentation, dated as received on 1/21/25, revealed staff were not notified a Resident admitted to the facility had a history of sexually deviant behavior with a law enforcement ordered tether monitoring device. The intake indicated the facility did not comprehensively assess the Resident to ensure their needs were identified and met upon admission and did not notify staff to ensure interventions and monitoring were in place for safety. Resident #703: On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-10 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Numbers MI00146271 and MI00146574. Based on observation, interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADL) care (showers, nail care, hair care, general hygiene) in a timely manner for six residents (#6, #25, #27, #29, #31, and #178) of 19 residents reviewed, resulting in a lack of hygiene with showers, nail care, hair washing, and general hygiene of six residents to have unmet needs, anger/frustration, embarrassment, and complaints. Findings include: Record review of the facility 'Activity of Daily Living (ADL)' policy dated 12/28/2023 revealed the facility takes measures to minimize the loss of resident's functional abilities, including Activities of Daily Living (ADL). Activities of Daily Living include the ability to: (1) Bathe, dress and groom . A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .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 · E2024-09-10 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide palatable meals for four residents (Resident #7, Resident #9, Resident #36, Resident #57) of 30 residents reviewed for the dining task, resulting in complaints of dried food items and soggy bread with the likelihood of decreased food consumption. Findings include. On 9/03/24, at 12:58 PM, Resident #36 complained they had to cut the top off the sweet potato because it was too dry to eat and was only able to eat the inside. On 9/03/24, at 1:16 PM, Resident #57 was in their room with their lunch meal which consisted of ham, bread, cauliflower and half of a yam potato. Resident #57 complained they had to cut off the dried top of the yam that was dried and crusted. Resident #57 picked up their bread which was soggy from the ham juice. On 9/03/24, at 1:38 PM, Certified Dietary Manager (CDM) A was interviewed regarding the provided lunch meal. CDM A was asked to explain how the yam was cooked and CDM A offered they cut in half and baked it. CDM A was asked if they used any butter or oil to keep it moist and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-09-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 a clean and sanitary kitchen, serve food sanitarily and discard expired foods for a census of 71 residents who consume food from the kitchen, resulting in the likelihood for food borne illness with possible hospitalization. Findings Include: Review of the U.S. Public Health Service 2009 Food Code, as adopted by the Michigan Food Law, effective October 1, 2012, revealed all potentially hazardous foods must have an open and use-by date. The food items must be disposed of on or after the use-by date. During the initial kitchen walk through done on 9/3/24 at 10:30 a.m., accompanied by Registered Dietitian A, the following concerns were observed: Kitchen initial tour: On 9/3/24 starting at 10:15 a.m., the initial tour of the kitchen accompanied by Registered Dietitian/RD A the following observations were made: -At 10:16 a.m., in the middle refrigerator was found sliced ham with the open date of 8/22/24, and the use-by date of 8/27/24; it was past it's use-by date (unsafe). -At 10:17 a.m., in the middle…
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 · D2024-09-10 · 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
This Citation pertains to Intake Number MI00146574. Based on observation, interview and record review, the facility failed to ensure that the A-Hall (the Memory Care/Dementia/Behavioral secured unit) eliminated lingering odors, resulting in unsanitary environment, lingering foul odors, angry staff, with the likelihood of embarrassment from residents and staff. Findings Include: Observation of A-Hall locked unit was done on 9/3/24 at 10:53 a.m. The carpet starting at the door down to the main dining/activity room had a very strong odor of urine. During an interview done on 9/4/24 at 10:10 a.m., Staff K stated You have to use hot water and disinfectant and it will deactivate the glue, it will be deactivated (carpet will come up). It was stained on the first day it was put down with (BM). During an interview done on 9/4/24 at 10:11 a.m., Housekeeper J said when they have to keep cleaning the carpet daily, it would take time away from their other housekeeping duties. During an interview done on 9/4/24 at 10:12 a.m., CNA L stated It makes no sense; it gets dirty daily. We have one…
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 · D2024-09-10 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 include a Post Traumatic Stress Disorder (PTSD) diagnosis in the comprehensive admission assessment noted on the CMS 802 form, dated 9/3/2024 and on 9/5/2024, for one resident (Resident #178) out of 19 residents reviewed for assessments, resulting in the likelihood for an inaccurate assessment of the resident's abilities, treatments and unmet needs. Findings include: Record review of the facility 'MDS (Minimum Data Set) 3.0 Policy' dated 1/24/2024 revealed it is the policy of the facility to utilize the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual as the source document for any/all MDS scheduling, encoding, completion, submission, correction, and retention requirements as outlined in chapters 2 through 6 of the RAI manuals. Chapter 4: provides guidance on Care Area Assessment (CAA) triggers, completion requirements, and care plan development. Resident #178: Record review of Resident #178's referral packet…
