No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Medilodge of Traverse City

2585 South LaFranier Road, Traverse City, MI 49686 · For profit - Corporation · 84 certified beds · (231) 947-9511 Medicare & Medicaid certified

Call the home — (231) 947-9511 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 20251 actual-harm citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2025
  • 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
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 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

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2781 Garfield Rd N · (231) 499-0631 · Call to confirm hours
Pharmacy
975 W South Airport Rd · (231) 946-5840 · Call to confirm hours
Grocery
1456 S Airport Rd W · (231) 421-1444 · Call to confirm hours
Park
2748 Garfield Rd N · (231) 342-0461 · Typically dawn to dusk
Place of worship
2770 La Franier Rd · (501) 283-0459

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 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.2%10.8%15.4%better
Long-stay residents who lose too much weight5.9%5.4%5.4%typical
Long-stay residents with a catheter left in their bladder1.1%0.8%0.9%worse
Long-stay residents with a urinary tract infection1.2%1.5%2.0%better
Long-stay residents with depressive symptoms3.1%4.3%6.5%better
Long-stay residents who were physically restrained1.2%0.1%0.1%worse
Long-stay residents with falls causing major injury4.9%3.0%3.3%worse
Long-stay residents whose ability to walk worsened6.6%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication28.6%19.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers3.2%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control15.2%20.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table19.1%14.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.0%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine84.1%79.5%79.4%typical
Short-stay residents rehospitalized after admission17.4%24.0%22.6%better
Short-stay residents with an outpatient ER visit8.1%11.7%12.0%better
Long-stay hospitalizations per 1,000 resident days1.091.841.67better
Long-stay outpatient ER visits per 1,000 resident days0.621.641.80better

§ 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.

56.3% 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 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.3%U.S. median 51.5%
Got home and stayed home
8.9%U.S. median 10.7%
Went back to hospital
68.1%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 68.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 47 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 55% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.3%CMS range 45.9–67.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.9%CMS range 5.6–13.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge68.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge57.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge53.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge95.5%98.7%Oct 2024–Sep 2025CMS 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 stay1.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.6%CMS range 4.2–15.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.961.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.18
RN hours/ resident / day
0.32
LPN hours/ resident / day
2.08
Aide hours/ resident / day
3.57
Total nurse hours/ resident / day
0.73
RN hoursweekends
45.1%
Total nursing turnover
27.8%
RN turnover

How full it usually is: this home is certified for 84 beds and averages 73.1 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 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.18 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.98 hrs/resident/day on weekends vs 3.81 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.36 to 0.73 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%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2025-05-02)
7
at the previous standard inspection (2024-03-20)

Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · Gcited before2024-03-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall with fracture for one Resident (R19) of five residents reviewed for falls. This deficient practice resulted a tibial (lower leg) fracture, with increased pain. Findings include: Review of R19's Minimum Data Set (MDS) assessment, dated 11/15/23, revealed R19 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease and depression. R19 required assistance with toileting and was independent with transfers and walking. R19 was unable to participate in the Brief Interview for Mental Status (BIMS) assessment, showing severe cognitive impairment. The sensory assessment revealed R19 was sometimes understood, and sometimes able to understand. Review of R19's accident and incident report, dated 11/17/23 at 10:14 a.m., revealed R19 was found by a housekeeping staff yelling for help and was observed sitting on the floor at the end of the bed, with her legs out facing her…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · G2023-04-03 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 adequate monitoring of a high risk resident (Resident #66) for inadequate intake of foods and fluids during a COVID infection. This deficient practice resulted in Resident #66 having an acute change in condition requiring hospitalization where she was found with acute dehydration and septic shock and expired seven days after readmission to the facility. Finding include: Resident #66 (R66): A review of R66's medical record revealed she admitted to the facility on [DATE] with diagnoses including quadriplegic cerebral palsy, dysphagia, hx (history) of sepsis, and dementia. A review of R66's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed she scored 6/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderately impaired cognition. This assessment also showed she required limited assistance of one staff for eating. A review of a 1/10/23 Dietary Progress note by former Registered Dietitian (RD) H revealed,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-02 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to prevent Resident to Resident physical abuse for four Residents (R34, R54, R63, and R68) of four residents reviewed for abuse. Findings include: R63 On 4/29/25 at approximately 2:00 p.m., R63 was observed pacing the hallway of the memory care unit without staff supervision. R63 was attempting to find someone, using derogatory language in her description and getting near residents and visitors faces. R63 then was observed grabbing the hand of R68 and stated, Come on! Come on! while attempting to redirect R68 down the hallway. R68 told R63, No!, when R63 began pinching R68's hand in between her thumb and index finger. R68 began to yell out when R63 closed her right hand to make a fist and hit R68 in the right upper arm, making R68 scream. Two staff members came from the hallway and from another resident room to separate the two residents with one staff member leading R68 into her room. R63 was then left unsupervised in the hallway and took another resident's hand, leading her towards the front door. A request for…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-02 · tag F0609 — failed to report abuse allegations — pattern
    Timely 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

