Windemere Park Health and Rehabilitation Center
31800 Van Dyke Avenue, Warren, MI 48093 · For profit - Individual · 92 certified beds · (586) 722-2600 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Oct 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (68%) runs well above the national median (45%)
- about 19% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.9% | 10.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.8% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.4% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.5% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.8% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 34.4% | 12.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 28.3% | 19.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 76.7% | 95.0% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 2.6% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 32.7% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.4% | 14.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.3% | 1.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 69.4% | 79.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 32.1% | 24.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.0% | 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.
50.7% 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 68 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.5% 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 26 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 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% 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 | 50.7%CMS range 38.8–63.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 6.9–15.9 | 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 | 61.5% | 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 | 61.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 76.9% | 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 | 72.7% | 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 | 95.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.1%CMS range 3.4–13.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.92 | 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 92 beds and averages 57.1 residents a day — about 62% occupied, or roughly 35 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.80 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 3.39 hrs/resident/day on weekends vs 3.96 on weekdays — 14% thinner on weekends. RN hours go from 0.53 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 68% is well above 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 fewer than at the previous inspection — improving. 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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · D2026-06-11 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake number 3003145. Based on observation, interview, and record review, the facility failed to maintain resident's right to privacy for five residents (R6, R5, and anonymous resident (AR B) of five reviewed for privacy. Findings include: R6 A review of an Intake called into the State Agency revealed, Complainant states for the past several months resident [R6] has been wandering in and out of [R13's] and other residents' rooms and taking their personal belongings . [R6] took [R13's] roommate [R4's] dentures twice, [R6] took an unknown (resident's) . bible, [R6] steals food from residents' trays and other items. The complainant states [R6] will also get into other residents' beds when they aren't in their rooms .residents have complained to nursing staff and they said nothing can be done because the resident [R6] has dementia. Complainant states staff make excuses for [R6] and said [R6] has the right to wander. The complainant states [R6] is allowed to violate [other residents] .…
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 · D2026-04-07 · 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
This citation pertains to intake 2800927:Based on observation, interview, and record review, the facility failed to implement fall care plan interventions for one resident (R902) of three residents reviewed for falls. Findings include:Review of a concern called into the State Agency documented concerns pertaining to R902's bed height, mechanical functioning of the bed, and the facility's management of the resident's risk for falls.Review of the facility record for R902 revealed a most recent admission date of 01/15/26 with pertinent diagnoses including Dementia and Muscle Weakness. The Brief Interview for Mental Status (BIMS) dated 02/02/26 indicated moderate cognitive impairment. The baseline care plan dated 01/16/26 revealed a fall risk reduction focus area that included the interventions Bed in lowest position when occupied (initiated 01/16/26) and Bilateral fall mats on floor when in bed (initiated 01/28/26 in response to a fall from the bed).On 04/07/26 at 11:15 AM, R902 was observed in bed. The bed was positioned with the mattress surface at a height of approximately three…
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 · D2026-02-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to Intake number 2716304.Based on interview and record review, the facility failed to provide scheduled showers for one resident (R700) of four residents reviewed for Activities of Daily Living (ADL's). Findings include: A review of a complaint allegation called into the state agency alleged, .the resident isn't provided with appropriate showers since admission.On 2/18/26 at 10:25 AM, a review of R700's Electronic Health Record (EHR) documented the resident was admitted into the facility on 1/07/26 with diagnoses that included congestive heart failure and emphysema. A review of R700's shower schedule noted, Bathing: Tuesday and Friday.A review of R700's shower record for the last 30 days revealed R700 received showers or bed bath on the following days, Thursday 1/8/26; Tuesday 1/13/26; Monday 1/19/26; and 1/26/26 (missing 3 showers).On 2/18/2026 at 2:00 PM, the Nursing Home Administrator (NHA) was asked about R700's missing showers and stated they were aware of the concern and reviewed the charting for documentation of refusals. NHA confirmed there were…
