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The Villa at City Center

11700 East Ten Mile Road, Warren, MI 48089 · For profit - Corporation · 152 certified beds · (586) 759-5960 Medicare & Medicaid certified

Call the home — (586) 759-5960 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
$8,454 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
Worth asking about
  • 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
  • the CMS record shows $8,454 in federal fines (most recent 2023-11-20)

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 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Urgent care / clinic
5700 E 11 Mile Rd · (586) 393-1364 · Call to confirm hours
Pharmacy
26834 Lawrence · (586) 757-2755 · Call to confirm hours
Grocery
26310 Van Dyke Ave · (313) 742-5315 · Call to confirm hours
Park
25300 Sherwood Ave · (586) 757-7417 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 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 2 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 weight3.7%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.3%0.8%0.9%better
Long-stay residents with a urinary tract infection0.2%1.5%2.0%better
Long-stay residents with depressive symptoms7.9%4.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.1%3.0%3.3%better
Long-stay residents whose ability to walk worsened10.8%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.9%19.4%18.9%typical
Long-stay residents given the seasonal flu vaccine96.9%95.0%95.3%typical
Long-stay residents with pressure ulcers3.6%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control16.7%20.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table23.5%14.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.2%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine81.9%79.5%79.4%typical
Short-stay residents rehospitalized after admission35.1%24.0%22.6%worse
Short-stay residents with an outpatient ER visit9.8%11.7%12.0%better

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

46.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 100 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.7%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
52.5%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 52.5% 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 59 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 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF46.7%CMS range 37.6–55.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 8.6–14.810.7%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 discharge52.5%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 discharge32.2%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 discharge45.8%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 identified94.5%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 setting92.3%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 discharge91.7%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 stay0.9%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 worsened1.8%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 hospitalization6.7%CMS range 3.9–11.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.081.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.29
RN hours/ resident / day
1.28
LPN hours/ resident / day
2.07
Aide hours/ resident / day
3.64
Total nurse hours/ resident / day
0.18
RN hoursweekends
33.1%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 152 beds and averages 139.2 residents a day — about 92% occupied, or roughly 13 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 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.19 hrs/resident/day on weekends vs 3.82 on weekdays — 17% thinner on weekends. RN hours go from 0.33 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 33% is below 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

5
deficiencies at the latest standard inspection (2026-03-12)
4
at the previous standard inspection (2025-01-08)

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.

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 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · D2026-06-10 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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