    Based on observation, interview and record review, the facility failed to report timely allegations of abuse (resident to resident), within two hours, to the State Agency (SA) for four Residents (R34, R54, R63, and R68) of four residents reviewed for abuse reporting. Findings include: R63 On 4/29/25 at approximately 2:00 p.m., R63 was observed pacing the hallway of the memory care unit without staff supervision. R63 was attempting to find a male, using derogatory language in her description and getting near residents and visitors faces. R63 then was observed grabbing the hand of R68 and stated, Come on! Come on! while attempting to redirect R68 down the hallway. R68 told R63, No! when R63 began pinching R68's hand in between her thumb and index finger. R68 began to yell out when R63 closed her right hand to make a fist and hit R68 in the right upper arm, making R68 scream. Two staff members came from the hallway and from another resident room to separate the two residents with one staff member leading R68 into her room. R63 was then left unsupervised in the hallway and took another…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-02 · tag F0725 — failed to have enough nursing staff — pattern
    Provide 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

    Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being in a locked memory care unit. This deficient practice resulted in the continuation of numerous resident to resident altercations and falls. Findings include: On 4/29/25 at approximately 2:00 p.m., R63 was observed pacing the hallway of the memory care unit without staff supervision. R63 was attempting to find someone, using derogatory language in her description and getting near residents and visitors faces. R63 then was observed grabbing the hand of R68 and stated, Come on! Come on! while attempting to redirect R68 down the hallway. R68 told R63, No! when R63 began pinching R68's hand in between her thumb and index finger. R68 began to yell out when R63 closed her right hand to make a fist and hit R68 in the right upper arm, making R68 scream. Two staff members came from the hallway and from another resident room to separate the two residents with one staff member leading R68 into her room. R63 was then left unsupervised in…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-02 · tag F0923 — pattern
    Have enough outside ventilation via a window or mechanical ventilation, or both.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure exhaust ventilation was functioning in resident bathrooms, on three halls, serving 22 of a total 74 residents. This deficient practice resulted in noxious odors permeating the resident environment, with the potential to cause unpleasant and uncomfortable living conditions. Findings include: On 4/30/25 at 10:45 AM, noxious odors were noted throughout the D hall. On 4/30/25 at 2:15 PM, in response to the presence of continued noxious odors on the D hall, an investigation was initiated into determining the functioning of the exhaust ventilation system for resident bathrooms. The bathrooms serving the following rooms were inspected for functioning exhaust by placing a paper towel over the ceiling mounted duct cover and determining if there was adequate negative pressure to hold the paper in place. The failure to hold the towel in place deemed a failure for that bathroom's exhaust system. This failure was noted in the bathrooms serving the following resident rooms: D Hall; 1, 5, 6 On 4/30/25 at 2:35 PM, an interview 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-02 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 assess for self administration safety in two residents (#67 & #8) of seven residents reviewed for safety with self medication administration. Findings include: Resident #67 (R67) On 4/30/25 at approximately 8:00 AM, during a medication administration, Registered Nurse A (RN A) was observed handing R67 a medication cup containing multiple medications. R67 then walked away without RN A verifying ingestion or providing supervision. R67 was left alone in their room with the medications. Review of R67's chart indicated that they had not been assessed for self-administration of medications. Resident #8 (R8) During an interview of R8 on 4/30/25 at 8:54 AM, the medication Trelegy, a prescription inhaler used for long term management of chronic obstructive pulmonary disease and asthma (respiratory conditions causing difficulty in breathing) was observed on the bedside table. R8 stated that they had administered the medications earlier in the morning. R8 stated that the nurse had left the medication there and had not…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-02 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 staff reviewed residents medical record for code status, ensure code status orders were signed by the physician, and ensure code status was uploaded to the resident chart in a timely manner for two Residents (R72 and R500) of three residents