Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Corewell Health Rehabilitation & Nursing Center - during CMS and state inspections, most recent first.
Kitchen sanitation and food labeling failures: The facility had multiple unclean food-contact and non-food-contact surfaces, including soiled ice machine chutes, dirty kitchenette refrigerator/freezers with spills and debris, contaminated storage pans and drawers holding disposable cups/lids, food processors with standing water or debris, and a can opener with sticky residue. Staff also found unlabeled or expired food items, including a nectar-thick beverage supplement, cheese, sliced beets, and an unlabeled squeeze bottle of vegetable oil.
Failure to Honor Food Preferences: A resident with ALS, dysphagia, malnutrition, and a vegetarian diet order reported that yogurt was requested for every meal but was not consistently provided. Meal tickets did not list yogurt, dietary staff said they would not know to serve it if it was not on the ticket, and the RD stated the facility yogurt was restricted by the computer system unless overridden. The resident and family member said yogurt, milk, and ice cream were important to her intake, and the resident became frustrated and tearful when her preferences were not being followed.
A resident with Alzheimer's dementia and a history of falls was prescribed lorazepam without adequate indication, monitoring, or consent. After starting the medication, the resident experienced multiple falls, culminating in a severe fall that caused pelvic fractures and death. The facility did not review the medication's role in the falls, failed to monitor for adverse effects, and did not obtain required consent, leading to significant harm.
A resident with dementia, left-sided paralysis, and chronic pain, who preferred to stay up late, was forced by staff to go to bed despite her resistance. During the process, she became agitated and combative, leading to multiple staff interventions. After being transferred to bed, the resident complained of severe left shoulder pain, and was later diagnosed with a fractured humerus. Staff interviews confirmed that her preferences were not honored, and her right to self-determination was not supported, resulting in frustration, an altercation, and injury.
A resident with Alzheimer's dementia and related conditions was administered Lorazepam without documented informed consent from their representative. The care plan lacked interventions for psychotropic medication use, and facility staff could not provide evidence of written or verbal consent, resulting in the resident's representative being unaware of the medication administration.
A resident with dementia and high fall risk did not consistently have a fall mattress properly placed next to the bed as required by the care plan and facility policy. Staff failed to ensure the intervention was in place, with interviews revealing miscommunication and lapses in following procedures, resulting in the resident being left without the intended fall protection.
Two residents with indwelling catheters were observed with catheter tubing and drainage bags in contact with the floor, contrary to facility policy. One resident's catheter bag was found resting on the floor while in bed, and another resident was seen self-ambulating with catheter tubing and a privacy bag dragging on the ground. Both residents had medical histories that increased their risk for infection, and one had recent evidence of a urinary tract infection.
The facility failed to maintain professional standards for food safety, with issues including debris accumulation in kitchen equipment, improper food storage, and inadequate temperature control. The ice machine and microwave were found with debris, and utensil drawers were not clean. Food items were improperly stored, with soy sauce not refrigerated and dish machine temperatures below required levels. Additionally, leftover food was not cooled or stored correctly, posing a risk of foodborne illness.
The facility was cited for deficiencies in its infection prevention and control program, including inadequate water management and improper hand hygiene practices. Maintenance staff were unaware of regular flushing procedures, leading to discolored water in several areas. Additionally, staff failed to use proper PPE during resident care, such as G-tube medication administration and incontinence care, increasing the risk of cross-contamination.
The facility failed to document advance directives accurately for three residents, leading to potential non-compliance with their medical care preferences. A resident had a DNR order without signed paperwork, another had incomplete documentation with a DNR form signed by the wrong advocate, and a third had a DNR order without signed documentation from the resident and physician. The social worker and nursing home administrator acknowledged the documentation issues.
A resident with multiple health conditions was found in a room with a heavily soiled mattress and damaged walls, indicating a failure to maintain a clean and safe environment. Interviews with staff revealed communication and follow-up issues regarding maintenance and cleanliness, with no evidence of completed work orders and insufficient maintenance personnel.
The facility failed to transmit MDS discharge assessments timely for two residents, leading to potential inaccuracies in discharge tracking. One resident's assessment was incomplete with sections GG, J, M, N, O, and P pending, while another's had section K pending. An MDS nurse confirmed the assessments should have been completed and transmitted by specific dates.