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 · F2025-04-30 · tag F0813 — widespreadHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store resident food items in accordance with professional standards for food service safety. This deficient practice had the potential to result in food borne illness among all 49 residents that potentially store food in the resident refrigerators. Findings include: On 4/28/25 at 10:20 AM, the 4th floor resident refrigerator was observed with Certified Dietary Manager (CDM) B. There were 4 expired cartons of milk, an undated deli sandwich, an undated brown bag lunch, 2 undated bowls of cooked oatmeal, an undated bowl of chili, and a moldy container of raspberries. On 4/28/25 at 10:30 AM, the 5th floor resident refrigerator was observed with CDM B. There was an undated foam container with chicken and rice. When queried, CDM B stated that nursing staff was responsible for ensuring the food items in the resident refrigerators were dated and discarded when expired. Review of the facility's policy Foods Brought by Family/Visitors revised October 2017 noted: 7. Food brought by family/visitors that is left with 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 · D2025-04-30 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (R35) of two residents reviewed for altered diet consistency, received the prescribed therapeutic diet. Findings include: On 4/28/25 at 01:02 PM, R35's spouse was observed feeding R35 a pureed textured main course foods. Also on the tray was regular textured fruit cocktail in a covered container. On 4/29/25 at 12:33 PM, an observation was made of Certified Nursing Assistant (CNA) A taking R35's tray into room to assist R35 with feeding. The main dish was pureed and there was a cup of regular textured pineapple chunks in a covered dish. There was also a half peanut butter and jelly sandwich. A review of the Electronic Medical Record (EMR) revealed R35 was most recently admitted on [DATE] with pertinent diagnoses of Alzheimer's Disease and Dysphagia (difficulty swallowing). Further review of the EMR revealed R35 has a Brief Interview for Mental Status (BIMS) score of 99 indicating R35 is rarely/never understood. Further…
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 · D2025-04-30 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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 call light accessibility for one (R13) of seven residents reviewed for call light accessibility. Findings include: Review of the facility record for R13 revealed an admission date of 04/12/24 with diagnoses including History of Falls and Chronic Heel Ulcers. R13's Brief Interview for Mental Status (BIMS) score of 10/15 indicated Moderate cognitive impairment. On 04/28/25 at 2:15 PM, R13 was observed laying in bed. The call light was observed on the floor under the bed out of the resident's reach. The resident was alert and able to communicate in a functional manner. Further review of R13's record revealed the Care Plan Focus area statement I have alteration in Activities of Daily Living self-care function related to dependence on staff for care needs and weakness associated with medical condition. This focus area included the Intervention item Call light to be kept in reach. Provide prompt response to requests for assistance. On 04/30/25 at 10:46 AM, R13 was interviewed in their room. The call light…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-01 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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: MI00147215. Based on observation, interview, and record review the facility failed to prevent incidents of misappropriation of narcotic pain medication for three residents (R604, R605, R606) of five residents reviewed for misappropriation of property. Findings include: A review of the Facility Reported Incident revealed the following, Incident Summary: Missing Medication: Lorazepam (Anti-anxiety) 0.5 MG (milligrams) 30 Tabs (tablets). On September 16, 2024 at approximately 8:45am [Licensed Practical Nurse (LPN) F], removed 5 controlled substances from her medication cart and handed off to [Director of Nursing (DON)] for destruction. At approximately 9:15(am), the pack of Lorazepam 0.5 MG 30 Tabs was missing from the DON's possession. During the investigation, the information did not line up. The Director of Nursing has been suspended pending investigation . On 10/1/24 at 10:04 AM, an interview was completed with LPN F via phone, and was asked about the day they provided…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-01 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to Intake: MI00147215 Based on interview and record review, the facility failed to report and investigate an allegation of misappropriation of narcotic medicaitons to the State Agency for two residents, (R605 and R606) of five residents reviewed for misappropriation of property. Findings include: On 10/1/24 at 10:42 AM, an interview was completed with Regeistered Nurse (RN) G regarding the Director of Nursing (DON) handling of medications that needed to be destroyed. RN G explained on 9/6/24, the DON stood at the nurses' station with a white container that is used to destroy medications along with a bag of narcotics. The nurse said the DON began punching medications out of blister packets onto the desk at the nurses' station making it difficult to identify what packet the medications were coming from. RN G explained they were able to organize and count the medications, they identified that 17 Hydrocodone pills were missing for R605 and R606. RN G said the DON had a new Licensed Practical Nurse (LPN) I sign documents presented to them by the DON regarding the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00145241. Based on interview and record review, the facility failed to schedule a follow up appointment for one resident (R701) of three reveiwed for quality of care. Findings include: A review of the intake allegation noted, [They] has been in the facility for approx (approximately). 