reviewed for advance directives. Findings include: R72 R72 was admitted to the facility on [DATE] with diagnosis of right femur head and neck fracture without operation. R72 was her own responsible party. Review of R72's progress notes revealed the following entry dated [DATE], This nurse entered resident's room to obtain blood glucose reading, Resident was observed in bed laying on right side, not responding to verbal stimulus. This nurse attempted to rouse resident by movement, but resident was still not responding. No pulse was observed when checking radial and carotid arteries. This nurse notified (Nurse Practitioner [NP]) of status. Absence of pulse was confirmed by this nurse and (NP). Family notified…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2025-05-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow interventions to prevent further falls for one Resident (R54) of three residents reviewed for falls. Findings include: R54 Review of the Electronic Medical Record (EMR) revealed R54 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease. Review of R54's Incident and Accident reports revealed the following incident dated 11/20/24 and read, in part, Resident sitting on dining room chair. She had slid onto the floor. Assessed for injury. No c/o (complaint of) pain .Care plan updated to have Dycem nonslip mat in her wheelchair and dinning room chair . On 5/2/25 at 9:45 a.m. an observation was made of the dining room in the Memory Care Unit which R54 resides. R54 was observed coming out of her room after receiving care from Certified Nurse Aide (CNA) D and was wheeled into the dining room. R54 did not appear to have Dycem underneath her in the wheelchair. An interview was conducted with CNA D who stated that she…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-15 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an injury of unknown origin (right hip fracture) to the State Agency (SA) for one Resident (R1) of three residents reviewed for abuse. Findings include: Review of R1's Electronic Medical Record (EMR) revealed admission to the facility on 8/23/24 with a discharge date of 9/8/24 to an acute care hospital. R1's diagnoses included Rhabdomyolysis (break down of skeletal muscles, history of falls, and muscle weakness. R1's 8/29/24 Brief Interview for Mental Status (BIMS) score was 15, indicating she was cognitively intact. Review of R1's History and Physical from [Hospital Name] dated 9/8/24 read, in part, .Assessment/Plan: Patient had CT (compute tomography) scan of lumbar spines and pelvis without contrast .there is equivocal nondisplaced fracture line through right femoral neck . An interview was conducted with the Nursing Home Administrator (NHA), Interim Director of Nursing (DON) and Unit Manager/Registered Nurse A on 10/14/24 at 1130 a.m. who…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-15 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 conduct a thorough investigation for an injury of unknown origin (right hip fracture) for one Resident (R1) of three residents reviewed for abuse. Findings include: Review of R1's History and Physical from [Hospital Name] dated 9/8/24 read, in part, .Assessment/Plan: Patient had CT (compute tomography) scan of lumbar spines and pelvis without contrast .there is equivocal nondisplaced fracture line through right femoral neck . An interview was conducted with the Nursing Home Administrator (NHA), Interim Director of Nursing (DON) and Unit Manager/Registered Nurse A on 10/14/24 at 1130 a.m. who stated that R1 was admitted to the facility on [DATE] from the hospital after a fall from home. The hospital had conducted an x-ray and found no fractures, so R1 was admitted to the facility. When the facility was notified of R1 having a right hip fracture on 9/8/24, the hospital notes stated that it could have been from the fall prior to admission. An internal…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-26 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 relates to Intake #MI00145188. Based on observation, interview, and record review, the facility failed to ensure dignified care was provided for one Resident (R1) of seven residents reviewed for dignity. This deficient practice resulted in an undignified care interaction for R1. Findings include: Review of the FRI (Facility Reported Incident) received by the State Agency (S.A.) revealed on 6/11/24 at approximately 8:30 p.m., R1 was observed by Registered Nurse (RN) B in the doorway assisting a resident to return to the secured memory care unit. At that time, R1 was attempting to exit the unit through the same door. Another nurse, RN A, told R1 she needed to stay on the unit and she had her hands over her ears. RN B reportedly observed RN A use a door-knocking gesture on R1's forearm to get her attention so she would not leave the unit. R1 did not sustain an injury per the skin assessment after the incident. The report showed an interview after the incident with RN A revealed they moved their hand…

