Orchard Creek Skilled Nursing
9731 East Cherry Bend Road, Traverse City, MI 49684 · For profit - Corporation · 22 certified beds · (231) 932-9272 Medicare only — no Medicaid
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 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 fell from 5 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.2% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 17.7% | 24.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 3.7% | 11.7% | 12.0% | better |
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.
70.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 139 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 78.4% 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 51 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 0.81 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 70.6%CMS range 63.8–77.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.3%CMS range 6.5–14.5 | 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 | 78.4% | 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 | 70.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 68.6% | 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 | 100.0% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.8%CMS range 4.5–13.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.84 | 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 22 beds and averages 17.9 residents a day — about 81% occupied, or roughly 4 beds typically open. It usually has some room. 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 5.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.21 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.60 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.82 hrs/resident/day on weekends vs 6.12 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.22 to 1.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
19 citations, most serious first. The 12 most serious are shown; the remaining 7 are one tap away and print in full.
- Actual harm · G2025-09-04 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from neglect by facility staff for one Resident (#4) of one residents reviewed for abuse and neglect. This deficient practice resulted in actual harm when Resident #4 experienced unnecessary pain and persistent feelings of fear and anxiety.Findings include:Resident #4 (R4) Review of R4's Electronic Medical Record (EMR) revealed initial admission to the facility on 8/13/25 with diagnoses including congestive heart failure, difficulty in walking, and pain in right shoulder. Review of R4's most recent Minimum Data Set (MDS) assessment, dated 8/25/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. On 9/2/2025 at 12:22 PM, an interview was conducted with R4 regarding their satisfaction with the level of care they were receiving at the facility. R4 stated a couple nights ago she needed to use the restroom while in bed, so a certified nursing assistant (CNA) placed 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.
- Actual harm · G2023-10-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00137609. Based on interview and record review, the facility failed to prevent a fall for one Resident (#18) of one resident reviewed, resulting in Resident #18 falling with staff present and sustaining multiple fractures requiring hospitalization and surgery. Findings include: Resident #18 (R18) Review of a Post Fall/Incident Note dated 4/8/2023 revealed R18 fell in the bathroom while the Certified Nursing Assistant (CNA) was with her. The note revealed [Patient] washed her hand, turned to get towel, and lost balance. fell on left side of face and body. Injuries included laceration on left eyebrow, bleeding around scab on left elbow, and bruising lateral side of left calf. The note revealed R18 was transferred to the hospital. The note also revealed resident should be CGA (Contact Guard Assist). Review of the hospital's History and Physical dated 4/8/23 revealed Patient states she was up with a 1 handed walker going to the restroom with assistance. Upon completion, she went 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 · F2025-09-04 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being of residents. Findings include: On 9/3/25 at approximately 11:30 a.m. an interview was conducted with Certified Nurse Aides (CNA) J and K in regard to complaints of low staffing numbers. CNAs J and K confirmed that during shift change, residents can wait 30 to 45 minutes after report for staff to come and assist. CNA K stated, Sometimes it can be up to 45 minutes before we are out on the floor and then we have to get people up, get them dressed, toilet, vitals, breakfast, etc. When there are only two of us, it can be a challenge, and they (residents) have to wait a long time. Both CNA J and K confirmed that the current population of residents is requiring more lifts and two person transfers, which causes them both to tend to one resident at a time. CNA J stated, We don't have enough (staff), with the high number of residents who need two staff assistance, it isn't…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-09-04 · 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by:Failing to label, date, and discard expired food in the reach-in refrigerator, walk-in refrigerator, walk-in freezer, and dry storage. Failing to ensure kitchen utensils were stored in a sanitary manner.Failing to ensure the ice cube machine/bin was free from mold accumulation.These deficient practices have the potential to result in food borne illness among any or all of the 17 residents in the facility.Findings include: On 9/2/25 at 11:24 PM, an initial tour of the kitchen was conducted with Dietary Manager (DM) G. The following observations were made in the reach-in refrigerator: Undated, unidentifiable meat in a plastic tub covered with plastic wrap. DM G identified this as sliced steak from the previous day's lunch meal. A bowl of what appeared to be cooked onion rings, covered with plastic wrap, undated. A bowl of cubed pineapple, covered in plastic wrap, undated. Two bagels in an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-09-04 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to annually review and update the required Facility Assessment, resulting in the potential for unidentified resources necessary to provide care and services to the resident population.Findings include: Review of the Facility Assessment document provided by the facility revealed the Facility Assessment was last completed, updated, or reviewed on 8/6/24.In an interview on 9/4/25 at approximately 11:30 AM, the Nursing Home Administrator (NHA) confirmed that the Facility Assessment had not been completed, updated, or reviewed since 8/6/24.