    This citation pertains to Intake 3024714. Based on interview and record review, the facility failed to ensure the resident's medications were available to administer per physician's orders for one resident (R901) of one reviewed for pharmacy services. Findings include:A review of a complaint called into the State Agency revealed the resident's (R901) seizure medication ran out and had to be reordered resulting in missed doses. A review of R901's medical record revealed they were admitted into the facility on 4/6/26 and discharged on 5/26/26 with diagnoses of Unspecified Convulsions. Further review revealed the resident was cognitively intact and required assistance with activities of daily living.Review of the medical record revealed the resident had the following physician's order dated, 4/29/26 to 5/27/26, Lacosamide (an anticonvulsive medication used to treat seizures) Oral Tablet 200 MG (milligrams) Give 1 tablet by mouth two times a day for convulsions.Review of R901's May Medication Administration Record (MAR) revealed the resident was not administered the Lacosamide on the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-12 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely submit a MDS (Minimum Data Set) assessment for five residents (R8, R30, R39, R88, R97) of nine residents reviewed for resident assessment. Findings Include:R8A record review revealed the MDS discharge assessment was 120 days overdue. Further review of the medical record noted R8 was admitted to the facility on [DATE]. R8 was discharged on 10/26/25. A review of the Minimum Data Set (MDS) assessment did not reveal a discharge MDS having been submitted. R30A record review revealed R30 was admitted to the facility on [DATE]. R30 was discharged on 12/7/25. A discharge MDS was not submitted.R39A record review revealed R39 was admitted to the facility on [DATE]. R39 was discharged on 12/7/25. A MDS was not submitted.R88A record review revealed R88 was admitted to the facility on [DATE]. R88 was discharged on 12/13/25. A MDS was not submitted.R97On 3/11/26, a record review revealed R97 was admitted to the facility on [DATE]. R97 was discharged on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-12 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan for one (R5) of six residents reviewed for baseline care plans. Findings include:A review of the record revealed R5 was admitted to the facility on [DATE] with relevant diagnoses of Intracerebral hemorrhage, Congestive Heart Failure, Benign Prostatic Hyperplasia and Urinary Retention. R5 was admitted with an indwelling urinary catheter and was on Enhanced Barrier Precautions (EBP). Further review of the Minimum Data Set Assessment (MDS) revealed R5 had a Brief Interview for Mental Status score of 13/15 indicating no cognitive impairment. Further review revealed R5 required partial/moderate assistance for upper body activities and substantial/maximum assistance for lower body activities including bathing and transfers. A review of the medical record revealed a baseline care plan that did not include the use of the indwelling catheter, infection control, activities of daily living, mobility or the level of assistance…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-12 · 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 implement post fall interventions for one resident (R145) of three whose falls were reviewed. Findings include: On 03/10/2026 at 9:52 AM, R145 was observed to be off balance as they walked up the hallway from the nurse station. R145 approached the surveyor and commented they felt dizzy and reported they felt like they were drunk but had not been drinking. R145 then began to turn around and as R145 turned around to their right they fell toward the handrail. R145 caught themself on the handrail. Licensed Practical Nurse (LPN) L noticed walked up and took R145 by the hand. They walked back toward the resident's room and R145 was observed to be on their knees in the intersection of the hallways by the nurse station holding onto the nurses' hand. At that time two additional staff walked up to LPN L and R145 with a wheelchair and the staff assisted R145 up and to their room. At 1:25 PM, R145 was seen walking out of another resident's room. At…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-12 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    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 follow through on physician recommendations following a change in condition for one (R5) of three residents reviewed for laboratory services. Findings include: A review of a progress note dated 3/9/26 revealed R5 experienced a change in mental status (disorganized thinking) during a Physical Therapy (PT) treatment session and was returned to his room and Medical Doctor (MD) K was called. A progress note dated 3/9/26, revealed MD K was notified of the change in mental status for R5, and recommended a Complete Blood Count (CBC) and Urinalysis (UA). Review of the physician orders did not reveal an order or results for the CBC or UA. A review of the record revealed R5 was admitted to the facility on [DATE] with relevant diagnoses of Intracerebral hemorrhage, Congestive Heart Failure, Urinary Retention. R5 was admitted with a urinary catheter. Further review of the record revealed R5 had a Brief Interview for Mental Status score of 13/15 indicating no…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-12 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident food preferences were honored for four residents (R32, R44, R65, R146), three anonymous residents, and three anonymous resident council group residents from a census of 137. Findings include: On 03/10/2026 at 9:05 AM, an anonymous resident reported the food was not grade A and was processed and overall did not care for it too much. The resident further reported dinner was the one to mostly come up cold. On 03/10/2026 at 9:23 AM, a second anonymous resident reported the food was good and bad but did not elaborate. On 03/10/2026 at 12:23 PM, the rice for R32 was served without gravy. R32 was asked if they received a regular or alternative menu and reported they did not but it would be good to have one. R32 reported the food for lunch was not hot and less than room temperature when served. LPN L was asked about the chance of getting gravy for the rice. LPN L reported that it was hit and miss on getting the kitchen on the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-01-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 1/6/25 between 9:00 AM-9:30 AM, during an initial tour of the kitchen with Certified Dietary Manager (CDM) E, the following items were observed: At the hand washing sink near the dish machine room, there was no hand washing signage, no paper towels, and no liner in the trash can. CDM E confirmed the lack of signage, towels and liner. According to the 2017 FDA Food Code section 6-301.12 Hand Drying Provision, Each handwashing sink or group of adjacent handwashing sinks shall be provided with: (A) Individual, disposable towels;. According to the 2017 FDA Food Code section 6-301.14 Handwashing Signage, A sign or poster that notifies food employees to wash their hands shall be provided at all handwashing sinks used by food employees and shall be clearly visible to food employees.…