A facility failed to complete a PASARR Level II assessment for a resident with severe cognitive impairment and mental health diagnoses, despite the need being identified in a Level I assessment. The social worker could not provide documentation of the Level I assessment or a completed Level II assessment, resulting in potential unmet mental health care needs.
A facility failed to develop a Hospice care plan for a resident with dementia and Alzheimer's disease, who had a severely impaired cognitive status and was receiving Hospice care. The MDS nurse misunderstood the responsibility for completing the care plan, leading to a deficiency in person-centered care planning.
A resident with severe cognitive impairment and dependence on staff for ADLs was observed with long, dirty fingernails, indicating a failure in nail care provision. Despite the resident's preference for clean nails, staff inconsistently provided care, with some CNAs stating it should be done during showers. An LPN acknowledged the need but did not complete the task due to time constraints. The DON expected nails to be clean, but there was no documentation of care, leading to the deficiency.
A resident with CHF and a pacemaker was not administered Lasix as ordered upon admission to the facility, leading to significant weight gain and worsening of his condition. Despite attempts to communicate the need for the medication, it was not consistently provided, resulting in hospitalization for fluid overload. The facility failed to report significant weight changes to the physician or adjust the diuretic medication, contributing to the resident's deteriorating condition.
Two residents at risk for pressure injuries did not receive adequate preventative care in a facility. One resident, with a history of pressure injuries, was often improperly positioned in a wheelchair without secure pressure-relieving boots, leading to a pressure ulcer on the heel. Another resident spent extended periods in a wheelchair without a pressure-reducing cushion, contrary to their care plan. Staff interviews confirmed these deficiencies, highlighting a failure to adhere to care plans and professional standards for pressure ulcer prevention.
The facility failed to control hot water temperatures, allowing them to exceed safe limits, and did not ensure safe transfers for two residents. One resident was transferred without a gait belt or additional staff, while another was transferred with an improperly attached hoyer sling, risking their safety.
Two residents with indwelling foley catheters did not receive proper care, leading to potential risks of catheter dislodgement, pain, and infection. One resident was not toileted as per her care plan and had an unsecured catheter causing discomfort. Another resident's catheter was not secured, and incontinence care was performed without changing gloves after contact with feces, risking cross-contamination. These deficiencies were observed during staff interviews and direct observations.
A resident with COPD was found with an empty water bottle on her oxygen concentrator, which was still running. The oxygen tech reported a delay in scheduled maintenance, and facility staff had differing views on who was responsible for monitoring the equipment. This led to a deficiency in ensuring proper maintenance of the oxygen delivery system.
A facility failed to ensure a physician documented review and follow-up on pharmacy recommendations for a resident, leading to potential medication side effects and unnecessary medications. The resident had several pharmacy recommendations, including changes to Lidoderm orders, re-evaluation of duplicate therapy, and adjustments to insulin and Zoloft dosages, which were not addressed by the physician. The facility's policy required timely action on pharmacy reports, but the physician's response was left blank, indicating a deficiency in medication management.
Surveyors observed that the facility did not have a battery back-up light installed in the electrical room containing the generator Automatic Transfer Switch (ATS), as required by NFPA 110. This deficiency was confirmed with the Maintenance Technician and could impact access to emergency equipment during a generator failure.
Surveyors found that doors to the Therapy storage closet and a back hall storage closet used for emergency food and water did not self-close to a positive latch as required by LSC 19.3.2.1. These deficiencies were confirmed during interviews with the Maintenance Technician and could potentially affect 20 occupants if a fire were to occur.
A smoke barrier door near a resident room was found to be improperly aligned, causing it to bind on the floor and preventing it from self-closing or releasing when the fire alarm was activated. This issue was confirmed by the Maintenance Technician during the survey.
A resident with a history of dysphagia and choking incidents died after choking on food due to inadequate supervision and safety measures. Despite being on a specialized diet, the resident chose to eat foods not suitable for his condition. The facility failed to enforce the care plan requiring communal dining for supervision, especially during a COVID-19 outbreak when the main dining room was closed. Staff were unaware of the need for increased supervision, leading to the resident's death from choking.
