Medilodge of Taylor
23600 Northline Rd, Taylor, MI 48180 · For profit - Limited Liability company · 142 certified beds · (734) 287-8580 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 27% of its spending goes to commonly-owned related companies
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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 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 — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 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 | 2.5% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.6% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.5% | 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 | 1.2% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 2.4% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.8% | 19.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.1% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.8% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.3% | 20.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.5% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.8% | 1.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 57.7% | 79.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 33.8% | 24.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.3% | 11.7% | 12.0% | better |
§ 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.
46.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 111 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 53 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 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 43% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.8%CMS range 38.6–57.2 | 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 | 12.6%CMS range 9.5–15.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 56.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 58.5% | 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 | 54.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 92.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 91.9% | 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 | 8.7%CMS range 5.9–12.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 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 142 beds and averages 131.7 residents a day — about 93% occupied, or roughly 10 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 3.81 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 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 3.24 hrs/resident/day on weekends vs 4.04 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.60 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · Dcited before2026-05-15 · 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
This citation pertains to intake 3001431.Based on interview and record review the facility failed to ensure the physician was notified when medications were not administered as ordered for one resident (R902) out of three residents reviewed for medication administration, resulting in missed opportunities for physician intervention, alternative treatment considerations and the potential for further spread of the resident's infection.Findings include:Record review of electronic medical record (EMR) of R902 revealed admission into the facility on 3/14/26 and discharged from the facility on 3/15/26, with pertinent diagnoses of chronic osteomyelitis (infection of bone) of the left ankle and foot and Type 2 diabetes mellitus (metabolic disorder). Further review of EMR revealed that the resident was alert and oriented x 4 (person, place, time, and situation) upon admission to the facility.A phone interview was conducted with R902 on 5/15/26 at 10:17 AM. R902 reported that while at the facility the resident did not receive a dose of insulin or antibiotics that were prescribed. It 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 · Fcited before2025-12-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include: On 12/8/25 at 9:40AM, observation of the kitchen hand sinks found that they have an automatic faucet that is activated by movement. Once activated, the sinks were only found to have a run time of 3-5 seconds unless continually reactivated. According to the 2022 FDA Food Code section 5-202.12 Handwashing Sink, Installation. (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 29.4 C (85 F) through a mixing valve or combination faucet. Pf (B) A steam mixing valve may not be used at a HANDWASHING SINK. (C) A self-closing, slow-closing, or metering faucet shall provide a flow of water for at least 15 seconds without the need to reactivate the faucet. On 12/8/25 at 9:50 AM, an interview with Dietary Manager (DM) D and Registered Dietician (RD) D found that the facility uses a cooling process for food two 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 · F2025-12-11 · tag F0813 — widespreadHave a policy regarding use and storage of foods brought to residents by family and other visitors.
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 fully implement a policy regarding use and storage of resident foods brought in from outside sources resulting in the potential for nutritional decline and decreased satisfaction for all residents. Findings Include:On 12/8/25 at 10:52 AM, observation of the nourishment rooms' large refrigeration unit, found minimal food storage. When asked where residents would store food brought in from outside sources that needed refrigeration, Registered Dietician D, stated the facility does not have a refrigerator for residents and only has residents keep shelf stable products in their rooms. A record review of facility policy entitled, Use and Storage of Food Brought in by Family or Visitors, revised 7/1/25, found that It is the right of the residents of this facility to have food brought in by family or other visitors. The policy goes on to state that, The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator., and that, . The facility staff will assist residents in accessing 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 · E2025-12-11 · 