    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 before2025-01-08 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure meals were served at a preferred and palatable temperature for one resident (R80) and four of eight confidential group residents reviewed for food palatability. Findings include On 01/06/25 at 10:02 AM, R80 was observed in room watching television. When asked about concern, R80 stated the food was often cold at meals. R80 stated the sausage for breakfast that morning was cold. On 01/07/25 at 09:30 AM, R80 was observed eating breakfast in the room. When asked about the meal, R80 stated it was cool but better than the previous day. On 1/07/25 at 2:00 PM, a confidential group meeting was conducted with a group of eight facility residents. The group members were asked about food palatability at the facility and four of the eight group residents indicated the food was frequently cold when it was served to them. On 1/08/25 at 12:50 PM, a lunch tray from second floor East food cart and tested by the Dietary Supervisor. The lunch tray foods tested as follows: Half of a baked potato-110.7 Degrees Fahrenheit,…

    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 · D2025-01-08 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 complete assessments to determine need for bed rails for one resident (R24) of one residents reviewed for bed rails. On 1/06/25 at 9:12 AM, R24 was observed lying in bed watching television with bilateral bed rails up on each side of the bed. On 1/07/25 at 11:07 AM, R24 was observed laying in bed with the bilateral bed rails up on each side of the bed. R24 was asked why there were rails on the bed and R24 shrugged shoulders and stated they keep me safe. A review of R24 medical record revealed R24 was admitted on [DATE] with multiple diagnosies including muscle weakness, type II diabetes mellitus with diabetic peripheral angiopathy with gangrene, and artherosclerosis of native arteries of extremities with gangrene right leg. A review of R24's Minimum Data Set (MDS) assessment dated on 10/2/2024 revealed a Brief Interview of Mental status (BIMS) assessment of 06 indicating moderate cognitive impairment. Further review of R24's medical…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-08 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure medications and supplies were discarded when expired in two of two medication carts and one of one medication storage room. Findings include: On 1/07/25 at 8:44 AM, a review of the medication cart on the low side of two east unit with Licensed Practical Nurse (LPN) B revealed an expired bottle of cranberry supplement with an open date of 10/23. On 1/07/25 at 9:00 AM, a review of the medication cart on the high side of the two west unit with LPN C revealed a bottle of aspirin with an expiration date of 9/5/24. On 1/8/25 at 9:30 AM, a review of the medication storage room on the two west unit with LPN D revealed an expired tube of Silvadene cream dated 2022 and an IV (intravenous) start kit with an expiration date of 5/23. On 01/08/25 at 11:44 AM, the Director of Nursing (DON) explained pharmacy staff is supposed to come monthly to stock items and throw out expired meds. The DON also explained the nursing staff should check the medication carts weekly for expired medications. A review of the facility's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Dcited before2024-08-15 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00146289. Based on interview and record review, the facility failed to ensure the resident's responsible party was informed of skin changes for one resident (R901) of three residents reviewed for skin management. Findings include: A review of the skin observation dated 06/18/24 at 1926 (7:26 PM) documented, Does the resident have any new skin issues? The yes box was checked. The form identified the right buttock as an open area and the left as excoriation (rash like area of skin disruption). Measurements for the areas were not included or documented. The observation and related progress note did not indicate the responsible party was notified. A review of the progress note for R901 dated 06/20/24 by Wound Care Nurse, Licensed Practical Nurse (LPN) A revealed, Writer alerted by (midnight) MN (certified nursing assistant) CNA regarding new skin impairment observed during (activities of daily living) ADL care. It was noted that the resident has a new skin impairment observed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00146289. Based on observation, interview, and record review, the facility failed reposition a dependent resident while in bed for one resident (R902) of three reviewed for skin management resulting in the re-opening of a sacral wound. Findings include. On 08/14/24 at 8:45 AM, 10:50 AM, 11:10 AM, R902 was observed to be on their back in bed. The arms were to the sides and the legs were crossed at the feet. Large puffy green boots which covered the foot and ankle were in place on both feet. R902 was dressed in a hospital style gown and the head of the bed was up around 45-60 degrees. No pillow, wedge or other device was observed to off load pressure from the back and buttocks area. At 1:15 PM, a staff member was observed standing at the left side of the bed assisting R902 to eat. The head of the bed was up 45-60 degrees, with R902 on their back in bed without any offload devices at the sides. At 3:44 PM, the head of the bed was lower around 30-45 degrees and R902 was on their…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-31 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This citation pertains to Intake MI00141837. Based on interview and record review, the facility failed to hold a medication per physician order for one resident (R700) out of one reviewed for physician orders. Findings include: A review of the medical record revealed that R700 admitted into the facility on 3/27/2022 with the following diagnoses, Dysphagia and Weakness. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 10/15 indicating an impaired cognition. R700 also was also dependent for transfers and bed mobility. A review of the progress notes revealed the following, Date:12/31/2023 at 15:27 PM (3:27 PM) .Upon doing wound care resident sacral wound started to bleed. Writer applied pressure and it stopped and then started again upon doing patient care but this time there was a significant amount of bright red blood noted coming from wound. Pressure has been applied and there has been no blood noted since. [Physician] has been informed and [they] ordered to hold Eliquis (anticoagulant) for 48 hours and if bleeding was to continue 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-10-25 · 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 maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 10/23/23 between 8:50 AM-9:20 AM, during an initial tour of the kitchen with Corporate Consultant D, the following items were observed. In the reach-in cooler, there was a pan of vanilla pudding with a use by date of 10/16. Corporate Consultant D stated they would discard the outdated pudding. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a 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 · E2023-10-25 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY R31 A review of R31's progress notes, revealed Medication Regimen Reviews (MMR's) dated 8/17/23, 9/19/23 see report. A review of R31's medical record revealed, R31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Cerebral infraction. A review of R31's Minimum Data Set (MDS) assessment dated [DATE] noted, R31 with an impaired cognition and required extensive assistance from one staff person for activities of daily living (ADLs). A review of the two pharmacist's recommendations dated, 8/17/23 and 9/19/23 both revealed the following: [R31] has an order for lisinopril 10 mg (milligram) daily and has had either high normal or above high normal serum potassium levels in the past several months. Please consider if lisinopril can be withheld or discontinued and will continue to monitor serum potassium. Further review of the recommendation in which the physician is to respond was blank regarding whether they agreed, disagreed, or other, and there was no signature noted. Based on interview…