2.5 wks (weeks). Staff were supposed to schedule [their] a follow-up appt. (appointment) with [their] cancer doctor, which hasn't been done. [They] . supposed to have a CAT scan (CT-Computed tomography is a noninvasive medical examination or procedure that uses specialized X-ray equipment to produce cross-sectional images of the body)w (with)/contrast done of [their] left lobe . A review of R701's medical record noted, R701 was admitted to the facility on [DATE] and readmitted [DATE] and then discharged on 7/5/24. A review of R701's admission Minimum Data Set (MDS) dated [DATE], revealed R701 with an intact cognition, used a walker, and required some assistance with activities of daily living.…
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 · F2024-04-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to clean and maintain food service equipment and maintain sanitary kitchen practices effecting 45 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 04/02/24 at 12:40 P.M., An environmental tour of the 5th Floor Dining Room was conducted by this surveyor. The following items were noted: The stainless steel non-insulated transport cart steering handles were observed bent and curved. 1 of 2 handles were also observed covered with black electrical tape. The worn and fragmented black electrical tape was also observed heavily soiled with accumulated and encrusted food residue. The ice and water dispensing machine (chutes) were observed heavily soiled with accumulated and encrusted mineral (lime and calcium) deposits. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT…
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 15 citations
- Potential for harm · Fcited before2024-04-04 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure all elements of the facility infection control program (ICP) were implemented and documented potentially affecting all 45 residents of the facility. Findings include: On 04/03/24 at 3:07 PM, a review of the infection control program was initiated with the Infection Control Preventionist Nurse. The ICP reported they had started in their role for the facility in Novembers of 2023. A review of the elements included a monthly summary of facility infections, the facility acquired rate of infection, the line list of resident infection, mapping the location of resident infections, documentation of the use of McGreer's Criteria, radiology reports, labs for culture and sensitivity for antibiotic use, a pharmacy report on the antibiotic use by the facility, staff education on infection control processes, and correlation of staff and resident illness. On 04/04/24 at 7:54 AM, a review of the documented elements was conducted. -January 2023 had a line list and mapping no other elements were included. -February 2023 had a line…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-04 · tag F0756 — failed to review each resident's drug regimen — patternEnsure 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 Based on observation, interview and record review, the facility failed to ensure the Pharmacy Consultant Medication Regimen reviews were completed monthly for five residents (R12, R10, R13, R17, and R19) of five residents reviewed for pharmaceutical services. Findings include: R12 On 04/02/24 at 4:03 PM, R12 was observed to be seated in their wheelchair on the right side of their bed. R12 reported itching to their arms back and legs. R12 had visible scabs to the arms with loose gauze dressings hanging from the arms. The record indicated R12 had complained of itching since 02/29/24 and had been seen by the nurse practitioner (NP). The medical team had prescribed Bactrim (antibiotic), Ivermectin (anti-parasite), Tramcinolone Cream (anti-inflammatory) and Prednisone (anti-inflammatory) since that time. R12 had 20 or more active medication orders. A review of the medical record documented the last Pharmacy Consultant Review was on 06/27/23. This report indicated to see the report for noted irregularities. A review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-04 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to clean and maintain the physical plant effecting 45 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and reduced air quality. Findings include: On 04/03/24 at 09:36 A.M., Record review of the Maintenance Work Orders generated for the last 90 days revealed no specific entries related to the documented maintenance concerns. On 04/03/24 at 09:50 A.M., An environmental tour of the facility Laundry Service was conducted with Director of Maintenance A. The following item was noted: Laundry Room: The flooring surface was observed missing numerous 12-inch-wide by 12-inch-long vinyl tiles. The damaged flooring surface measured approximately 10-feet-wide by 24-feet-long. The damaged flooring surface was also observed extremely moist, due to excessive water exposure from the washing machine discharge pipes. On 04/03/24 at 10:08 A.M., An environmental tour of the facility Central Supply 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.