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 ensure dignity was provided during care for one (R26) of two cognitively impaired residents and for five of eight cognitively intact residents that participated in an Anonymous Resident Council meeting reviewed for resident's rights, resulting in feelings of being ignored and discomfort.Findings include:On 12/10/2025 at 12:35 p.m., while standing in the hall across from R26's bedroom in which the door was closed, loud laughter could be heard coming from the bedroom. With moving closer to the door, two nurse aides (CNA G and CNA H) were heard laughing and talking loudly and having a personal conversation using profanity while giving R26 activity of daily living care. The aides did not verbally interact with R26, just with each other. After CNA G and H exited the room, R26 was observed resting in bed. An interview was attempted with R26, however was not completed due to the R26's impaired cognition. R26 appeared confused and had difficulty…
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 · E2025-12-11 · 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 food at a palatable temperature for five of eight cognitively intact residents that participated in an Anonymous Resident Council meeting, and all residents who consume food resulting in the potential for decreased food consumption and potential nutritional decline.Findings include:Anonymous Resident Council- On 12/11/25 at 11:00 a.m. an Anonymous Resident Council meeting was held with eight cognitively intact residents. Five of eight residents verbally expressed strong dissatisfaction with food services. One of the five residents that expressed concern of food palatability eats their meal in their room, the other four eat their meals in the dining room. The residents stated, Food that is supposed to (be) hot (soup) is cold and foods that are supposed to (be) cold are hot (ice cream). The grill cheese sandwiches are so cold that the bread and cheese are as hard as the table. Eggs and sausage are cold to touch and taste. The food is overcooked and often hard and difficult to chew. The group said 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 · E2025-12-11 · tag F0806 — failed to honor food preferences — patternEnsure 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 offer additional food preferences, alternative or optional food choices for two (R117 and R120) residents out of 13, and three of eight cognitively intact residents that participated in an Anonymous Resident Council meeting reviewed for food, potentially resulting in weight loss and dissatisfied dining/nutrition experiences. Findings include: Anonymous Resident Council- On 12/11/25 at 11:00 a.m. an Anonymous Resident Council meeting was held with eight cognitively intact residents. Three of eight residents verbally expressed strong dissatisfaction with food services. Three residents that have concerns with food preferences being honored eat in the dining room. One resident whose family member was present during the meeting stated, My (family member) is on a special diet and cannot eat potatoes or tomatoes due to high potassium and they still give it anyway. I have written on the meal ticket not to give potatoes or tomatoes and handed them to the kitchen staff, and they still put potatoes or tomatoes on my…
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 · E2025-12-11 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Complaint 2681324Based on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment resulting in an increased potential for contamination and a possible decrease in the satisfaction of living for residents in the 100, 200, and 300 halls. Findings Include:On 12/8/25, at 10:59 AM, observation of the Ice room on the 200 Hall found an increased accumulation of black debris in the cabinet under the sink. On 12/8/25 at 1:20 PM, observation of the 100 Hall day space found an accumulation of Kleenex and debris stuffed into the side of chair and couch cushions. On 12/8/25 at 2:15 PM, observation of the 300 Hall Clean Utility room found an open wire rack of clean linen with an accumulation of debris, dust, and trash on the floor under the rack. On 12/8/25 at 2:46 PM, observation of the 200 hall shower room found storage racks in both shower stalls with gloves and towels open and exposed to contamination from residents showering. When…
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 · D2025-12-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120 F. This resulted in an increased risk of injury among residents residing in the facility.Findings Include:On 12/8/25 at 1:33 PM, observation of resident room [ROOM NUMBER] found the hot water in the shower reached a temperature of 126F when tested with a rapid read thermometer. The temperature of the hand sink was 118F at this time and noted to have a point of use mixing valve installed to temper the hot water. On 12/8/25 at 1:38 PM, observation of resident rooms [ROOM NUMBERS] found hot water from the sinks and showers under the maximum 120F for resident care areas. On 12/8/25 at 2:16 PM, an interview with Maintenance Director (MD) F found that hot water temperatures are maintained between 105F-120F and a sample of rooms are checked every morning in a quantity that allows for all hot water fixtures to be checked monthly. MD F went on to state that all sinks have a point…
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 · D2025-12-11 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview, and record review the facility failed to follow standards of practice for accurate reconciliation of Controlled Medications in three of eight medication carts resulting in the potential for drug diversion. Findings Include:Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence On 12/09/2025 at 11:04 AM inspection of 'Medication Cart - A ' on the 200-hall with Licensed Practical Nurse (LPN) A a review of the Controlled Substance Verification Log revealed it was incomplete. There were no licensed nurse's signatures to verify the Controlled Medications were reconciled for the last 24 hours; on 12/8/25 from the day shift to the night shift and on 12/9/25 from night shift to the day shift. LPN A said, Oh I counted this morning with the night shift nurse, but we forgot to sign the sheet. We should have signed it. LPN A could not say why the night…