    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 · D2023-10-25 · 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 pertains to Intakes MI00138808 and M100139419. Based on observation, interview and record review, the facility failed to ensure that one (R8) of seven residents reviewed was treated with dignity, resulting in the resident experiencing feelings of depression and hopelessness regarding their potential for improved independence and increased socialization. Findings Include: Review of the facility record for R8 revealed an admission date of 02/28/23 with diagnoses that included Multiple Sclerosis, Paraplegia, Major Depressive Disorder and Stage IV (full thickness skin and tissue loss with exposed dermis, adipose (fat) tissue and various underlying structures) Sacral Pressure Ulcer. The Minimum Data Set (MDS) assessment dated [DATE] indicated R8 required primarily Total/Maximum level assistance for transfers, mobility and bathing/dressing. The Brief Interview for Mental Status (BIMS) assessment score of 14/15 indicated intact cognition. On 10/23/23 at 11:03 AM, during initial resident screening R8…

    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 · D2023-10-25 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    This citation pertains to Intake MI00138776. Based on interview and record review, the facility failed to conduct quarterly care conferences for one resident (R67) out of one reviewed for care planning, resulting in the guardian not being involved in the plan of care. Findings Include: A review of Intake MI00138776 revealed the following, As [R67] legal guardian and [family member], I am the first point of contact, and I was not notified of any health concerns [R67] was having . A review of the medical record revealed that R67 readmitted into the facility on 1/7/2023 with the following diagnoses, Dysphagia and Alzheimer's Disease. Further review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating that R67 was unable to complete the assessment. R67 also required extensive two person assist with transfers and limited one person assist with bed mobility. Further review of the medical record did not reveal any care conference notes and none were provided by end of survey. On 10/25/2023 at 11:07 AM, an interview was conducted 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-25 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake: MI00140274. Based on interview and record review, the facility failed to operationalize policies and procedures by notifying the resident's representative and physician of a fall in a timely manner for one resident (R387) of one reviewed for notification resulting in, the resident's representative and physician being unaware, and the inability to participate and make medical decisions regarding care and treatment. Findings include: A review of R387's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Cerebral Infarction, Hypertension, Dysphagia and Dementia. Further review of R387's medical record revealed that they were severely cognitively impaired, and required extensive to total dependence on staff for Activities of Daily Living. A review of R387's medical record revealed the following late entry progress notes entered on 10/12/23 from a fall that occurred on 10/5/23: 10/5/2023 23:00 (11:00pm) SBAR (situation background,…