- Potential for harm · D2024-04-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe environment for one resident (R1) of two residents reviewed for homelike environment. Findings include: On 04/02/24 at 10:54 AM, R1 was observed lying in bed in their room watching television. A large hole was noted in the wall behind the residents bed. The hole was approximately 12 inches long and was deep enough to see the wire in the wall from a plug nearby. Streaks of plaster was coming out of wall. R1 was asked about the hole and stated I didn't do it. It was there before I got here. It needs to be fixed. On 04/03/24 at 1:15 PM, R1 was observed sitting in wheelchair in the room watching television. The large hole with visible wiring remained the same. 04/04/24 01:40 PM, R1 was observed sitting in wheelchair in the room watching television. The large hole with visible wiring remained the same. Record review revealed that R1 was admitted on [DATE] with the following medical diagnoses of Schizophrenia, Hypertension, Open…
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 · F2023-01-11 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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 — the official record, unedited, 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 insulin pens were dated or discarded when expired in one of three medications care reviewed, resulting in the potential for decreased efficacy of the medication. Findings include: On [DATE] at 10:15 AM, a review of the medications in cart one on the fourth floor was conducted with Nurse H. A Novolog pen was open and not dated. A second Novolog pen for the same resident was dated [DATE]. Nurse H reported the resident had moved to the fifth floor and the pen would be discarded as it was past 30 days. A Humalog insulin pen was also open and not dated. According to Medscape (professional medical website, www.medscape.com) insulin should be stored opened no longer than 28 days at room temperature for insulin aspart (Novolog, Humalog) .
- Potential for harm · F2023-01-11 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure a sufficient number of dietary staff, resulting in resident meals being served with plastic utensils, disposable dishware, and disposable foam drinking cups, affecting all residents that eat meals from the kitchen, resulting in the potential for dissatisfaction with the dining experience. Findings include: On 1/9/23 at 8:35 AM, during an initial tour of the of the facility it was observed that all of the residents were being served their breakfast in disposable containers, with plastic utensils and Styrofoam cups. On 1/10/23 at 8:20 AM, Dietary Manager (DM) A was interviewed about the use of disposable dishes, plastic utensils, and foam cups when serving meals to residents and stated, We don't have enough kitchen staff. On 1/10/22 at 10:15 AM, a review of resident council meeting minute documentation revealed that during the months of August 2022 and September 2022, group residents indicated that the plastic knifes did not cut the ham being served to them. On 1/11/23 at 3:07 PM, Kitchen staff/Cook B was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-01-11 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
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 the Quality Assurance and Performance Improvement (QAPI) meetings were effective and identified ongoing deficiencies, resulting in the decreased over sight of facility staffing practices and ongoing use of disposable services items for resident's meals. Findings include: On 01/11/23 at 11:08 AM, The QAPI program was reviewed with the Administrator. It was reported that that Administrator had been in their role about two years. Some items identified as concerns during the survey were reported and included cold food, kitchen staffing and the use of disposable dishes and utensils. The Administrator reported QAPI was to promote positive change, growth and development of the facility, staff and residents. The Administrator further noted the difficulty to maintain staff in the management roles such as the Director of Nursing and Minimum Data Set (MDS) Assessment and a genrally high staff turnover rate. An ongoing issue during the Administrators tenure has been the use of disposable plastic utensils and foam service items…
