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

Cherry Hill for Nursing and Rehabilitation

38410 Cherry Hill Road, Westland, MI 48185 · For profit - Limited Liability company · 127 certified beds · (734) 326-1200 Medicare & Medicaid certified

Call the home — (734) 326-1200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 2025Resident-funds citation (F0565)Behavioral-health or dementia-care citations — no harm found (F0740, F0758)
Insights

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

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)
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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 3 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
37649 S Butler Cir · (734) 728-9332 · Call to confirm hours
Pharmacy
37530 Cherry Hill Rd · (734) 727-0322 · Call to confirm hours
Grocery
5727 N Lotz Rd · (734) 844-1352 · Call to confirm hours
Park
36651 Ford Rd · (734) 722-7620 · 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 3 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
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 increased5.1%10.8%15.4%better
Long-stay residents who lose too much weight4.6%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.8%0.8%0.9%better
Long-stay residents with a urinary tract infection0.5%1.5%2.0%better
Long-stay residents with depressive symptoms1.7%4.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.0%3.0%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened8.7%12.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.6%19.4%18.9%better
Long-stay residents given the seasonal flu vaccine99.1%95.0%95.3%typical
Long-stay residents with pressure ulcers4.7%5.1%4.7%typical
Long-stay residents with worsening bladder/bowel control21.3%20.0%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table9.9%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine60.8%79.5%79.4%worse
Short-stay residents rehospitalized after admission33.3%24.0%22.6%worse
Short-stay residents with an outpatient ER visit9.8%11.7%12.0%better
Long-stay hospitalizations per 1,000 resident days2.021.841.67worse
Long-stay outpatient ER visits per 1,000 resident days1.301.641.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ 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.

41.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.3%U.S. median 51.5%
Got home and stayed home
12.3%U.S. median 10.7%
Went back to hospital
37.9%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 37.9% 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 29 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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 SNF41.3%CMS range 27.4–59.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.3%CMS range 8.6–16.710.7%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 discharge37.9%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 discharge34.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge48.3%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 identified100.0%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 settingnot 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 4.0–13.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.211.02Oct 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

0.56
RN hours/ resident / day
0.82
LPN hours/ resident / day
1.77
Aide hours/ resident / day
3.15
Total nurse hours/ resident / day
0.41
RN hoursweekends
49.5%
Total nursing turnover
46.7%
RN turnover

How full it usually is: this home is certified for 127 beds and averages 111.7 residents a day — about 88% occupied, or roughly 15 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 3.15 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.77 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.93 hrs/resident/day on weekends vs 3.24 on weekdays — 10% thinner on weekends. RN hours go from 0.62 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2026-01-15)
6
at the previous standard inspection (2024-10-24)

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · E2026-01-15 · tag F0847 — pattern
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    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 arbitration agreements were signed by the resident or appropriate responsible party, and in a manner which was explained and understood by the resident or responsible party for four residents (R23, R35, R90, and R104) of reviewed for arbitration agreements. Findings include: On 1/13/26 at 10:38 AM, an entrance conference was completed with the Nursing Home Administrator (NHA) indicating the facility offers arbitration agreements. At that time, a request for the residents who entered into an agreement was requested. A review of the list noted 77 residents who had entered into arbitration agreements. R23A review of the arbitration agreement list revealed R23 had entered into an arbitration agreement. Further review revealed a signing date of 7/25/25 by someone other than the resident. A request for guardianship documentation was requested on 1/15/26 at 10:26am however, this was not received by end of survey. A review of R23's medical record revealed the resident was their own responsible party but had a significant…