    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 · D2023-10-25 · tag F0626 — isolated
    Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
    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 readmit or document reason for readmission to the facility following a hospitalization, for one sampled resident (R187) of three residents reviewed for hospitalization, resulting in dissatisfaction in care and a transfer to another facility. Findings include: On 10/23/23 at 9:38 AM, during initial tour R187 was interviewed and stated, I am happy to be back here. They said I couldn't come back when I was in the hospital. R187 further explained that they went out to the hospital and was not allowed to return to this facility. R187 was not sure what happened but was told by the hospital that they had a Covid outbreak. R187 explained that when it was time for discharge from the hospital the facility did not allow them to come back to their bed and was transferred to a sister facility. R187 was asked when this happened and stated, about 3 weeks ago. A review of R187's medical record revealed, R187 was admitted to the facility on [DATE] and readmitted on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement care planned interventions for two residents (R11 and R9) out of four reviewed for care plans, resulting in the increased potential for accidents, hazards and unmet care needs. Findings Include: R11 On 10/24/2023 at 9:00 AM, R11 was observed eating breakfast. R11's ticket noted that they were supposed to have a disposable set-up. R11 was observed with a regular plate and silverware. On 10/24/2023 at 12:29 PM, R11 was observed eating lunch with a regular plate and silverware. A review of the medical record revealed that R11 admitted into the facility on 1/4/2022 with the following diagnoses, Cerebral Infarction and Dysphagia. Further review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 6/15 indicating impaired cognition. R11 also required one-to-two-person extensive assistance with bed mobility and transfers. Further review of the care plan revealed the following, Focus: I am at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes MI00138808 and MI00140274. This citation has two deficient practice statements. Based on observation, interview, and record review, the facility failed to provide 1:1 feeding assistance for two resident (R11 and 81) out of three reviewed for meal assistance, resulting in the potential for aspiration and inadequate food intake. Findings Include: R11 On 10/24/2023 at 9:00 AM, R11 was observed eating breakfast. R11's meal ticket noted 1:1 assistance in red and bolded. R11 was observed sitting up, eating breakfast without staff assistance. On 10/24/2023 at 12:29 PM, R11 was observed eating lunch without staff assistance. A review of the medical record revealed that R11 admitted into the facility on 1/4/2022 with the following diagnoses, Cerebral Infarction and Dysphagia. Further review of the Minimum Data Set assessment (MDS) revealed a Brief Interview for Mental Status score of 6/15 indicating impaired cognition. R11 also required one-to-two-person extensive assistance with bed…

    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 · D2023-10-25 · 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

    Based on observation, interview, and record review, the facility failed to provide meaningful activities for one resident (R31) of two resident reviewed for activities, resulting in a lack of meaningful activities and increased symptoms of depression. Findings include: R31 On 10/23/23 at 9:44 AM, R31 was observed lying in bed dressed in a hospital gown and with their television on. R31 was asked about the stay at the facility and stated, I'm depressed. R31 was asked, if they were on medication to treat their depression and stated, Yes. R31 was asked if they got out of bed and participated in activities and stated, I think that would help. It has helped before. R31 was not observed out of their room or with any activities in their room on this day. On 10/24/23 at 8:11 AM, R31 was observed lying in bed dressed in a hospital gown and with their television on. R31 was not observed out of their room or with any activities in their room. R31 was asked if they had been cleaned up by staff and stated, No. On 10/24/23 at 12:39 PM, R31 was observed lying in bed dressed in a hospital gown 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 · D2023-10-25 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 splints/braces were applied for one resident (R31) of two residents reviewed for positioning/mobility resulting in the potential for decreased range of motion (ROM). Findings include: R31 On 10/23/23 at 9:44 AM, R31 was observed lying in bed dressed in a hospital gown and with their hands contracted. R31's left hand nails were observed to turned into the palm of R31's hand. On 10/24/23 at 8:11 AM, R31 was observed lying in bed dressed in a hospital gown and with their hands contracted. R31 was not observed with hand splints, braces, or hand carrot in their hands. On 10/24/23 at 12:39 PM, R31 was observed in the same condition as observed previously. R31 was asked if they had been cleaned up and if staff offered to get them out of bed. R31 stated, No. On 10/24/23 at 12:46 PM, R31's hand carrot and brace were observed in the night stand draw. The hand carrot was observed to be dirty with a white substance in color on it. On 10/24/23 at…