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 · F2023-01-11 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
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 the Medical Director or their designee attended the Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly, resulting in the and or the potential for decreased over sight of facility infection control practices, medical coordination and resident care. Findings include: On 01/11/23 at 11:08 AM, The QAPI program was reviewed with the facility Administrator. Aong with the Administrator, a review of the QAPI meetings since the last recertfication survey revealed: A March 2022 meeting; A June 2022 meeting; A July 2022 meeting; A September 2022 meeting; An October 2022 meeting; A November 2022 meeting and a December 2022 meeting. The Medical Director nor a designee was documented as having attended a QAPI meeting in the last four months of 2022. The Administrator acknowledged that the Medical Director does have assigned residents at the facility and would reach out to the physician to attend the meetings. The Administrator also confirmed recent positive COVID cases for staff and residents. 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 · Fcited before2023-01-11 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has three deficient practices. Deficient Practice Statement #1. Based on interview and record review, the facility failed to implement an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the 48 residents in the facility. Findings include: On 1/9/23 at 10:00 AM, the building water management plan was requested from the Administrator. On 1/9/23 at 1:00 PM, the plan had not yet been provided, and the Administrator was again queried regarding the building water management plan. The Administrator stated she thought the information had been provided, and stated she would get that information right away. On 1/9/23 at 1:30 PM, the Administrator provide a binder with documentation of water testing for legionella, which had last been completed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-01-11 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide food at a palatable temperature for four (R20, R12, R30, and R8) of 16 sampled residents resulting in dissatisfaction with meals and the potential for decreased quality of life and inadequate nutritional intake. Findings include: Review of the facility record for R20 revealed an admission date of 12/16/22 with diagnoses which included Pneumonia and Acute Respiratory Failure. Minimum Data Set (MDS) dated [DATE] indicated R20 required setup assistance for eating. R20 was observed to be consistently alert and oriented to person, place and time and Brief Interview of Mental Status score (BIMS) was15 which indicated intact cognition. On 1/09/23 at 8:50 AM, R20 was observed to have eaten very little of their breakfast. R20 reported that the food is always cold. The breakfast was observed to be served in a disposable foam container. On 1/09/23 at 1:23 PM, R20 was observed to have lunch in a diposable foam container. R20 reported that 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 · D2023-01-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of 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 upon observation, interview and record review the facility failed to maintain call lights within resident reach for three (R250, R21, and R27) of 16 sampled residents resulting in the potential for residents not being able to request or receive assistance in a timely manner and the potential for unmet care needs. Findings include: On 1/09/23 at 9:16 AM, R250 was observed sitting at the edge of the bed with the head reclined in a position that left R250 leaning to the right against the head of the bed. R250's call light was under the pillow in a position that it could not be reached. R250 was quietly calling help me, help me, I'm hungry as the breakfast container was out of reach from R250's position. On 1/10/23 at 1:46 PM, R250 was observed sitting up in bed eating lunch. The call light was on the nightstand out of reach of the resident. On 1/11/23 at 9:31 AM, R250 was observed sitting up in the wheelchair eating breakfast. The call light was on the nightstand out of reach of the resident. On 1/11/23 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.