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

    Resident Rights Deficiencies · Past Non-Compliance
Show the remaining 14 citations
  • Potential for harm · F2024-03-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in a food borne illness among any and all 58 residents. Findings include: On 3/18/24 at approximately 10:30 AM, a bag of food was observed in the upright refrigerator in the kitchen. The bag was from a local fast food restaurant and labeled with a resident's name. An interview with conducted with Kitchen Manager (KM) A at this time and it was learned the bag was brought into the facility by the resident's family member, accepted by kitchen staff and stored in the refrigerator. The bag contained breakfast sandwiches according to KM A. It was further learned this is a common event in which the food is brought into the kitchen then heated in the kitchen microwave oven. KM A acknowledged the food was not supposed to be stored in the kitchen due to the potential contamination brought in from an unknown source. A review of the policy Use and Storage of food…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-20 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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 ensure the right to privacy for four Residents (R10, R11, R34, and R37) related to intrusive wandering behaviors of one Resident (R14), of five residents reviewed for privacy. This deficient practice resulted in feelings of frustration from violations of privacy and ongoing, intrusive wandering behaviors for R14. Findings include: Review of R14's MDS assessment, dated 11/8/23, revealed R14 admitted to the facility on [DATE], with diagnoses including dementia and depression. R14 was independent with transfers and walking and required moderate assistance with toileting. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 0/15, indicating R14 had severe cognitive impairment. The behavioral assessment showed R14 had verbal behaviors directed at others and wandering behaviors daily. During an observation on 3/18/24 at 2:03 p.m., R14 was observed exiting a male resident's room on the unit with another female resident,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-20 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure expired medications and loose pills were disposed of properly in two of four medication storage carts reviewed for medication storage. Findings include: On 3/18/24 at 4:27 PM, an inspection of the medication cart for A-hall was conducted for medication storage and was found to have the following expired medications: a.) nystatin topical power 30 grams with lot number 402336 and expiration date of 06/2023, and lacked an open date was dispensed on 1/17/2022 b.) cyclosporine ophthalmic emulsion single use eye drops solution 0.05% with lot number 393113 and expiration date of December 2023 On 3/18/24 at 4:35 PM, an interview was conducted with Registered Nurse (RN) L and confirmed that expired medications should not be left in the cart. On 3/18/24 at 4:40 PM, an inspection of the medication cart for C-hall was conducted for medication storage and was found to have the following loose medications: The third drawer had 7 loose pills, of which two were identified as baclofen 5 mg and sucralfate 1 gm. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to provide emergency tracheostomy care for one Resident (Resident #263) of three residents review for respiratory care. This deficient practice had the potential for respiratory distress and anxiety for Resident #263. Findings include: Resident #263 (R263) On 3/18/24 at 11:18 AM, an interview was conducted with R263 in his room. R263 was observed to have a tracheostomy and a urinary catheter. R263 stated he just got to the facility three days ago. On 3/18/24 at 11:20 AM, an observation was made of R263's room. The room contained a suction unit, inner tracheostomy cannulas (disposable tube inserted into tracheostomy) and an empty tracheostomy box with no other emergency replacement tracheostomy in his room in case of accidental tracheostomy tube dislodgement. R263 was asked if he had a replacement tracheostomy for such emergencies and replied, The nurse just replaced it today because when she was suctioning me earlier, she thought it was plugged. On 3/18/24 at 1:40 PM, an interview was conducted with Registered…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-20 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure competent and knowledgeable staff regarding laboratory services provided to facility residents and free from expired blood collection tubes reviewed for competent nursing staff. Findings include: On 3/18/24 at 11:00 AM, an observation was made of the education room where a portable lab cart was stored. The portable lab cart was observed to have the following blood collection tubes: a.) Four tall purple top blood collection tubes with lot number B22063W and expiration date of 12/1/23 b.) Seven short purple top blood collection tubes with lot number B2211346 and expiration date of 3/2/24 c.) Four light blue top blood collection tubes with lot