- Potential for harm · D2025-09-04 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to obtain complete and comprehensive informed consents prior to the administration of psychotropic medications for three Residents (#4, #17, and #20) of five residents reviewed for unnecessary medications.Findings include:Resident #17 (R17)Review of R17's electronic medical record (EMR) revealed initial admission to the facility on 7/1/25 with diagnoses including cerebral infarction (stroke) and vascular dementia. Review of R17's most recent Minimum Data Set (MDS) assessment, dated 7/15/25, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicative of severe cognitive impairment.Review of R17's EMR revealed the following pharmacy order, initiated 7/1/25: Duloxetine HCl Oral Capsule Delayed Release Particles 60 MG (milligram) [an antidepressant (psychotropic) medication], Give 1 capsule by mouth two times a day for depression/pain.Review of R17's EMR revealed a document titled, Consent for Psychoactive Medications which read, in part: The resident's provider has ordered the following psychoactive medications.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assure that procedures were developed and implemented for consistent and accurate processing of medication orders for two Residents (#8 and #15) of six residents reviewed for pharmacy services. This deficiency resulted in Resident #8 being administered the incorrect dosage of an anxiolytic medication and the potential for the inaccurate administration of an anticoagulant for Resident #15. Findings include: Resident #8 (R8)Review of the Minimum Data Set (MDS) assessment, dated 3/24/2025, revealed R8 was admitted to the facility on [DATE] and had diagnoses including coronary artery disease, chronic obstructive respiratory disease (COPD) and anxiety.Review of R8's March 2025 medication administration record (MAR) revealed the following orders: Ativan (a controlled medication used to treat anxiety) Oral Tablet 1 MG [milligram] . Give 4 tablet[s] by mouth every 4 hours for anxiety. Start Date: 3/19/2025 1800 [6:00 PM]. D/C [discontinued] Date: 3/20/2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assure the implementation of Enhanced Barrier Precautions (EBP) according to physician order and current standards of practice for two Residents (#10 and #18) of four residents reviewed for EBP utilization.Findings include:Resident #10 (R10)Review of the Minimum Data Set (MDS) assessment, dated 9/8/2025, revealed R10 was admitted to the facility on [DATE] and had diagnoses including left femur fracture, breast cancer and anxiety. Further review of the MDS assessment revealed R10 required substantial/maximal assistance with bathing, lower body dressing and transfers, and partial/moderate assistance with toileting hygiene.Review of R10's electronic medical record revealed R10 had a Stage 2 (partial-thickness tissue loss) pressure injury to her spine. Review of R10's Wound Evaluation, dated 8/31/2025, revealed the pressure injury measured 0.67 centimeters (cm) in length and 0.51 cm in width. Review of the photograph attached to the Wound…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-04 · tag F0943 — isolatedGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to maintain an effective abuse training program for two out of five staff members reviewed for new hires and annual training. Findings include:A review of staff education records and competencies on 9/4/25 revealed the following staff members had not completed the required abuse, neglect and exploitation training:Certified Nurse Aide (CNA) E - Hired on 7/16/25 and had not completed abuse training prior to start date.CNA F - Hired on 8/21/23 with last completed abuse training on 6/26/24.An interview conducted with the Director of Nursing (DON) on 9/4/25 at approximately 10:30 a.m. confirmed staff abuse training had not been completed per the facilities policy.Review of the facility's Abuse, Neglect, Misappropriation or Exploitation Policy/Procedure, undated, read, in part, .employees will receive training regarding abuse, neglect, exploitation, misappropriation of property, or mistreatment during new employee orientation and on an annual basis.