Kitchen sanitation and food labeling failures
Penalty
Summary
The facility failed to keep kitchen and kitchenette food-contact and non-food-contact surfaces consistently clean and sanitary. During observations, the ice machine in the kitchen had unknown black, orange, and pink material on the exterior of the white ice chute, and the ice machine outside the kitchen had unknown orange and black material on the white ice chute and red material on the clear plastic chute cover. The kitchen ice machine remained visibly soiled on a later observation. Maintenance staff reported the ice machines were cleaned by a third-party vendor approximately twice a year, and a service order form documented cleaning of the ice machine on 2/6/26. Multiple kitchenette refrigerator/freezers were observed with spills, debris, and dead bugs. The back 200 unit kitchenette freezer/refrigerator had dead bugs and brown debris in the freezer door and a large red spill in the freezer interior. The front 200 unit kitchenette had a brown spill in the interior. The front 100 unit kitchenette had a brown spill in the refrigerator and freezer interior, unknown debris in the freezer, and a spill in the middle drawer. The back 100 unit kitchenette had a spill with debris in the bottom freezer drawer, red frozen material on wire racks, and a brown spill in the refrigerator interior. Kitchen supervision stated refrigerators should be cleaned daily. Other kitchen storage and equipment were also observed in unclean conditions. A clear plastic food pan on the drying rack had brown and white debris inside it. A large clear plastic food pan holding disposable cups and lids had white and yellow debris on the bottom, and a drawer containing clean disposable cups and lids had debris on the bottom with one lid resting directly on a stained drawer surface. The kitchen’s food processors had standing water in the bowls during one observation and dried orange and white food debris during another. The can opener attached to the central food preparation table had sticky black and brown debris on the piercing part, and kitchen supervision stated it had been used about an hour to an hour and a half earlier to open cans for ambrosia salad. The facility also failed to consistently date, label, and discard food items appropriately. A plastic cup of brown thickened liquid in the small refrigerator next to the tray line had no label identifying the item, preparation date, or discard date; kitchen supervision identified it as a nectar thick beverage supplement for a resident and discarded it. In the kitchen refrigerator, cheese was labeled with a use-by date of 4/13/26 and was confirmed to be past that date. In the walk-in refrigerator, sliced beets were labeled 4/13/26 and were confirmed to be at their expiration date. An unlabeled and undated squeeze bottle on the central food preparation table contained an unidentified yellow liquid, which kitchen supervision identified as vegetable oil.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food preferences for Resident #121, a female admitted with ALS, unspecified protein-calorie malnutrition, dysphagia, and a vegetarian diet order. During interview, the resident reported she had requested yogurt at every meal and was frustrated and angry that it was not being provided. She stated she and her family member had both spoken with the RD about this preference, and she reported that yogurt was important to her intake because it helped her swallow pureed food and maintain calories. Record review showed the resident was on a pureed diet with moderately thick liquids, with nutrition supplements ordered, and her care plan directed staff to honor food preferences as able and provide additional calories and protein. However, meal tray tickets reviewed did not list yogurt as a preference, and the resident reported yogurt was not consistently served with meals. On observation, yogurt was present on the tray at one meal after the CNA called the kitchen to request it, but the resident stated it had not been on the tray when served. At another observation, she reported she had not been served yogurt at dinner the night before and had not been served ice cream since admission. The RD documented speaking with the family member about the resident’s food preferences and stated the facility yogurt contained gelatin and was not allowed on a vegetarian diet, while also noting that yogurt could be provided only by overriding the computer system. The MSS reported yogurt was not listed on the meal tickets and dietary staff would not know to serve it if it was not listed. The resident later stated she was a vegetarian, not vegan, and that she ate milk, yogurt, and eggs, and she became tearful while saying she felt staff were not listening to what she wanted and needed for her intake.
Failure to Monitor and Prevent Unnecessary Psychotropic Medication Use Resulting in Resident Harm
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications without adequate indication and failed to monitor a resident for adverse effects after initiating such medication. A female resident with severe late-onset Alzheimer's dementia, a history of recurrent falls, insomnia, and depression was prescribed lorazepam daily. Prior to the prescription, the resident had not experienced any falls since her admission in February. After starting lorazepam, the resident experienced multiple falls in May, with no major injuries initially, but there was no evidence that the facility reviewed her medications or monitored for adverse consequences following these incidents. Documentation revealed that the resident's care plan identified her as being at risk for falls due to impaired balance and the use of psychoactive medications, but there was no policy or clear intervention for visual checks or monitoring for medication side effects. Behavior logs and care plans did not show a focus on monitoring psychotropic medications, and there was no documented increase in wandering or agitation prior to the medication change. The resident's family was not informed or asked for consent regarding the addition of lorazepam, and there was no documentation of consent for the medication. Staff interviews indicated that the resident was independent, not aggressive or combative, and could be redirected, with no significant behavioral escalation documented prior to the medication change. After the initiation of lorazepam, the resident experienced a significant fall resulting in an impacted acetabulum and pelvic fracture, leading to hospitalization and subsequent death. There was no indication that the facility reviewed the resident's medications after each fall to determine if they contributed to the incidents. The consultant pharmacist was not made aware of the increase in falls after the addition of lorazepam, and the facility's medication management policy was not effectively implemented to ensure monitoring and prevention of unnecessary drug use. The lack of monitoring, failure to obtain consent, and absence of medication review after falls directly contributed to the deficiency.