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 · D2024-09-10 · 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 This Citation pertains to Intake Number MI00146574. Based on observation, interview and record review, the facility failed to develop a comprehensive and individualized care plan related to Resident #178 required oxygen therapy at bedtime and Activities of Daily Living (showers) of 19 residents reviewed, resulting in Resident #178 to have the likelihood of unmet needs. Findings include: Record review of the facility 'admission to Facility' policy dated 1/1/2022 revealed that the primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. Prior to or at the time of admission, the resident's attending physician must provide the facility with information needed for the immediate care of the resident . Care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed interdisciplinary care plan. Record review of the facility 'Oxygen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-10 · 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 This Citation pertains to Intake Number MI00146574. Based on observation, interview and record review, the facility failed to order and ensure the administration of oxygen at bedtime for one resident (Resident #178) out of 2 residents reviewed, resulting in the likelihood for oxygen desaturation at nighttime, confusion, and shortness of breath/hypoxia. Findings include: Record review of the facility 'Oxygen Safety' policy dated 1/1/2022, revealed the facility is to provide a safe environment for residents, staff and public. licensed staff using oxygen equipment will be trained in its operation. Record review of the facility 'Oxygen Administration' policy dated 10/26/2023 revealed oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air with intent of treating or preventing the 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 · Dcited before2024-09-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure that three medication carts and one treatment cart were clean and sanitary of 5 medication carts and 2 treatment carts, resulting in the unsanitary condition of medication carts, cross contamination, and the unaccounted for loss of 1 medication. Findings Include: Observation of medication cart C and cart D was done on 9/3/24 at 9:48 a.m. and at 9:55 a.m., accompanied by Nurse, LPN J. During observation of medication cart C, drawers second and third were noted to have crushed medications and papers in the back of the drawers. During observation of medication cart D, the second drawer had white crushed medications and papers in the back of the drawer. During an interview done on 9/3/24 at 9:55 a.m., Nurse J stated Night's cleans it (6:00 p.m. to 6:00 a.m., cleans medication carts). During observation of the treatment cart for C and D hall done on 9/3/24 at 10:03 a.m., accompanied by Nurse J, a large container of ketoconazole shampoo was found to have an excessive amount of dried shampoo drippings on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-10 · 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
Based on observation, interview and record review, the facility failed to follow food preferences and food dislikes for two residents (Resident #31, Resident #57) of 2 residents reviewed for preferences and food dislikes, resulting in decreased food intake, and frustration with the possibility of hunger. Findings include: On 9/03/24, at 12:56 PM, Resident #31 was in their room with their lunch meal. Their meal ticket had tomato soup and grilled cheese on it. Resident #31 complained they didn't get those items and could only eat the ham with mustard. There was no mustard provided. On 9/03/24, at 1:16 PM, Resident #57 was in their room with their lunch meal which consisted of ham, bread, cauliflower and half of a yam potato. A record review of their meal ticket which revealed cottage cheese written on it. There was no cottage cheese provided. Resident #57 offered, no, I didn't get any cottage cheese. On 9/03/24, at 1:38 PM, A record review along with CDM A of Resident #31's meal ticket along was conducted which revealed grilled cheese and tomato soup typed on it. CDM A offered, they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-25 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00145682 Based on observation, interview, and record review, the facility failed to ensure that residents were treated with dignity and respect and failed to ensure that residents' concerns/grievances were promptly reviewed for 7 of 9 residents (Resident #24, #8, #7, #11, #12, #13, and #14) and residents in attendance at a Resident Council Meeting, reviewed for dignity and respect, resulting in feelings of anxiety and frustration. Findings include: Resident #24 (R24) Review of an admission Record revealed R24 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: debility and heart disease. Review of a Minimum Data Set (MDS) assessment for R24, with a reference date of 8/23/23 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated R24 was moderately cognitively impaired. Review of R24's Quality Assistance Form dated 11/10/23 revealed, Re: (Certified Nursing…
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 before2024-07-25 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Numbers MI00136509 and MI00142061. Based on interview and record review the facility failed to follow professional standards of nursing practice for medication administration for 6 residents (Resident #17, #18, #19, #23, #14, and #21), out of 10 residents reviewed for the provision of nursing services, resulting in the lack of assessments, medications administered outside of the physician ordered parameters, and medication errors. Findings include: Resident #17 (R17) Review of an admission Record revealed R17 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R17's Order Summary revealed Hydrocodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for pain Take medication with food -Start Date- 07/02/2024 -D/C Date- 07/06/2024 . Review of R17's Controlled Substance Record revealed a dose of Hydrocodone-Acetaminophen was documented as administered on 7/7/24 at 8:00 AM. 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.