- Potential for harm · D2024-10-02 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a consent was signed for psychoactive medication use and an AIMS (Abnormal Involuntary Movement Scale) assessment was completed appropriately for one Resident (R12) of five residents reviewed for unnecessary medications. This deficient practice resulted in the potential for the unnecessary use of mind-altering medications, negative side-effects of medications and decreased quality of life. Findings include: Review of R12's Electronic Medical Record (EMR) revealed admission to the facility on 9/16/24 with diagnosis including dementia with behaviors, delirium, and anxiety. Review of R12's 9/23/24 admission Minimum Data Set (MDS) assessment revealed a 10/15 on the Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. R12 was noted in Section N of the MDS assessment to be taking an antipsychotic medication on a routine basis only. An interview was conducted with Registered Nurse (RN) F on 10/2/24 at 9:52 a.m. RN F confirmed R12 was currently receiving an antipsychotic medication. A…
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 · F2023-10-25 · tag F0578 — failed to honor advance directives / code status — widespreadHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure accurate advance directive information was in place for three Residents (R6, R9, and R10) of three Residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings Include: Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 (Revised 3-25-14), revealed, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two witnesses [AGE] years of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-10-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure proper label and dating of foods with the potential to effect 7 of 8 residents (1 resident receives nothing by mouth) resulting in the increased risk of food borne illness. Findings include: During an inspection of a refrigerator located in the resident dining room on 10/23/2023 at 11:41 AM, the following was observed: Opened container of Thick and Easy clear Hydrolyte Thickened Water, no opened date Opened package of cheddar cheese cubes, no opened date Two containers of coffee creamer, no opened date Opened 20 ounce Diet Pepsi, no opened date Two loaf of white bread, No opened or use by date An observation on of a sign displayed on the face of the refrigerator in the dining room revealed all items in this refrigerators must be sealed/covered, labeled and dated or they will be discarded. Items may only be kept for a maximum of three days . In an interview on 10/25/23 at 9:02 AM, Dietary Manager C stated items were discarded after three days so the expectation would be to label the item when opened with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 7 citations
- Potential for harm · D2023-10-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report an allegation of visitor to resident verbal abuse to the State Agency for one Resident (#6) of one resident reviewed, resulting in an allegation of abuse that was unreported to the State Agency and the potential for further abuse allegations to go unreported. Findings include: Resident #6 (R6) Review of the medical record revealed R6 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included anxiety. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/26/23 revealed R6 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R6 had an activated power of attorney in place. Review of the Health Status Note dated 10/4/2023 and written by Director of Nursing (DON) B revealed I was notified by the charge nurse that the resident's son [name redacted] was yelling and swearing at the resident in his room. I approached him…
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 · D2023-10-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to investigate an allegation of visitor to resident verbal abuse for one Resident (#6) of one resident reviewed, resulting in an allegation of abuse that was not investigated and the potential for further abuse to occur. Findings include: Resident #6 (R6) Review of the medical record revealed R6 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included anxiety. The Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/26/23 revealed R6 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R6 had an activated power of attorney in place. Review of the Health Status Note dated 10/4/2023 and written by Director of Nursing (DON) B revealed I was notified by the charge nurse that the resident's son [name redacted] was yelling and swearing at the resident in his room. I approached him and instructed him to leave 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 · D2023-10-25 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement comprehensive care plans for 2 Residents ( #5 & #12) of 7 residents reviewed resulting in the potential for unmet care needs. Resident #5 (R5) Review of the medical record revealed R5 was admitted to the facility on [DATE] with diagnoses that included type two diabetes with unspecified complications, Covid 19 and anemia in chronic kidney disease. The Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 10/13/23 revealed R5 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). In an observation and interview on 10/23/23 at 9:23 AM, R5 was seated in her room