Removal Plan
- Review all residents' charts to identify residents on psychotropic medication to ensure adequate monitoring.
- Create worklist tasks for all residents on psychotropic medications to monitor for adverse reactions, specifying medication class and symptoms to monitor.
- Audit all residents on psychotropic medications for consent forms; complete consent forms for any resident missing one and obtain signature.
- Upload completed consent forms to Epic.
- Educate the Medical Director on F605 regulations, with emphasis on the appropriate use of psychotropic medications.
- Provide a list of all residents on psychotropics to the Medical Director.
- Educate the Nurse Practitioners on F605 regulations.
- Review behavior logs during the Interdisciplinary Team (IDT) meeting, including review of care plans for affected residents.
- Educate nurses regarding the requirement to implement non-pharmacological interventions prior to initiating psychotropics.
- Educate the social worker on the expectation to implement non-pharmacological interventions, and educate the second social worker.
- Re-educate nurses, led by the DON, for all nursing leaders and on-duty staff; do not permit any nurse to work until this education is completed.
- The DON or designee will pull an Epic report to identify newly prescribed psychotropics and verify that consent forms and monitoring tasks are in place.
- Review new symptoms during the IDT meeting and communicate to providers using the SBAR format.
- Educate social workers on obtaining consent for psychotropic medications; re-educate one social worker and re-educate the second.
- Educate the consultant pharmacist on the medication review process and confirm understanding.
Failure to Honor Resident's Right to Bedtime Choice Results in Injury
Penalty
Summary
A resident with a history of chronic pain, left upper arm contracture, debility, stroke, left-sided paralysis, and dementia was reviewed for her right to self-determination and choice. The care plan noted that the resident may refuse to return to her room for incontinence care or go to bed at a reasonable time, with interventions to assess decision-making ability and provide a consistent routine. Despite this, staff attempted to put the resident to bed between 9:00 PM and 10:00 PM, although she was known to resist going to bed and preferred to stay up. During the process of undressing her and preparing her for bed, the resident became agitated, fought with staff, and began swinging her arm. Staff left the room to seek assistance, and multiple CNAs attempted to help, but the resident continued to resist and became increasingly upset. Subsequently, the resident was transferred to bed using a Hoyer lift by another CNA, during which she was observed to be crying and calling staff names. Later, the resident complained of severe pain in her left shoulder, which was assessed by nursing staff and found to be swollen and tender. She was sent to the emergency department, where imaging revealed a closed fracture of the surgical neck of the left humerus. The resident reported to staff and emergency personnel that her arm had been pulled during care, and she repeatedly stated that her arm was broken by staff. Staff interviews confirmed that the resident was typically resistive to going to bed and that her preferences were not accommodated on the night of the incident. Observations and interviews with staff and the resident indicated that her right to make choices about her bedtime and care routine was not honored. Staff acknowledged that the resident preferred to stay up late and often refused to go to bed, but on the night in question, they proceeded with care despite her resistance. The failure to respect the resident's choices and to re-approach her at a later time contributed to her agitation and the subsequent altercation, which resulted in a significant injury.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for one resident with severe late onset Alzheimer's dementia, agitation, insomnia, and depression. Review of the resident's care plans showed no focus or interventions related to the use of psychotropic medications or monitoring for adverse consequences. Multiple orders for Lorazepam were present in the resident's record, but there was no documented consent for these medications, either written or verbal. The resident's family member and Durable Power of Attorney (DPOA) was not aware that the resident was receiving Lorazepam and reported not having given permission for its use. Interviews with facility staff revealed that the process for obtaining and documenting consent was inconsistent and lacked a standard procedure. The social worker was unable to locate any notes indicating that consent had been obtained for the prescribed Lorazepam, and the nurse liaison confirmed there was no documentation of verbal consent in the resident's record. The absence of proper documentation and communication resulted in the resident or their representative not being fully informed or able to make decisions regarding the risks, benefits, and alternatives to the prescribed psychotropic medication.
Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement care plan interventions and follow facility policy to prevent falls for a resident with dementia, confusion, incontinence, reduced mobility, and end-stage Alzheimer's disease. The resident was identified as a fall risk, and the care plan included interventions such as keeping the bed in a low position, placing a fall mattress next to the bed, and conducting regular visual checks. Despite these interventions being documented, staff did not consistently ensure the fall mattress was properly positioned next to the bed as required. On one occasion, a CNA observed the resident attempting to get out of bed and sliding to the floor, after which additional fall prevention measures were added, including placing one side of the bed against the wall and using a full-thickness mattress on the open side. However, during a later observation, the fall mattress was found standing on its side rather than lying flat on the floor next to the bed. Staff interviews revealed that the CNA forgot to lay the mattress down after removing the resident's roommate, and the LPN assumed the CNA would do it, resulting in the intervention not being in place as intended. The facility's policy required that interventions to prevent falls be implemented and care plans updated as needed. Despite the resident's high risk for falls and the documented need for a fall mattress, staff failed to consistently follow the care plan and policy, leaving the resident without the required fall protection at the bedside. This lapse in following established interventions and policy contributed to the deficiency cited by surveyors.
Failure to Maintain Catheter Tubing and Drainage Bags Off the Floor
Penalty
Summary
The facility failed to prevent the risk of urinary tract infection by not ensuring that urinary catheter tubing and drainage bags were kept off the floor for two residents with indwelling catheters. One male resident with a history of stroke and gross hematuria was observed lying in bed with his catheter bag resting directly on the floor without a barrier. This was confirmed by an LPN, who subsequently placed a towel under the bag. The clinical nurse supervisor confirmed the resident had a Foley catheter, which had last been changed the previous month. A female resident with dementia, insomnia, and diabetes was observed self-ambulating in her wheelchair with her catheter bag in a privacy bag, but with approximately 12 inches of catheter tubing dragging on the floor. Multiple observations confirmed that both the tubing and the privacy bag containing the catheter bag were in contact with the floor as she moved around the facility. The urine in the tubing appeared dark yellow, orange-tinged, and cloudy. Staff interviews confirmed that this resident had recurrent urinary tract infections, and a recent urinalysis showed evidence of infection. Facility policy requires that catheter tubing and drainage bags be kept off the floor, but this was not followed in these cases.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The Certified Dietary Manager (CDM) revealed that maintenance staff and an external vendor were responsible for cleaning the ice machines. However, an inspection of the ice machine's dispensing spout showed a significant accumulation of black and brown debris. Additionally, the microwave in the main kitchen had a buildup of debris and chipping surfaces, and utensil drawers contained crumb debris. These conditions indicate a lack of proper cleaning and maintenance, which could lead to food contamination. Further observations revealed improper storage and temperature control of food items. An open gallon container of soy sauce was stored under a preparation table despite instructions to refrigerate after opening. The dish machine was not consistently reaching the required minimum wash temperature of 160°F, as evidenced by multiple cycles showing temperatures below this threshold. The CDM admitted that staff were not diligent in maintaining logs to ensure the dish machine's proper functioning, and the device used to test the machine was reportedly malfunctioning. The facility also failed to properly cool and store leftover food items. During a review of the walk-in cooler, items such as chili, creamy vegetable soup, and cooked pork loin were found at temperatures above the recommended 41°F. The CDM was unsure of the cooling methods used and decided to discard the items. A subsequent visit found a pan of pork gravy at 69°F, which was also discarded. These findings highlight a lack of adherence to FDA Food Code standards for cooling and storing food, potentially leading to foodborne illnesses among residents.