    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 · Dcited before2026-01-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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 maintain the cleanliness of the 200-hallway shower room for one (R105) and failed to maintain linen in good repair for one (R111) of three residents reviewed for the environment. Findings include: On 01/13/2026 at 11:04 AM, R105 was interviewed in their room and reported they did not want to use the 200-hallway shower room because they felt it had mold present that was visible along the lower rear wall seam between the wall and floor. On 01/14/2026 at 1:15 PM, observation of the 200-hallway shower room revealed: 1. A black substance along the seam of the back wall and the floor where there was a gap of approximately two-three inches in the tile leaving an area that was only grout. The black substance was easily wiped onto a napkin. 2. Two areas of broken tile on wall corners leaving exposed drywall approximately four to six inches wide. 3. A clump of brown substance that appeared to be feces and a large clump of hair. On 01/15/2026 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-15 · 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 ensure a low air loss mattress (LAL) was powered on for one resident (R59) of three reviewed for wound management. Findings include:On 01/13/2026 at 10:37 AM and 11:35 AM, R59 was observed to be in a LAL specialty bed. The bed had side bolsters and R59 was sunk low in the bed between the bolsters. An observation of the power unit for the bed revealed no active lights or display screen to indicate the mattress was powered on. R59 had a green wedge behind their torso and faced toward the right side of the bed. At 4:01 PM, the power unit for the mattress remained not powered on. The base of the mattress was firm and R59 reported they felt like they were laying on the frame and was adjusted their position slightly. R59 further noted they did not get out of bed often. On 01/14/2026 at 8:47 AM, R59 was observed to be in bed, sitting up and eating breakfast. The power unit for the bed had no lights or active display screen and was not powered 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 · D2026-01-15 · 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 Based on observation, interview, and record review, the facility failed to float (positioning the heels to prevent sustained contact between the heels and the bed) a resident's heels per physician order for one (R19) of three resident's reviewed for pressure ulcer prevention. Findings include: Review of the medical record for R19 revealed they were admitted into the facility on [DATE] with diagnoses including Type-Two Diabetes Mellitus and Chronic Kidney Disease. Review of R19's Minimum Data Set (MDS) information indicated a history of facility-acquired pressure ulcers and the Brief Interview for Mental Status (BIMS) score of 8/15 indicated moderate cognitive impairment. Review of R19's current physician orders confirmed an active order stating Skin prep to bilateral heels, float heels while in bed. On 01/13/2026 at 1:47 PM, R19 was observed in bed. Their feet were laying directly on the mattress without any support to float the heels or any float boots in place. R19 was queried as to whether they knew if 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 · D2026-01-15 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    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 address the behavioral health needs of one resident (R23) of one reviewed for behavioral health resulting in an assault of another resident. Findings include: On 1/13/26 at 11:44 AM, R23 was observed lying in bed and asked about a recent incident involving their previous roommate and stated, [they] thought I was [their] whipping boy and I hit [them] with a weight. R23 did not provide any additional information regarding the incident.A review of R23's medical record revealed they were admitted into the facility on 7/23/25 with diagnoses which included Post-Traumatic Stress Disorder, Hemiplegia and Hemiparesis, and Hypertension. Further review revealed the resident was cognitively intact and required one-person assist with activities of daily living (ADL's).A review of the following progress notes revealed the following: 10/8/2025 08:30 (8:30am) Behavior Note: Patient has been observed being confused and aggressive. Patient was redirected several times because [they were] trying to climb out of bed and walk…

    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 · D2026-01-15 · tag F0756 — failed to review each resident's drug regimen — isolated
    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