watching television. R5 reported she had recently contracted coronavirus so she was unable to attend outside community service appointments, but was able to attend her dialysis appointments which were scheduled for Mondays, Wednesday, and Friday. Review of the Care Plan revealed R5 had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-25 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to assist residents/representatives to engage/participate in the care planning process, including attendance at care planning conferences with facility Interdiciplinary Team(IDT) for one Resident (R10), of seven residents reviewed, resulting in the liklihood of unmet care needs and delay in discharge planning. Findings: Review of the facility, Care Planning - Interdisciplinary Team Policy, dated 8/31/22, reflected, The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident ' s care plan .Care plan meetings will be held as needed and every effort will be made to schedule care plan meetings at the best time of the day for the resident and family . Resident #10 (R10) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R10 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted to the facility on [DATE] and 10/17/23 related to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: (1.) prevent Urinary Tract Infections (UTI's); (2.) failed to follow up with urology appointment; and (3.) provided catheter care per CDC standards of practice for one Resident (#10) of one resident reviewed for catheters and UTI's, resulting in the likelihood of signs and symptoms of catheter complications going unnoticed, catheter dislodgment, missed urology follow up appointment, and catheter associated urinary tract infection with hospitalization and prolonged illness. Findings include: Resident #10 (R10) Review of the Face Sheet and Minimum Data Set (MDS) assessment dated [DATE], reflected R10 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted to the facility on [DATE] and 10/17/23 related to acute urinary tract infections and inflammatory reaction due to indwelling urethral catheter, with other diagnoses that included recent fall with fracture left hip, urinary retention, macular degeneration, respiratory…
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.
- No harm found · C2023-10-25 · tag F0607 — failed to have anti-abuse policies — widespreadDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop an abuse policy consistent with current regulatory language for reporting allegations of abuse to the State Agency, resulting in the potential for allegations of abuse to not be reported timely to the State Agency for all eight facility residents. Findings include: Review of the facility's undated Abuse, Neglect, Misappropriation, or Exploitation Policy/Procedure revealed 1. When an alleged or suspected incident of abuse, neglect, misappropriation of resident property, and exploitation, the facility Administrator, or his/her designee, will notify the following persons or agencies of such incident. a. The facility Medical Director b. The resident's responsible party c. The State licensing agency responsible for surveying/licensing the facility . Reporting time line requirements: Within 2 hours of receiving an allegation of abuse or forming suspicion of abuse if there is serious bodily injury. Within 24 hours of receiving an allegation of abuse or forming suspicion of abuse if there is not serious bodily injury .…
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.
- No harm found · Ccited before2023-10-25 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to annually review and update the facility-wide assessment to address the resident population, acuity, staffing levels, physical environment and risk assessment which had the potential to affect all 8 residents residing at the facility. This deficient practice resulted in the increased likelihood for insufficient resources to provide for resident care and emergency/disaster needs. Findings include: On 10/23/23 at 9:33 AM, during the entrance conference for the annual survey, a copy of the Facility Assessment was requested. NHA A reported the current census was 8 related to a recent COVID-19 outbreak. Review of the facility's assessment, failed to reveal the following: 1). Evaluation of all contracts, memorandums of understanding including third party agreements for the provision of goods, services, or equipment to the facility during both normal operations and emergencies. 2). Staff competencies details that were necessary to provide for the level and types of care needed for the resident population. 3). An evaluation of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2025-10-02 for 8 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ORCHARD CREEK HEALTH CARE INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/21/1997 |
| MEYER, RICHARD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 07/21/1997 |
| CHILCOTE, DALE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/11/2011 |
1 organizational owner 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 $342K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Michigan Medicaid page for homes that do.
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 235611. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-04, 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.