Plan Of Correction
Element #1 No specific Residents were identified in citation. Ice Machine and Dish Machine were serviced/cleaned by vendor, microwave was replaced. Utensil drawers were cleaned of debris, floor area behind ice machine has been cleaned. Soy Sauce disposed of at time of observation. Observed gallon of chili, vegetable soup and pork loin discarded at time of observation. Element #2 Residents residing in facility who have food prepared in the dietary department have potential to be affected. Element #3 Nutrition Services staff have re-educated on 2017 FDA food Code sections 4-601.11, Food Contact, Section 3-501.16 Time/Temp control for safety food hot/cold handling by CDM. Element #4 Nutrition Services Manager/designee will complete random weekly sanitation audits, cooling log and Dish Temperature audits. Variances will be addressed at the time of observation. Weekly audits to be forwarded to the facility QAPI committee for review and further recommendations. Element #5 The Administrator is responsible for sustained compliance.
Deficiencies in Infection Control and Water Management
Penalty
Summary
The facility was found to have deficiencies in its infection prevention and control program, specifically related to the management of water systems and hand hygiene practices. During a tour, it was observed that the facility lacked an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens in its plumbing system. Maintenance staff were unaware of regular flushing procedures for unused water fixtures, and brown, discolored water was observed in several areas, indicating a lack of routine flushing. Additionally, the facility did not have an active team overseeing the water management plan, and there was uncertainty about the permitting of the secondary treatment system. Infection control practices were also found to be lacking during resident care. For instance, a CNA was observed providing incontinence care to a severely cognitively impaired resident without changing gloves or performing hand hygiene between dirty and clean tasks. Similarly, an RN and an LPN failed to use proper PPE during G-tube medication administration and dressing changes for residents under enhanced barrier precautions. The RN did not change gloves or perform hand hygiene while handling various items and performing tasks, and the LPN did not wear a gown during medication administration, contrary to facility policy. The facility's infection control policy requires enhanced barrier precautions, including gown and glove use, during high-contact care activities. However, staff interviews revealed a lack of understanding and adherence to these precautions. The Director of Nursing and the Staff Educator/Infection Preventionist acknowledged the need for proper PPE use and hand hygiene but noted that glove use during incontinence care was not frequently audited. These deficiencies highlight significant lapses in infection control practices, increasing the potential for cross-contamination and disease transmission among residents.
Plan Of Correction
DSP A Element #1 No residents identified. Element #2 Residents residing in the facility have the potential to be affected. Front and Back 200 Spa rooms have been flushed to include tubs and commodes. Front and Back 100 soiled utility rooms have been flushed to include hopper sprayers. Element #3 Maintenance Technician and EVS supervisor have been re-educated on facility Water Safety and Management plan to include routine flushing and commissioning of portable water systems and Wednesday Water flushing protocols. Element #4 EVS/Designee to complete random weekly audit of required Wednesday flushing to include Spa and soiled utility areas. Variances will be addressed at the time of observation. Weekly audits to be submitted to the facility QAPI committee for review and further recommendations. Element #5 The Administrator is responsible for compliance. F880 DSP B Element #1 Residents #1, #29, #52, and #65, have had no adverse outcomes related to observations. Element #2 Residents residing in the facility have potential to be affected. Element #3 Licensed nursing staff have been reeducated on Infection Prevention and Control policy, including hand hygiene, peri care, enhanced barrier precautions, and g-tube care. Infection Control and prevention policy has been reviewed by DON and Administrator and deemed appropriate. All staff were re-educated on hand hygiene and enhanced barrier precautions. Element #4 Don/Designee will complete random weekly audits to ensure appropriate PPE, infection control practices including EBP, hand hygiene, peri care/catheter care, and g-tube care are followed. Variances will be addressed at the time of observation. Weekly audits to be submitted to the facility QAPI committee for review and further recommendations. ELEMENT #5 The Administrator is responsible for sustained compliance.
Incomplete Advance Directives Documentation
Penalty
Summary
The facility failed to accurately and completely document advance directives for three residents, leading to potential non-compliance with residents' medical care preferences. Resident #37 was admitted with a DNR order in the physician's orders, but there was no signed paperwork in the resident's chart confirming this status. The social worker was unsure if the resident was informed about the code status, and the resident himself was uncertain about his preference and whether he had signed any related documents. The nursing home administrator confirmed the absence of specific code status paperwork for this resident. Resident #312 had a DNR order, but the required documentation was incomplete. The DNR form was signed by the second advocate instead of the first, and there was no capacity form or two physician signatures to confirm the resident's inability to make decisions. The social worker acknowledged the missing documentation, and the nursing home administrator mentioned efforts to improve the process. Similarly, Resident #60 had a DNR order without signed documentation from the resident and physician. The social worker admitted that hospital discharge paperwork indicating a DNR status could not be used for the facility's DNR order and was unaware of the issue until it was brought to attention.