    Based on interview and record review, the facility failed to follow pharmacy recommendations for one resident (R77) of five reviewed for Medication Regimen Reviews (MRRs). Findings include: A review of R77's monthly MRR's noted the following dates the resident had irregularities reported by the pharmacist: 5/19/25, 6/24/25, and 7/21/25. A review of the irregularities report for 5/19/25 indicated the following, Please ensure lab results for the following labs are completed and scanned into [electronic medical record] as ordered 4/14/25, as results could not be located in this resident's chart at the time of review, CMP and CBC (comprehensive metabolic panel and complete blood count), Fasting lipid panel (measures the amount of certain fat molecules in the blood), HgbA1c level (measures the amount of glucose in the blood). A review of the irregularities report dated for 6/24/25 indicated the following, Please ensure lab results for the following labs are completed and scanned into [electronic medical record] as ordered 4/21/25, as results could not be located in this resident's chart…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-15 · 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 store medication not at the bedside for one resident (R50) of one resident reviewed for storage of drugs and biologicals.Findings include: On 1/13/26 at 9:30 AM, R50 was observed laying in their bed watching television. Their bed was cluttered with papers other items. A bag of cough drops, an over-the-counter inhaler, and two prescription inhalers were observed at the bedside. When asked about the medications at bedside R50 stated the nurse gave them to them.On 1/14/26 at 10:30 AM, R50 was observed sitting up on the side of their bed going through the clutter. Three inhalers were observed at the bedside.Record review on 1/15/26 revealed R50 was admitted into the facility on 2/25/23 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD); anxiety disorder and acute cough. R50's most recent Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15 indicating intact cognition. Further review identified no active physician orders for R50 to self-medicate.01/15/2026 at 1:46 PM, an…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-04 · tag F0551 — isolated
    Give the resident's representative the ability to exercise the resident's 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 MI00153028 and MI00153168. Based on observation, interview and record review, the facility failed to acknowledge and ensure the Durable Power of Attorney (DPOA) was allowed to exercise the residents' rights for one resident (R901) out of three residents reviewed for resident rights exercised by their representative. Findings include: On 6/3/25 at 02:30 PM, an interview with DPOA A revealed they were told, when presenting to facility staff the DPOA paperwork, it was not valid because signatures on the papers were not notarized. Review of the document revealed a DPOA document containing two witness signatures, the resident signature, and the DPOA signature as prepared by a law firm, dated 3/30/21. DPOA A was advised by facility staff to provide the DPOA paperwork to the Social Worker the next business day. DPOA A further revealed they told the staff member, the current document had been in effect since 2021 (the signature date). On 6/3/25, a review of the Electronic Medical Record (EMR)…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation refers to Intake MI00153374. Based on interview and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse by staff (Certified Nursing Assistant - CNA I) for one (R903) of three resident's reviewed for abuse. Findings include: A review of the Intake MI00153374 revealed: On 05/24/25 at about 4:00 PM, R903 approached the nurses' station with a packet of sweetener and requested assistance to open it. Licensed Practical Nurse (LPN) E assisted R903 to open the packet. CNA K, CNA L, and CNA I were seated at the nurse station. R903 threw the open packet of sweetener over the nurses station towards CNA I. CNA I started to swear at R903. R903 was observed to stand up and R903 and CNA I then grabbed each other by the wrists over the nurses' station. Staff were then reported to have separated R903 and CNA I. On 6/04/25 at 11:30 PM and during the survey, R903 was observed to be walking round and round the halls talking appropriately with staff and 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-04 · 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 This citation pertains to Intake MI00153028. Based on observation, interview, and record review, the facility failed to develop a care plan for bladder incontinence with interventions to address resistance to toileting for one (R901) of two residents reviewed for care plans. Findings include: A review of the Electronic Medical Record (EMR) revealed R901 was admitted to the facility on [DATE] with the following relevant diagnoses: Vascular Dementia, Gastroesophageal Reflux Disease, and a Cognitive Communication Deficit. A Brief Interview for Mental Status was conducted resulting in a score of 4/15 indicating severe cognitive impairment. R901 was dependent for activities of daily living, was incontinent of urine and R901 requires prompting and assistance for toileting. On 6/3/25 at approximately 2:56 PM, R901 was interviewed in their room with their Durable Power of Attorney (DPOA) A. DPOA discussed R901's sometimes resistance to toileting and R901 is sometimes willing to walk to the bathroom with assistance. DPOA…