number B221136X and expiration date of 11/1/23 d.) Four pink top blood collection tubes with lot number 2227139 and expiration date of 1/31/24 e.) One light green top blood collection tube with lot number 1228169 and expiration date of 8/31/22 f.) Three dark green top blood collection tubes with lot number B2209359 and expiration date of 1/1/24 g.) Four gray top…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-12-20 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 post accurate staffing information for Certified Nurse Aides (CNA) directly responsible for resident care per shift. This deficient practice had the potential to affect all 57 residents in the facility and resulted in the potential inability of residents and visitors to determine the number of staff available to provide resident care. Findings include: On 12/20/23 at 10:00 a.m., the Nursing Home Administrator (NHA) was questioned regarding the location of the posting for staffing information. The NHA indicated the information was posted near the nurses' station on B Hall. The posting was a form labeled, Daily Staffing for Wednesday December 20, 2023 and was reviewed with the NHA present. The form had a column for shift time, a column for census, a column for Certified Nurse Aids (CNA), a column for Licensed Practical Nurses (LPNs), and a column for Registered Nurses (RNs). Each column was separated by rows indicating shift times. A review of day shift times for CNAs, for which there were 3 rows, indicated…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-04-03 · tag F0680 — widespread
    Ensure the activities program is directed by a qualified professional.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Activities Director had minimum qualifications to perform the duties of the position effectively for one Resident #19, and had the potential to affect the entire facility resident population. This deficient practice resulted in delayed care planning development, inadequate activities documentation, insufficient individualized activities, lack of monitoring, and the potential to cause feelings of depression, isolation, and boredom. Findings include: On 3/30/23 at 10:10 a.m., the facility was asked to provide evidence that Activities Director B was qualified to be an Activities Director. A review of Activity Director Bs employment application dated 7/21/22 revealed she was employed as an Activities Associate at some type of health center from February 2013 through May 2018. In this section was written I began as a housekeeper and worked my way up to Activities Associate . This did not indicate how many years she was a housekeeper and how many…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-04-03 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    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 a qualified nutrition professional was employed to ensure quality of nutrition and hydration care with the potential to effect all residents residing in the facility. This deficient practice resulted in a lack of oversight of nutrition and hydration and the potential for significant weight loss and dehydration. Findings include: Resident #66 (R66): A review of R66's medical record revealed she admitted to the facility on [DATE] with diagnoses including quadriplegic cerebral palsy, dysphagia, hx (history) of sepsis, and dementia. A review of R66's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed she scored 6/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderately impaired cognition. This assessment also showed she required limited assistance of one staff for eating. A review of a 1/10/23 Dietary Progress note by former Registered Dietitian (RD) H revealed, Weight Warning. Value: 118.8 (pounds)…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-03 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 provide care to maintain one resident's (Resident #19) dignity, out of 16 residents reviewed for dignity. This deficient practice resulted in R19 being told she needed to wait to go to the bathroom resulting in feelings of frustration and incontinence. Findings include: Resident #19: On 3/28/23 at 11:49 a.m., R19 was observed in her chair in her room with her meal tray on an overbed table in front of her. R19 was tilted left in the chair and was observed with water all over the floor around her. Certified Nurse Aide (CNA) F was observed going into R19's room and was heard stating to R19, We've made a mess, didn't we? to which R19 responded, I'm sorry. On 3/28/23 at approximately 12:04 p.m., Licensed Practical Nurse (LPN) A was observed going into R19's room. LPN A was heard stating to R19, There are several people waiting to eat. What can I do for you? R19 stated to LPN A' that she needed to go to the bathroom. LPN A stated to R19, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-03 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 thoroughly investigate a bruise of unknown origin for one resident (Resident #54) of two residents reviewed for abuse. This deficient practice resulted in the potential for undetected abuse and subsequent sustained abuse