- Potential for harm · D2024-07-25 · 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 This Citation pertains to Intake Numbers MI00136715 and MI00137985. Based on interview and record review, the facility failed to ensure that one resident (Resident #3), who had been deemed incompetent to make medical decisions, had a legal guardian in place to guide medical decision making according to the resident's Advanced Directives. Findings include: Resident #3 (R3) Review of an admission Record reflected R3 admitted to the facility on [DATE] with diagnoses that included heart disease, kidney disease, type 2 diabetes, major depressive disorder, anxiety and a history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. The admission record indicated R3 had a Responsible Party-Financial Conservator. Review of Letters of Conservatorship dated 6/15/2018 reflected that a conservator had been appointed with authority with respect to all assets of the estate. The Order Regarding Appointment of Conservator indicated Upon presentation of clear and convincing evidence, the adult…
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 before2024-07-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00142331. Based on interview and record review, the facility failed to ensure a resident who experienced a fall was assessed timely with adequate monitoring, assessments, and physician notification for 1 of 10 residents (R#11) reviewed for quality of care, resulting in a delay in care and treatment for an acute T11 spinal fracture. Findings include: Resident #11 (R11) Review of an admission Record revealed R11 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: low back pain and a history of collapsed vertebra and fractures with routine healing. Review of R11's Nursing readmission Evaluation-Part 2 dated 7/24/24 revealed R11's short-term memory and long-term memory were intact. R11's cognitive skills for decision making were Independent-decisions consistent/reasonable. Confirming R11 was cognitively intact. Review of R11's Skilled Daily note dated 7/24/24 revealed that R11 was alert and oriented to person, place,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-21 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1) Ensure that staff treated residents with dignity and respect (honoring preferences and staff to resident dignified communication for 5 residents (Residents #35, #36, #50, #59, #165) and per confidential Resident Council Group meeting held on 9/20/23 at 11:00 a.m., and 2) Ensure that Activities of Daily Living (ADL/personal care) was completed for one resident (Resident #29), resulting in the likelihood for decreased self-esteem, verbalization of anger, fearfulness of staff and embarrassment with increased behaviors. Findings Include: Review of the facility Promoting/Maintaining Resident Dignity policy dated 1/1/22, reported All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident's rights. When interacting with a resident, pay attention to the resident as an individual. Groom and dress residents according to resident preference. Speak respectfully to residents; avoid…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-21 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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) Ensure proper reference checks upon hire, and 2) Ensure adequate staffing to meet resident needs and answer call lights per confidential resident counsel interviews and individual resident interviews, resulting in the potential for insufficient and unmet resident care needs, feelings of frustration, and facility census of 49 (9 in secure dementia unit) on the main resident living area to have 24 residents that required two person/staff assistance with daily care and the facility to only schedule one certified nurse assistant per hallway potentially affecting all 49 residents. Finding include: Record review of the facility 'Staffing to Acuity and Resident Needs Policy and Procedure' undated policy, revealed that to ensure staffing needs for direct care nursing are individualized based on the facility's specific population, and tools are utilized which take into account the resident's individual needs and rely on more than ranges and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-21 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: 1) Correctly label and date medications for two residents (Resident #21 and Resident #31) and 2) Ensure that Medication Cart 'C' was free of loose tablet medications for 1 (C-hall) cart of 4 medication carts, resulting in the potential for medications to be mislabeled and expired due to the lack of open dates, and potential for cross contamination and ineffective medications. Findings include: Record review of the facility 'Medication Storage' policy, dated [DATE], revealed it is the policy of the facility to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. (6.) Light Protection: All