    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
Show the remaining 17 citations
  • Potential for harm · D2025-06-04 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 refers to Intake MI00153168. Based on observation, interview, and record review, the facility failed to identify 6% weight loss from 5/1/25 to 5/29/25 for one (R901) of three residents reviewed for weight loss. Findings include: On 4/25/25, R901 was admitted to the facility on [DATE] with the following relevant diagnoses: Vascular Dementia and Cognitive Communication Deficit. A Brief Interview for Mental Status was conducted resulting in a score of 4/15 indicating severe cognitive impairment. R901 is dependent for activities of daily living and uses a wheelchair for mobility. R901 is minimally verbal. R901 is dependent on for nutritional and hydration needs through a percutaneous gastrostomy tube (PEG-feeding tube) inserted into R901's abdomen. On 6/4/25 an interview with R901's Durable Power of Attorney (DPOA) revealed they were aware that R901 becomes agitated and fidgety pulling on the feeding tube. DPOA A said they were unaware if the tube was ever pulled out on any occasion since admission. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-24 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to answer call lights timely for eight confidential group meeting residents (C1, C2, C3, C4, C5, C6, C7, and C8) of 19 residents reviewed for dignity. Findings include: On 10/23/24 at approximatley 11:40 a.m., eight confidential interviewable group residents (C1, C2, C3, C4, C5, C6, C7, C8) reported feeling frustrated and being discouraged as they were waiting more than a half hour for their call light to be answered. Resident C1, reported they had filed grievances with the Activity Director, Staff F, and had made the facility aware of the resident's call light concerns, with limited follow up. Two residents described specific incidents, as follows: C2: Reported they waited 45 minutes for staff to answer their call light a couple weeks ago, at night, when he fell and hurt their shoulder. C3: Reported they sometimes waited an hour and a half to use the bathroom, during the day shift, causing incontinence. Five of the eight residents indicated they waited 45 minutes or more at times for their call lights to be answered, which…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-24 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    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 adequate space and privacy for resident counsel group meetings for 19 of 19 residents reviewed for organized group meetings. Findings include: On 10/23/24 at approximately 11:20 a.m., 19 residents were observed in the activity room, with the Activity Director, Staff F present. Residents were observed crowded into this smaller room, with some seated only one to three feet apart. There were frequent knocks at the closed door, either by staff or residents. A few residents arrived later, or left, and had difficulty negotiating room entry or exit around the residents who were seated in wheelchairs. On 10/23/24 at 11:31 a.m., the group meeting participants collectively reported feelings of frustration and privacy concerns meeting in the activity room at the facility. Two residents reported they and the residents preferred to meet in the large facility dining room, however there were too many interruptions by staff coming in an out of the space, no matter what time they held the meeting. Staff F said they…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-24 · 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