to occur. Findings include: Resident #54: On 3/28/23 at 10:16 a.m., during an interview, Resident #54 stated she had a sore spot on her left side. Registered Nurse (RN) M confirmed Resident #54 has a bruise on her left chest wall and axilla area. RN M indicated the area appeared dark purple/black. When asked when this incident occurred, RN M stated charting for the area started on 3/26/23. On 3/28/23 at 10:20 a.m., Resident #58, who was her roommate, stated Resident #54 got in a fist fight with a nurse. On 3/28/23 at 10:22 a.m., during a follow-up interview, Resident #54 stated she did not feel scared of anyone, but could not tell this Surveyor what happened. Resident #54 stated she should probably get it checked out but it feels like it might be broken. Resident #54 was referring to 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-03 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 meaningful activities for one resident (Resident #19) out of one resident reviewed for activities. This deficient practice resulted in a lack of meaningful activities and the potential for increased behaviors and symptoms of depression. Findings include: Resident #19: Observation of R19 from 3/28/23 through 3/30/23 revealed the following: On 3/28/23 at 9:00 a.m., R19 was in her room with the door closed. On 3/28/23 at 11:49 a.m., R19 was observed alone in her room in a geri chair with her meal in front of her and water spilled around her on the floor. On 3/28/23 at 12:10 p.m., R19 was in her room with the door closed. On 3/29/23 at 12:16 p.m., R19's door was closed. Upon knocking an unidentified staff stated, patient care. On 3/29/23 at 12:34 p.m., R19 was observed sitting in her chair in her room. Certified Nurse Aide (CNA) X was outside the room and reported that R19 had finished eating already and had eaten about 50% of her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide oxygen services per standards of practice, facility policy, and per physician's orders for two residents (Resident #8, Resident #220) of two residents reviewed for oxygen services. This deficient practice resulted in the potential to result in hypoxia [below-normal level of blood oxygen], respiratory/medical decline, and the development of respiratory infections. Findings include: Resident #220: R #220 was admitted to the facility on [DATE] with diagnoses including: acute respiratory failure, chronic obstructive pulmonary disease, and pneumonia. Review of R #220's 3/25/23 Minimum Data Set (MDS) assessment revealed a score of 15/15 on the Brief Interview for Mental Status (BIMS) score indicating he was cognitively intact. In Section O of the 3/25/23 MDS R #220 was marked as receiving oxygen therapy treatments. On 3/29/23 at 12:00 p.m. R #220 was observed in the main dining room waiting for his lunch meal. R #220 was coughing 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-03 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assure the continuum of care for pain-related concerns for one resident (Resident #2) of two residents reviewed for pain. This deficient practice resulted in the potential delay in treatment and subsequent potential relief of pain. Findings include: Resident #2: During an interview on 3/28/23 at 11:44 a.m., Resident #2 stated he was told by someone a pain pump was going to be looked into because he had a failed right hip surgery. Resident #2 stated he has struggled with pain since the surgical procedure. Resident #2 stated he had a bout of excruciating pain when he was on a Leave of Absence (LOA) to a local restaurant and had to be transported to the hospital about a month ago. A review of progress notes for Resident #2 revealed the following: 3/3/2023 23:00 [11:00 p.m.] Nurses' Notes Note Text: Resident [#2] stated that he went out to pay a bill, found out that he did not have a bill to pay so he went to [Local Restaurant]. Resident [#2]…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-03-20 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to develop and implement a Water Management Plan in a manner that reduced the risk of Legionella transmission through the potable water system potentially affecting all 58 residents. Findings include: On 3/18/24 a review of the facility's water management plan (WMP) was conducted, along with data sheets provided. The following was missing from the WMP: 1. A procedure to follow in collecting data (disinfectant residual) for the potable water supply. 2. What Corrective action would be implemented related to critical limits failing to be attained. 3. Evidence the data was reviewed to ensure adherence to the WMP. A review of the Monthly Water Assessment form, used by the facility to document water disinfectant residuals reported a critical limit of 0.7 PPM (parts per million) for free available chlorine (FAC). Nine reported tests recorded for January, February and March 2024 were all reported as 0.07 PPM, a factor of ten below the targeted critical limit. On 3/18/24 at approximately 1:30 PM, an interview 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to 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 →