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 · D2025-12-11 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (R45) out of five residents reviewed for immunizations, was provided an influenza vaccination and education resulting in the potential for the development and spread of influenza among vulnerable residents in the facility. Finding include:On 12/9/2025 at 9:28 AM the Infection Preventionist (IP) J was interviewed and reported (R45) did not have documentation of a current influenza immunization or refusal signed by the guardian. Record Review of R45's Electronic Health Record (EHR) revealed R45 was admitted on [DATE] with a diagnosis of Psychomotor deficit following Cerebral Infarction (stroke). R45 did not have documentation to indicate that the influenza vaccine was declined by the guardian or was contraindicated. On 12/11/2025 at 8:50 AM, the Director of Nursing (DON) was interviewed and said the expectation was for the guardian to be contacted and get consent or a declination regarding immunizations. Review of the facility policy…
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 14 citations
- Potential for harm · D2025-12-11 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 one resident (R45) out of five residents reviewed for immunizations, was provided a COVID-19 vaccination and education resulting in the potential for the development and spread of COVID-19 among vulnerable residents in the facility. Findings include: On 12/9/2025 at 9:28 AM the Infection Preventionist (IP) J was interviewed and reported (R45) did not have documentation of a current COVID-19 immunization or refusal signed by the guardian. Record Review of R45's Electronic Health Record (EHR) revealed R45 was admitted on [DATE] with a diagnosis of Psychomotor deficit following Cerebral Infarction (stroke). R45 did not have documentation to indicate that the COVID-19 vaccine was declined by the guardian or was contraindicated. On 12/11/2025 at 8:50 AM, the Director of Nursing (DON) was interviewed and said the expectation was for the guardian to be contacted and get consent or a declination regarding immunizations. Review of the facility policy…
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 · D2025-08-20 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake 2583399.Based on interview and record review, the facility failed to timely notify the guardian of a resident fall for one resident (R101) out of four residents reviewed for falls. Findings include:Record Review of R101's Electronic Health Record (EHR) revealed admission to the facility on 7/24/25 with diagnoses which included Unspecified Fracture of Right Femur, Chronic Lymphocytic Leukemia of B-Cell Type, Legal Blindness. Date of discharge 7/31/25 at 8:11 AM to acute care hospital.Review of 101's Brief interview for Mental Status (BIMS) assessment performed on 7/29/25 revealed a BIMS of 8/15 moderately impaired cognition. R101 is listed as having a guardian. Review of R101's functional abilities status revealed substantial/maximal assistance for bed mobility and dependent for transfers.On 8/21/25 at 9:05 AM, Certified Nursing Assistant (CNA) C was interviewed and said that on 7/29/25 at approximately 6:30 AM, she found R101 on the floor next to the bed. CNA C notified Licensed Practical Nurse (LPN) D and together they put R101 back in bed. CNA C…
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 · D2025-08-20 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake 2583399.Based on interview and record review, the facility failed to report an injury of unknown origin to the State Agency (SA) for one resident (R101) out of four residents reviewed for injuries of unknown origin. Findings include:On 7/31/25 the State Agency (SA) received a complaint from Adult Protective Services regarding R101 sustaining a fractured leg.Record Review of R101's Electronic Health Record (EHR) revealed admission to the facility on 7/24/25 with diagnoses which included Unspecified Fracture of Right Femur, Chronic Lymphocytic Leukemia of B-Cell Type, Legal Blindness. Date of discharge 7/31/25 at 8:11 AM to acute care hospital.Review of 101's Brief interview for Mental Status (BIMS) assessment performed on 7/29/25 revealed a BIMS of 8/15 moderately impaired cognition. R101 is listed as having a guardian. Review of R101's functional abilities status revealed substantial/maximal assistance for bed mobility and dependent for transfers.On 8/21/25 at 9:05 AM, Certified Nursing Assistant (CNA) C was interviewed and said that on 7/29/25…
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 · D2025-08-20 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake 2583399.Based on interview and record review, the facility failed to investigate an injury of unknown origin for one resident (R101) out of four residents reviewed for injuries of unknown origin. Findings include:On 7/31/25 the State Agency (SA) received a complaint from Adult Protective Services regarding R101sustaining a fractured leg.Record Review of R101's Electronic Health Record (EHR) revealed admission to the facility on 7/24/25 with diagnoses which included Unspecified Fracture of Right Femur, Chronic Lymphocytic Leukemia of B-Cell Type, Legal Blindness. Date of discharge 7/31/25 at 8:11 AM to acute care hospital.Review of 101's Brief interview for Mental Status (BIMS) assessment performed on 7/29/25 revealed a BIMS of 8/15 moderately impaired cognition. R101 is listed as having a guardian. Review of R101's functional abilities status revealed substantial/maximal assistance for bed mobility and dependent for transfers.On 8/21/25 at 9:05 AM, Certified Nursing Assistant (CNA) C was interviewed and said that on 7/29/25 approximately at 6:30 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake 1351543Based on