    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 · D2023-10-25 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    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 routine dental services, for one resident (R31) of three reviewed for dental care, resulting in the potential for further oral health decline. Findings include: On 10/23/23 at 9:41 AM, R31 was observed in their room lying in bed. R31's teeth were observed to be discolored and in disrepair. R31 was asked if they had seen a dentist at the facility and stated, No. On 10/24/23 at 1:01 PM, Social Service (SS A) was asked about R31's dental care and when was the last time R31 was seen by the Dentist. SS A reviewed their documents and stated, May 8, 2023, was a visit that was canceled because the resident was sick and in isolation. SS A continued and explained that the Dentist is scheduled to come out on October 31st and that she would add R31 to the list. SS A was asked the type of appointment was on the 8th and stated, A general evaluation. SS A was asked if R31 had any dental visits prior to May 8th, SS A stated, I don't see any other…

    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 before2023-10-25 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to serve food in a palatable manner and at the preferred temperature for two residents (R46 and R81) and seven confidential group residents of fifteen residents reviewed for food palatability, resulting in dissatisfaction during meals. Findings include: R46 On 10/23/23 at 10:05 AM, R46 reported the food is always cold or just not good. A review of R46's medical record noted, R46 was admitted to the facility on [DATE] and readmitted [DATE] with diagnosis of Acute Posthemorrhagic Anemia. A review of Minimum Data Set (MDS) assessment noted, an intact cognition and that R46 required extensive assistance to complete activities of daily living. R81 On 10/24/23 at 8:43 AM, R81 was observed in bed laying with their back towards the wall, along the wall was their over bed table with a breakfast tray on it. The delivery time was unknown. R81 was unable to be interviewed due to cognitive impairment. On 10/24/23 at 8:49 AM, the tray remained on the over…

    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 · D2023-10-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain tube feeding pole and a nebulizer mask in a sanitary manner, for one resident (R70) of one, resulting in the potential for contamination of equipment and cross contamination. Findings include: On 10/23/23 at 9:06 AM, R70 was observed lying in bed. R70 was asked about care at the facility and did not report any complaints. Observed in R70's room was a tube feeding pole and machine that displayed the words feed error. The tube feed formula bottle was observed to be empty. A review of R70's care plan noted, Focus: The resident requires tube feeding r/t (related to) dysphagia. Date Initiated: 08/19/2023. Goal: The resident will remain free of side effects or complications related to tube feeding through review date. Date Initiated: 08/19/2023. Interventions: Monitor/document/report as needed any s/sx (signs or symptoms of: aspiration, fever, SOB (shortness of breath), tube dislodged, infection at tube site, self extubation, tube…

    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

$8,454 in federal fines across 5 penalties.

  • $2,117 — penalty dated 2023-11-20
  • $1,764 — penalty dated 2023-11-13
  • $1,411 — penalty dated 2023-11-06
  • $1,764 — penalty dated 2023-10-30
  • $1,398 — penalty dated 2023-10-10

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.

Part of a chain

This home belongs to VILLA HEALTHCARE — 18 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 52.8+1.2 vs chain
Health inspection 4 of 52.3+1.7 vs chain
Staffing 3 of 52.7+0.3 vs chain
Quality measures 4 of 54.5-0.5 vs chain
The other 17 homes this chain runs (chain average 2.8★, per CMS)

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
OMNIA OPCO HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2023
AARON, JONATHANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2023
BAUMOL, YEHOSHUAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2023
GRAF, MARCELLAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2023
OWUSU-ANSAH, KWADWOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/15/2023
SINGERMAN, JOSEPHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2023
BERGER, MENACHEMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/11/2025
ISRAEL, BENJAMINIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/22/2025
KROLL, GABRIELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/22/2025
NAGEL, STEVENIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/22/2025
STERN, TODDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/22/2025

CMS files one row per role, so the 14 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$17.3M
Net patient revenuemost recent cost report
-7.2%
Operating marginrevenue minus expenses
$3.0M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 66%Medicare 6%Other / private 29%

This home reported $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$369per resident / day
operating cost
$11,218per month
≈ monthly operating cost
$344per 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 235325. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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