RatingThis homeChain avg
Overall 4 of 53.1+0.9 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 5 of 54.0+1.0 vs chain
The other 52 homes this chain runs (chain average 3.1★, per CMS)
1 of 5Medilodge of FarmingtonFarmington, MI 1 of 5Medilodge of Grand BlancGrand Blanc, MI 1 of 5Medilodge of Grand RapidsGrand Rapids, MI 1 of 5Medilodge of HowellHowell, MI 1 of 5Medilodge of MarshallMarshall, MI 1 of 5Medilodge of Montrose IncMontrose, MI 1 of 5Medilodge of MunisingMunising, MI 1 of 5Medilodge of Sault Ste. MarieSault Ste. Marie, MI 1 of 5Medilodge of SouthfieldSouthfield, MI 1 of 5Medilodge of WestwoodKalamazoo, MI 2 of 5Medilodge at the ShoreGrand Haven, MI 2 of 5Medilodge of Capital AreaLansing, MI 2 of 5Medilodge of CheboyganCheboygan, MI 2 of 5Medilodge of East LansingEast Lansing, MI 2 of 5Medilodge of FrankenmuthFrankenmuth, MI 2 of 5Medilodge of GTCTraverse City, MI 2 of 5Medilodge of KalamazooKalamazoo, MI 2 of 5Medilodge of LudingtonLudington, MI 2 of 5Medilodge of St. ClairEast China, MI 2 of 5Medilodge of Sterling HeightsSterling Heights, MI 2 of 5Medilodge of West BloomfieldWest Bloomfield, MI 3 of 5Medilodge of Campus AreaEast Lansing, MI 3 of 5Medilodge of HillmanHillman, MI 3 of 5Medilodge of LivingstonHowell, MI 3 of 5Medilodge of LivoniaLivonia, MI 3 of 5Medilodge of Mt. PleasantMt. Pleasant, MI 3 of 5Medilodge of PortagePortage, MI 3 of 5Medilodge of ShorelineSterling Heights, MI 3 of 5Medilodge of Tawas CityTawas City, MI 3 of 5Medilodge of TaylorTaylor, MI 3 of 5Medilodge of ZeelandZeeland, MI 3 of 5The Lodge at TaylorTaylor, MI 4 of 5Medilodge of GaylordGaylord, MI 4 of 5Medilodge of HollandHolland, MI 4 of 5Medilodge of LansingLansing, MI 4 of 5Medilodge of LeelanauSuttons Bay, MI 4 of 5Medilodge of MilfordMilford, MI 4 of 5Medilodge of OkemosOkemos, MI 4 of 5Medilodge of RichmondRichmond, MI 5 of 5Medilodge of AlpenaAlpena, MI

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 / managerTypeRoleShareSince
EVEREST OPCO GROUP LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 02/01/2018
B&Y HEALTHCARE S CORPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/01/2018
B&Y TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/01/2018
CODY HEALTHCARE S CORPOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/01/2018
CRAIG FLASHNER 2007 TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/01/2018
NORCROSS, ROBERTIndividualCONTRACTED MANAGING EMPLOYEEsince 02/01/2018
ROGERS, STACEYIndividualCONTRACTED MANAGING EMPLOYEEsince 02/01/2018
KIRK, KRISTINEIndividualW-2 MANAGING EMPLOYEEsince 02/01/2018
FLASHNER, CRAIGIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2018
PERLSTEIN, YITZCHOKIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2018
BLOSSOM HEALTHCARE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 02/01/2018
PRESTIGE ADMINISTRATIVE SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 02/01/2018

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.

$8.1M
Net patient revenuemost recent cost report
-3.5%
Operating marginrevenue minus expenses
$408K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 7%Other / private 26%

This home reported $408K 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

$364per resident / day
operating cost
$11,075per month
≈ monthly operating cost
$352per day
avg. revenue, all payers

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

What families pay in MI

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235336. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-02, 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.

What to do next