observation, Interview, and record review, the facility failed to ensure a call light was answered within a timely manner for one resident (R906) out of six residents reviewed for call lights, resulting in the R906 being left of the toilet for an extended period, discomfort, disrespect, and feelings of anxiety.Findings include:On 7/22/25 at 12:35 pm, R906 was observed in their room sitting in a wheelchair. R906 was interviewed about the care received at the facility. R906 said they were not receiving good care. R906 stated they went to the bathroom on 6/21/25 around 1:30 pm. R906 said, I was able to put myself on the toilet.I put the call light on and waited almost two hours for staff to answer the bathroom call light. R906 stated their family was visiting and went looking for staff but could not find anyone to help. R906 was asked if family was able to assist and the resident said, No they can't help me. At this time, R906 said, I was begging for help.I was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure enhanced barrier precautions (EBP) were applied during wound care for one resident (R912) out of one resident reviewed for infection control.Findings include:Record review of R912's electronic medical records (EMR) revealed admission into the facility on 5/28/23 with a pertinent diagnosis of pressure ulcer of sacral area (upper buttocks) region Stage 4 (deep wound were bone and muscle can be observed). An observation conducted on 7/23/25 at 9:56 a.m. revealed a sign posted on the outside of R912's door instructing staff to wear personal protective equipment (PPE) during care. Additionally, a storage unit containing PPE was observed outside the resident's room.An observation on 7/23/25 at 10:00 am, was made of Licensed Practical Nurse (LPN) C entering R912's room without donning the required PPE. During the wound care procedure, after R912's soiled bandages were removed, the wound was observed with red-colored drainage.Record review of R912 's physician's orders, dated 5/30/25 at 3:00 p.m., documented,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-10-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to properly date-label food in the kitchen and ensure the drain from the coffee machine was properly air gapped. Findings include: On 10/15/24 at 8:50 AM, during the initial tour of the kitchen with Dietary Manager (DM) D and Registered Dietitian (RD) C the following was observed: Three loaves of white bread, two loaves of wheat bread, and one bag of white hotdog buns were opened and undated on the bread rack. RD C stated food items should specify delivery, opened, and discard dates. Inside the reach in cooler, an opened five-pound bag of shredded cheese was dated 10/8/24. DM D and RD C were unable to identify if the date signified the delivery, opened, or discard date. Additionally, an opened five-pound tub of sour cream did not specify an expiration date. The drain line from the coffee machine did not have the required minimum one-inch air gap (an unobstructed vertical space between the end of the drain line and the flood rim of the floor drain). On 10/17/24 at 12:40 PM, the Nursing Home Administrator (NHA)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-17 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one resident (R76) was updated in a timely manner regarding preference to move to another home, resulting in resident experiencing frustration. Findings include: On 10/15/24 at 12:12 PM, R76 was observed awake and lying in his bed. When queried about his stay in the facility, R76 said he wanted to speak to the social worker. R76 stated, I want to move to (Facility XX). I haven't spoken with anyone about this in two months. A review of the clinical record for R76 revealed an admission into the facility on 4/8/24 with diagnoses of metabolic encephalopathy, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. R76 was his own responsible party. A Minimum Data Set assessment dated [DATE] documented intact cognition. A Social Service progress note dated 8/22/24 documented the following: MSW (Masters of Social Work) notified by SS asst. (Social Service Assistant) that patient is wanting referral sent to (Facility XX).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide adequate nail care, facial hair grooming, and hair washing for two (R18 and R118) of seven residents reviewed for activities of daily living for dependent residents resulting in unmet hygiene needs, loss of dignity, and emotional distress. Findings include: R18: On 10/15/24 at 11:25 a.m. R18 was observed in bed watching television. R18 was also observed with matted braided hair that was greasy and full of dandruff. R18 facial hair was overgrown and unkept. R18 had impaired speech, however when asked the last time his facial hair was trimmed and hair was washed, the resident replied, good question (indicating it has not been done). R18 became tearful when asked if the staff offered to wash hair and trim facial hair. R18 responded, No! No! No! R18 was asked do you want your hair washed and facial hair trimmed. Tearfully R18 said, Yes! Yes! Yes! Please, please, please. On 10/15/24 at 11:59 a.m. CNA O was interviewed and confirmed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure continuous tracheostomy humidification for one (R125) of three residents reviewed for respiratory therapy, resulting in the potential for thickened secretions, dehydration of airway secretions, and the potential for lung infection. Findings include: On 10/16/24 at 08:39 AM, R125 was observed in bed on their back, with eyes opened. R125 was lying on their back with their left arm pulled up to their chest and right hand culled tight towards their palm. The humidifier canister that holds water for humidification was completely empty (without water to generate humidification). On 10/17/24 at 08:40 AM, R125 was observed in bed on their back, with eyes closed. R125 was lying on their back with their left arm pulled up to their chest and right hand culled tight towards their palm. The humidifier canister that holds water for