    This citation relates to Intake #MI00146436. Based on observation, interview, and record review, the facility failed to provide palatable, appetizing meals at the proper temperature for 19 of 19 confidential group meeting residents. Findings include: On 10/23/24 at 11:31 a.m., residents collectively shared concerns related to the meals at the facility which had been occurring over the past few months, and possibly longer. The resident council President and [NAME] President were in attendance, as well as the Activity Director, Staff F, per their request. Residents collectively shared their concerns as follows: 1. They wanted hot meals at mealtimes, and reported the trays were frequently not served from the meal carts anywhere from 15 minutes to 45 minutes. 2. The meals tasted bland and were not appetizing, as they had no flavor. 3. They wanted more variety of the menu, and said they had the same foods most weeks. 4. They did not like the Tilapia fish, and several residents said, It tastes nasty. 5. They reported they were told there was no budget for any extra preferences. 6. Most…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-24 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably 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 on observation, interview, and record review, the facility failed to place call light within reach and provide a closet door for two residents (R89 and R84) of four residents reviewed for accommodation of needs. Findings include: R89: On 10/22/24 at 1:11 p.m., R89 was observed laying in their bed, wearing a hospital gown. They were observed leaning to the left side of their bed, resting their head on the enabler bar, which appeared uncomfortable. R89 reported they were in significant pain and wanted pain medication. Further observation revealed their touch pad call light was out of reach, on the right side of the bed on their dresser. On 10/22/24 at 1:15 p.m., R89 was asked if they used their call light. R89 reported they used their call light for pain medication, or if they needed other assistance. On 10/24/24 at 11:44 a.m., R89 was observed sleeping in their hospital bed, leaning against the left enabler bar. R89's call light was on the right side of their bed, on their dresser, out of reach. Review of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-24 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure medications were labeled and dated when opened and or discarded when expired in two of four medication carts and one supply room reviewed. Findings include: On [DATE] at 9:09 AM a check of the medications in medication cart three with Licensed Practical Nurse (LPN) I revealed: A Breo Ellipta inhaler was not dated on the actual inhaler; A Humalog insulin vial with open date of [DATE] was expired; A Lantanoprost eye drops vial dated 09/25 on the box was not dated on the vial; a brimonidine eye drop was not dated when opened on the vial or the box; a second Latanoprost eye drop was not dated when opened on the vial or box; and a Dorzolomide eye drop was not dated when opened on the vial. On [DATE] 9:36 AM, a review of the number four medication cart with LPN J revealed: the glucose strips not dated when opened, an Ademolog insulin was dated 09/26 on the box but not on the vial, a novolg insulin had an expired dated of [DATE] and a…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-24 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make 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 store an oxygen tank in an safe manner involving one resident (R45) of four residents reviewed for environment. Findings include: On 10/22/24 at 12:44 PM, an observation was made of an oxygen tank without a holder, behind the bed, against the wall in R45's rooom. R45 was interviewed about the oxygen tank in their room and stated, I don't know, saying the oxygen tank had been in their room ever since admission. R45 denied receiving oxygen therapy. A record review of R45's electronic medical record (EMR) confirmed that R45 did not receive oxygen therapy. Further review of R45's EMR revealed that R45 was originally admitted to the facility on [DATE] with diagnoses that included, Paroxysmal atrial fibrillation (Irregular rapid heartbeat) and Alcohol abuse. R45's most recent minimum data set assessment (MDS) dated [DATE] indicated R45 had an intact cognition. On 10/24/24 at 11:06 AM, Licensed Practical Nurse (LPN) D was interviewed and asked…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-27 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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 This citation pertains to Intakes M100144781 and M100145103. Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, homelike environment for four (R701 and R703) of four residents reviewed for homelike environment. Findings include: R701 On 06/27/24 at 10:25 AM, R701 was observed lying in bed in their room watching television. R701 stated, The shower room is so nasty; I wouldn't dare walk in there barefoot. Its just nasty and it's not fair. On 6/27/24 at 11:30 AM, an observation was made of the shower room on 2 hall. Upon entering the area a dried brown stain was noted on the floor outside of door and trailing inside the room. A pile of feces was noted in the shower room drain. Trash and debris was noted in the corners of the room. A record review revealed that R701 was admitted on [DATE] with the following medical diagnoses of Morbid Obesity, Bipolar Disorder, Raynaud's syndrome with Gangrene. A review of the most recent Minimum Data Set assessment dated [DATE]…

    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 · Ecited before2024-05-16 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably 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 This citation pertains to MI00142238, MI00141119, MI00140817, MI00140327. Based on observation, interview and record review, the facility failed to ensure four residents (R904, R905, R906, R909) of four reviewed for adaptive equipment were allowed to have reachers (device about two feet long with a trigger/grip at one end that activates a jaw at the opposite end which can be used to grip and pick up items), resulting in feelings of lost independence, decreased self esteem, and fear of falls. Findings include: A review of four complaints called into the State Agency revealed; - .the removal of reachers from all residents poses an increased risk of falls and injuries. This decision, stemming from an isolated incident, has received numerous complaints from residents and their families, highlighting the need for a reconsideration of this policy . - .Residents report concerns that the nursing home has taken reachers away from residents. Residents report this affects their ability to be self-sufficient as possible.…