drugs, which require light protection while in storage, remain in the original package, in closed drawers or cabinets, or in a specially…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-21 · 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 interview and record review, the facility failed to do a complete and accurate line list (tracking) of resident and staff infections/illnesses, and analysis of resident and staff infection control data for August 2023, resulting in the high likelihood for cross contamination, resident illnesses, increased antibiotic usage, an increase in multiple antibiotic resistant organisms with possible hospitalization. Findings Include: Review of the facility Monthly Analysis and Summary/QAPI Committee Infection Prevention/Control Report dated August 2023, revealed no documentation at all in sections: - Communicable Diseases Identified - Audits Completed (monthly audits) - Hand Hygiene Observations and Summary - Date of last infection PIP and any active POC's - New or changed policies reviewed - Data of Quarterly Surveillance Rounds - Date of Annual Infection Risk Assessment - Date of Annual TB Risk Assessment - Date of Annual Review of Respiratory Protection Program - Antibiotic Use Reported to Prescribing Providers - Annual Antibiogram review Due Date - Education related 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 · E2023-09-21 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure that 10 residents (Residents #1, #9, #16, #21, #26, #32, #33, #43, #42 and #46) were up to date on their Prevnar 20/Pneumococcal 20/PVC 20) vaccine, resulting in the high likelihood for pneumonia infection (respiratory infection), hospitalization with possible death. Findings Include: Review of the facility Pneumococcal Vaccine policy dated 5/1/22, reported It is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. Review of all facility resident's vaccination records (admission dates), revealed 10 resident's (Resident's #1, #9, #16, #21, #26, #32, #33, #43, #42 and #46) where not up to date with their PVC 20. Review of the facility Infection Control Job Description (un-dated) revealed it was the responsibility of the Infection Control Nurse to maintain compliance with regulatory requirements regarding resident vaccination status. During an interview done on 9/19/23 at 2:09 p.m., Infection Control…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-21 · 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 that two residents (Resident #46 & Resident #57) were assessed and removed from the floor per facility post-fall protocol, resulting in the likelihood for injury, and hospitalization with a fracture. Findings include: Record review of the facility 'Fall Prevention Program' policy dated 1/1/2022 revealed a fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force . When a resident experiences a fall, the facility will: Assess the resident, Complete a post fall assessment . Record review of the facility 'Fall- Clinical Protocol' policy dated 1/1/2022 revealed once a fall occurs it is important to gather as much information as possible: observe for evident trauma . Resident #57: Record review on 09/20/23 at 11:05 AM of Resident #57's closed electronic medical record revealed the resident had a fall on 9/12/2023 and was not sent 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to MEDILODGE — 53 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.1 | -0.1 vs chain |
| Health inspection | 2 of 5 | 2.7 | -0.7 vs chain |
| Staffing | 5 of 5 | 3.7 | +1.3 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 52 homes this chain runs (chain average 3.1★, per CMS)
Showing 40 of 52; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EVEREST OPCO GROUP LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/01/2018 |
| B&Y HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| B&Y TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| CODY HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| CRAIG FLASHNER 2007 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/01/2018 |
| NORCROSS, ROBERT | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 02/01/2018 |
| ROGERS, STACEY | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 02/01/2018 |
| KIRK, KRISTINE | Individual | W-2 MANAGING EMPLOYEE | — | since 02/01/2018 |
| FLASHNER, CRAIG | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
| PERLSTEIN, YITZCHOK | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
| BLOSSOM HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
| PRESTIGE ADMINISTRATIVE SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2018 |
CMS files one row per role, so the 16 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
7 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 $414K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235379. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-12, 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.