humidification was completely empty (without water to generate humidification). On 10/17/24 at 10:15 AM, R125 was observed in bed on their back, with eyes closed. R125 was lying on their…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-17 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 MI00146662. Based on interview and record review the facility failed to maintain complete and accurate medical records for one resident (R130) out of three residents reviewed for wound care. Findings Include: Record review of R130's electronic medical record (EMR) revealed admission into the facility on 2/8/24 with a pertinent diagnosis of acquired absence of left leg below knee. According to the Minimum Data Set (MDS) dated [DATE], R130 had intact cognition and required assistance with Activities of Daily Living (ADLs). Record review of Physician Orders documented, LBKA (left below the knee amputation) cleanse with wound cleanser pat dry and apply dry dressing every day for surgical incision. Start Date-02/15/2024 0700. Record review of Treatment Administration Record (TAR) revealed that a dressing was applied on 2/15/24. On 2/16/24, Licensed Practical Nurse (LPN) L documented that R130 refused to have dressing changed. On 2/17/24 LPN I documented that dressing change was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00141087. Based on interview and record review, the facility failed to shower one resident (R506) of three reviewed for scheduled showers, resulting in the lack of resident personal grooming and hygiene. Findings include: A review of R506's Electronic Medical Record (EMR) revealed R506 was admitted to the facility 10/17/23 and discharged from the facility 11/17/23. R506 had the following medical diagnoses: low back pain, Scoliosis, Arthritis, Repeated Falls, and Abnormalities of Gait and Mobility. A review of R506's Minimum Data Set (MDS) dated [DATE] revealed R506 had a Brief Interview of Mental Status (BIMS) score of 10/15 moderate cognition). According to the MDS, R506 required moderate assistance with showering/bathing, required moderate assistance with shower transfers, and required moderate assistance with bed mobility. A review of R506's Activities of Daily Living (ADL) care plan, with an initiation date of 10/17/23, documented, Bed Mobility: one person .Transfer: 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 · D2023-09-28 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a complete order for the application and removal of a topical pain patch for one resident (Resident #99) of 28 residents reviewed during medication pass, resulting in the likelihood of causing the resident to be over medicated or under medicated. Findings include: On 9/27/2023 at 8:29 a.m., an observation was made with Licensed Practical Nurse (LPN) F 's morning Medication Pass for R99 on the (400's Hallway). Unit Manager/Licensed Practical Nurse (UM/LPN G' and a Certified Nursing Assistance (CNA) assisted R99 with turning in bed allowing LPN F to apply a topical pain patch (Hot and cold pack). Prior to applying the patch on R99's lower back, there was no other patch observed. LPN F was asked the instructions for the Patch to be applied and taking off. LPN F said, It does not have a removal time, but it goes on at 09:00. I put it on yesterday too, but I don't know when the patch was removed. UM/LPN G said, I have to look but I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to provide appropriate supra-pubic catheter care (s/p catheter; flexible tube surgically inserted through the abdomen wall into the bladder to drain urine) for one (R16) of two residents reviewed for urinary catheters resulting in the potential for skin irritation around the catheter insertion site, discomfort or dislodgement of the catheter, and urinary tract infections. Findings include: On 9/25/23 at 10:42 AM R16 was observed in his room seated in his wheelchair with the front of his pants visibly wet in center and down left pant leg (thigh area). The resident was wearing a brief underneath his pants. The resident's pants were wet in two spots; over the top of the brief along the front of the abdomen in an oval shape, and down the left pant leg thigh area. R16 had a urinary catheter tubing inside his left pant leg that exited at the ankle opening. The tubing was connected to a collection bag that was resting on the floor. R16 was alert and able to communicate with a letter board on a tray attached to his…
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 | 3 of 5 | 3.7 | -0.7 vs chain |
| Quality measures | 5 of 5 | 4.0 | +1.0 vs chain |
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 |
|---|---|---|---|---|
| FIFTEENINONE OPCO GROUP LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/24/2013 |
| B&Y HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/24/2013 |
| B&Y TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/24/2013 |
| CODY HEALTHCARE S CORP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/24/2013 |
| CRAIG FLASHNER 2007 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/24/2013 |
| NORCROSS, ROBERT | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 06/24/2013 |
| ROGERS, STACEY | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 10/20/2014 |
| KIRK, KRISTINE | Individual | W-2 MANAGING EMPLOYEE | — | since 01/01/2016 |
| FLASHNER, CRAIG | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/24/2013 |
| PERLSTEIN, YITZCHOK | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/24/2013 |
| GENERATIONS HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/24/2013 |
| PRESTIGE ADMINISTRATIVE SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2016 |
CMS files one row per role, so the 14 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 $3.4M paid to related parties — landlords or management companies under common ownership — equal to about 27% 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
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 235300. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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