    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 before2024-05-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00141238. Based on observation, interview, and record review the facility failed to provide safe storage of medication for three residents (R903, R907, and R908) of three residents reviewed for storage of biologicals. Findings include: R903 On 5/16/2024 at 10:00 AM, R903 was observed in their bed with the head of the bed elevated to 45-60 degrees, leaning to the right. The bedside table was in front of the resident with many items on the table and a medicine cup with a blue and white small capsule, an orange coated tablet, a large white oval tablet, and a small white tablet. R903 was not attempting to consume the tablets. When queried if they knew what the medications were and how did they get there, the response was, I'd rather not answer that. A record review of R903 revealed an admission date of 02/26/2024 with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side; Diabetes Mellitus, Type Two; Chronic Kidney…

    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 · F2023-08-30 · 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 the kitchen and ice machine in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 8/29/23 at 9:50 AM, the ice chute inside the ice machine was observed with black, speckled stains adhered along the bottom edge of the chute. There was a cleaning log attached to the ice machine that noted the last cleaning had been done 7/27/23. When wiped with a paper towel, the black substance was easily removed from the ice chute surface. When queried at that time, Certified Dietary Manager (CDM) A stated that Maintenance was responsible for cleaning the ice machine. On 8/29/23 at 10:15 AM, Maintenance Supervisor B was queried about the cleaning of the ice machine, and stated I focused more on the outside of the ice machine last time I cleaned it. According to the 2017 FDA Food Code section 4-602.11 Equipment Food-Contact Surfaces and Utensils, (E) Except when dry cleaning methods are used as specified under § 4-603.11,…

    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 · D2023-08-30 · 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 R52 On 8/28/23 at 9:44 AM, R52 was observed in bed and asked if they had any concerns related to the care that they have received in the facility, and explained that they would like to be shaved more often, and had questions about their dental care, specific to their dentures. A review of R52's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Chronic Kidney Disease, Heart Disease, Diabetes, and Seizures. Further review of R52's medical record including their care plan, revealed that the resident was severely cognitively impaired and required one staff participation with bathing and showers. A review of R52's medical record revealed that the resident is scheduled to receive showers on Tuesday and Fridays, and that within the last 30 days, the resident should have received nine showers. A review of the R52's showers revealed that they received showers on the following dates: 8/11, 8/15, 8/18, 8/25, 8/29, with one documented refusal on 8/22/23. A review of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-30 · 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

    Based on observation, interview, and record review, the facility failed to effectively identify an environmental hazard (metal kick plate), potentially affecting one of one resident (R4), in which created the potential for injury/skin laceration. Findings include: On 8/29/23 at 1:24 PM, while this surveyor was interviewing another resident, R4 was observed near their bathroom door in their room and pointed to a large metal kick plate at the bottom of the door that was bent up at a significant angle and had a sharp, pointed edge. R4 exclaimed, This is f*ed up! R4 was asked if he had asked someone to fix it to which he replied, Yeah, one of the guys. The metal piece was observed through touch to be hard and the corner sharp. R4 was noted to be able to take himself into the bathroom subsequently passing the bathroom door with the sharp metal. On 8/29/23 at 1:29 PM, Certified Nursing Assistant (CNA) D was interviewed in R4's room and was queried regarding the piece of metal sticking out on the bathroom door. CNA D acknowledged the issue but stated she didn't know anything about it 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 · D2023-08-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 observation, interview, and record review, the facility failed to 1) enter a stop date on an as-needed (PRN) anti-anxiety medication, 2) obtain informed consent for continued use of psychotropic medication, and 3) document attempts at non-pharmacological interventions prior to the administration of a PRN anti-anxiety medication, affecting one resident (R71) of five reviewed for unnecessary medications, resulting in the potential for prolonged unnecessary use of psychotropic medication without an appropriate diagnosis and consent, with the potential for adverse reactions and/or negative psychosocial outcomes. Findings include: On 8/28/23 at 11:17 AM, R71 was interviewed in their room. R71 was noted to be calm and cooperative, and also noted to have expressive aphasia (partial loss of the ability to produce language with comprehension generally remaining intact). R71 was able to answer short, pointed interview questions when given enough time to respond. When queried regarding her communication barrier,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-30 · 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 secure medications on two medication carts, for the residents that live on the 200 unit, resulting in the potential unauthorized access to residents medication. Findings include: On 8/28/23 at 10:50 AM, during the initial tour of the 200 unit (low hall), a medication cart was observed to be unlocked without nurse supervision. On 8/29/23 at 11:37 AM, a medication cart unlocked on the 200 unit (high hall). On 8/30/23 at 3:16 PM, the Director of Nursing (DON) was asked the facility's expectation for the medication carts and stated, They should be locked when they (nurse) walk away. A review of the facility's policy titled, Storage of Medication, dated 2001, noted, Policy Statement: The facility shall store all drugs and biologicals in safe, secure, and orderly manner . 7. Compartments (including, but not limited to, drawers, cabinets, rooms refrigerators, carts, and boxes.) containing drugs and biological's shall be locked when not in use, and trays or carts used to transport such items shall not be left…