Plan Of Correction
Element #1: Resident #37, #312, and #60 Advanced Directives have been updated to reflect patient goals of care. Element #2: Residents that currently reside in the facility have potential to be affected. Element #3: Facility Social Workers have been re-educated on Michigan Do-Not-Resuscitate Procedure Act. Advanced Directives of residents currently residing in the facility have been audited; any identified concerns will be corrected in the moment. Element #4: Social Worker/Designee will complete 5 weekly Advanced Directive audits to ensure they meet requirements of the Michigan Do-not-Resuscitate Act and resident goals of care. Variances to be corrected at time of observation. Audits to be submitted to facility QAPI for review and further recommendations. Element #5: The Administrator is responsible for sustained compliance.
Facility Fails to Maintain Clean and Safe Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for Resident #75, who had multiple health conditions including macular degeneration, legal blindness, dementia, diabetes, and kidney disease. Observations revealed that the resident's room contained a mattress on the floor next to the bed, which was heavily soiled with dried liquid stains, dried food, dusty shoe prints, and white dried material. Additionally, the room had significant damage to the walls, including gouges and missing paint, with exposed drywall and metal corner guards. Interviews with facility staff, including a CNA, RN, Housekeeping Manager, and Maintenance personnel, indicated a lack of effective communication and follow-up regarding maintenance and cleanliness issues. The CNA and RN reported that they would inform the nurse or environmental services about such issues, but there was no evidence of work orders being completed. The Housekeeping Manager acknowledged the responsibility for cleaning the mattress, while the Maintenance staff noted that funding for room repairs had not been secured. The maintenance staff also reported that they were the only maintenance personnel present, which may have contributed to the lack of timely repairs and maintenance in the resident's room.
Plan Of Correction
Element# 1 Medical equipment for resident #75 has been cleaned and sanitized. Gouges, dings, and dents on #75 wall have been repaired. Element# 2 Residents residing at the facility have the potential to be affected. All resident mattresses on the floor have been cleaned and sanitized. Facility Maintenance Technician/designee has audited facility resident rooms and work orders were placed for any rooms found with gouges, dings, and dents. Element #3 Environmental services have been educated on mattress cleaning protocol. Facility Maintenance technician has been re-educated on the process to track and retrieve work orders. Element #4 Environmental Services lead or designee(s), will conduct random weekly audits of medical equipment cleanliness and wall integrity. Audits will be forwarded to the facility QAPI committee for review and further recommendations. Element #5 The Administrator is responsible for sustained compliance.
Failure to Transmit MDS Discharge Assessments Timely
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) discharge assessments in a timely manner for two residents, resulting in the potential for inaccurate tracking of discharges. Resident #82 was discharged on 9/19/2024, but her MDS discharge assessment, with an assessment reference date (ARD) of 9/20/2024, was incomplete and not transmitted. The sections GG, J, M, N, O, and P were still in progress. Similarly, Resident #93 was discharged on 9/17/2024, and her MDS discharge assessment, with an ARD of 9/17/2024, was also incomplete and not transmitted, with section K still in progress. During an interview, MDS nurse D confirmed that the discharge assessments for both residents should have been completed and transmitted by specific dates in October 2024.
Plan Of Correction
Element 1: MDS discharge assessment for residents #82 and #93 were completed and transmitted. Element 2: Residents that discharge from the facility have the potential to be affected. The last 6 months of discharges have been reviewed for MDS completion and transmission. Identified concerns were addressed at time of observation. Element 3: MDS Nurses have been re-educated on encoding and transmitting data requirements of CMS. Element 4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s) will conduct random weekly audits of discharge MDS completion and submission. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5: The Administrator is responsible for sustained compliance.