- Potential for harm · D2023-01-11 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 provide documentation of a resident or resident representative bed hold for one resident (R45) of one resident reviewed for hospitalizations, resulting in the potential for denial of readmission or the unexpected incurrence of financial liability. Findings include: On 1/10/23 at 11:31 AM, a record review of R45's electronic medical record (EMR) revealed the following progress note dated 11/12/22 at 1:52 AM: Resident transferred to [Hospital] via stretcher @ (at)1:48 am with 4 EMS [Emergency Medical Staff] personnel for change of condition. DON [Director of Nursing] notified & guardian notified by voicemail. Resident sent with med list & face-sheet. On 1/10/23 at 11:40 AM, a further review of R45's EMR revealed that a bed hold policy/notification was not documented as provided/offered to the resident or resident representative when R45 was sent to the hospital. On 1/10/23 at 11:45 AM, continued review of R45's EMR revealed that R45 was admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-11 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide care and services according to facility policy and standards of clinical practice, by not 1) supervising medications left at the bedside, 2) ensuring physicians were notified of medications held, and 3) offering mouth rinse after use of a steroid inhaler for one resident (R14) of six residents observed during medication pass, resulting in the potential for resident not to received recommended doses of medications and physician unaware of changes in resident care needs. Findings include: On 01/11/23 at 7:59 AM, a medication pass observation was conducted with Licensed Practical Nurse (LPN) E for R14. The medication pass revealed the following: -R14's blood pressure (BP) documented as 112/59 (systolic/diastolic) and a heart rate (HR) of 75. -Blood pressure medications ordered to be administered were: Amlodipine 10 mg (milligrams), Toprol XL(extended release) 25 mg (hold systolic [BP] less than 100, hr less than 55) one time a day;…
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 · D2023-01-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Resident's who were prescribed psychotropic medication had adequate indication for use, and had adequate documentation to justify use beyond 14 days for PRN (as needed) medication for two residents (R21, R248) of five reviewed for unnecessary medications, resulting in the potential for decreased oversight for psychotropic use, decreased use of non-pharmacological interventions, inappropriate use and unnecessary medication. Findings include: A review of the record for R21 revealed, R21 was admitted into the facility on [DATE] and readmitted on [DATE]. Diagnoses included Dementia Without Behavioral Disturbance (dated 03/29/22), Alzheimer's (dated 04/04/20) and Delusional Disorder (dated 03/15/21). The Minimum Data Set assessment dated [DATE] indicated severely impaired cognition and the need for extensive assistance of one person for bed mobility, transfer, dressing and personal hygiene. R21 triggered for delusions. A review of the physician orders…
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 · D2023-01-11 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5% when an incorrect medication dose (Risperdal 1.5 tablets and Sertraline 1.5 tablets) and drug (Asprin EC-enteric coated-to decrease stomach irritation) was administered for two residents (R37, R248) of six reviewed during medication pass observation, resulting in three medication errors and a medication error rate of 9.38%. Findings include: On 01/11/23 at 8:25 AM, a medication pass observation for R37 was conducted with Licensed Practical Nurse (LPN) F. LPN F dispensed one Risperdal .5 mg tablet, and one Sertraline 50 mg tablet along with a 0.5 mg tablet of Ativan and a one multivitamin tablet. LPN F confirmed they were ready to administer the medications removed. LPN was then asked to review the orders for the Risperdal and Sertraline. The order for the Risperdal indicated, Risperdal tablet 0.5 mg [Risperidone] Give 1.5 tablet by mouth one time a day for psychosis/aggression in the morning with breakfast. The order for the Sertraline indicated, Sertraline HCL…
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WINDEMERE GROUP LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/16/2011 |
| LISA MANCINI LIVING TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/28/2011 |
| MANCINI, LISA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/28/2011 |
| VENTIMIGLIA, DOMENICA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/28/2011 |
| HAUTAMAKI, DAVID | Individual | W-2 MANAGING EMPLOYEE | — | since 01/12/2015 |
| JOHNSON, BARBARA | Individual | W-2 MANAGING EMPLOYEE | — | since 03/16/2015 |
| SHENOY, VIJAY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR | — | since 10/28/2011 |
CMS files one row per role, so the 8 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 19% 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235714. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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