    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 · D2023-08-30 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete medical records for one sampled resident (R52) of one reviewed for medical records, resulting in untimely entry of nursing notes in the medical record and the potential for an inaccurate reflection of resident conditions/status. Findings include: On 8/28/23 at 9:44 AM, R52 was observed in bed and asked if they had any concerns related to the care that they have received in the facility, and explained that they would like to be shaved more often, and had questions about their dental care, specific to their dentures. A review of R52's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Chronic Kidney Disease, Heart Disease, Diabetes, and Seizures. Further review of R52's medical record including their care plan, revealed that the resident was severely cognitively impaired and required supervision to limited assistance for Activities of Daily Living. Further review of R52'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-08-30 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    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 the survey binder was easily accessible to residents, and inform residents, families, and visitors of the location of the facility's survey results (Statement of Deficiencies -Form CMS-2567 and the Statement of Isolated Deficiencies generated by the most recent standard survey and any subsequent surveys) for four residents who attended a confidential group meeting, resulting in the potential for all residents, families, and visitors to be uninformed of the facility's deficient practices. Findings Include: On 8/29/23 at 11:10 AM, during the confidential group meeting, residents were asked if they knew where the facility's survey results were located. One resident stated, I think it's at the front while three other residents indicated that they did not know. On 8/30/23 at 2:21 PM, signage was located inside of a glass bulletin board. The sign was out of sight to anyone at wheelchair height, and read, state survey book is available upon request. On 8/30/23 at 2:23 PM, the Director of Nursing (DON) 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LME FAMILY HOLDINGS — 15 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 52.1+1.9 vs chain
Health inspection 4 of 52.2+1.8 vs chain
Staffing 3 of 52.3+0.7 vs chain
Quality measures 3 of 52.9+0.1 vs chain
The other 14 homes this chain runs (chain average 2.1★, 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
ADMN GROUP LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST24%since 07/31/2024
SAMARA HOLDINGS COMPANY LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST26%since 07/31/2024
SCHIOWITZ, MARCIndividualCORPORATE OFFICER; ADP OF THE SNFsince 09/01/2019
ADVANCED CARE CONSULTANTS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/03/2026
CLINICAL CONSULTING SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/03/2026
SUMMATION FINANCIAL SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/03/2026
BUCKMAN, SETHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/08/2024
SHAH, SARJUIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2019
8410 WESTLAND PROPERTY LLCOrganizationADP OF THE SNFsince 09/01/2019

CMS files one row per role, so the 15 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

$10.0M
Net patient revenuemost recent cost report
-0.6%
Operating marginrevenue minus expenses
$615K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 91%Medicare 3%Other / private 5%

About 91% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $615K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$274per resident / day
operating cost
$8,332per month
≈ monthly operating cost
$273per 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 235228. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

What to do next