Failure to Complete PASARR Level II Assessment
Penalty
Summary
The facility failed to ensure that a PASARR Level II assessment was completed for a resident, resulting in the potential for unmet mental health care needs. The resident, a female with diagnoses including recurrent major depressive disorder, dementia with behavioral disturbances, and bipolar affective disorder, was admitted to the facility and had a BIMS score indicating severe cognitive impairment. Despite the need for a Level II assessment being identified in the initial PASARR Level I assessment, no Level II assessment was found in the resident's electronic medical record. During an interview, the social worker reported that the PASARR Level I assessment was completed, indicating the need for a Level II assessment. However, the social worker could not produce a paper copy of the Level I assessment and confirmed that there was no completed Level II assessment or recommendation letter available on the OBRA website for the resident. The absence of a PASARR Level II assessment or recommendation letter was confirmed by the survey exit.
Plan Of Correction
Element #1 Resident #16 had a completed PASARR assessment. Resident was assessed for psychosocial well-being and found to be at baseline. Care Plan and Resident Care Summary reviewed and found to be appropriate to reflect resident care needs. Element #2 Residents residing in the facility have the potential to be affected. PASARR assessments for current residents were reviewed for timely completion. Any gaps identified have been addressed. Element #3 The facility Social Workers have been re-educated to the PASARR requirements. Element #4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Administrator, or designee(s), will randomly audit residents weekly to validate timely completion of PASARR assessments. The QAPI Committee will review findings and determine ongoing need for audits. Element #5 The Administrator is responsible for sustained compliance.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was receiving Hospice care, resulting in a deficiency. The resident, identified as Resident #58, was admitted with diagnoses including dementia and Alzheimer's disease and had a severely impaired cognitive status. A significant change in the resident's condition was noted, leading to the initiation of Hospice care. However, upon review, it was found that there was no Hospice care plan developed for the resident, which is a requirement for individualized care. During an interview, the MDS nurse revealed a misunderstanding regarding the responsibility for completing the Hospice care plan. The nurse initially believed that the Social Worker was responsible for this task, but later acknowledged that it was her responsibility. The facility's Care Planning and Coordination Policy mandates that each patient must have an individualized written plan of care, which was not adhered to in this case, leading to the potential for unmet care needs for the resident.
Plan Of Correction
Element #1 Residents #58 no longer resides in the facility. Element #2 Residents residing in the facility have the potential to be affected. Resident care plans have been reviewed and updated to reflect current care needs. Element #3 The interdisciplinary team has been re-educated on the Care Planning and Coordination policy. Element #4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s) will conduct weekly audits of care plans to ensure appropriateness. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5 The Administrator is responsible for sustained compliance.
Failure to Provide Adequate Nail Care to a Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care to a dependent resident, resulting in an unkempt appearance and potential for infection. Resident #52, who was severely cognitively impaired and dependent on staff for activities of daily living (ADLs), was observed multiple times with long, dirty fingernails caked with black debris. Despite the resident's expressed preference for clean and trimmed nails, staff did not provide the necessary care. The care plan indicated that Resident #52 required extensive assistance with ADLs, including nail care. Interviews with staff revealed inconsistencies in the provision of nail care, with some CNAs stating it should be done during showers, while others indicated it could be done anytime. An LPN acknowledged the need for nail care but left the resident's room without completing it, citing time constraints. The Director of Nursing expected nails to be clean and trimmed as needed, but there was no documentation of nail care in the resident's records. This lack of consistent care and documentation contributed to the deficiency identified by surveyors.
Plan Of Correction
Element #1: Nail care was provided for Resident #52. Element #2: Residents' dependent for fingernail grooming/hygiene have the potential to be affected. These Residents who are dependent for fingernail grooming/hygiene will be observed for appropriate fingernail grooming/hygiene and any concerns will be addressed at time of observation. Element #3: Certified Nursing Assistants and Licensed Nurses will be re-educated on ADL standards of care. Element #4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Nurse Manager, or designee(s), will randomly audit dependent residents for ADL standards of care. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5: The Administrator is responsible for sustained compliance.
Failure to Administer Diuretic Medication Leads to Hospitalization
Penalty
Summary
The facility failed to provide care in accordance with physician orders and professional standards for Resident #49, who was admitted with diagnoses including congestive heart failure (CHF) and a pacemaker. Upon admission, the resident's diuretic medication, Lasix, was not administered as ordered, leading to significant weight gain and worsening of his medical condition. Despite the resident's attempts to communicate the need for Lasix to the nursing staff, the medication was not consistently provided, resulting in hospitalization for fluid overload and management of skin breakdowns. The Clinical Nurse Supervisor (CNS) confirmed that the resident's diuretic was listed on hospital paperwork but was not administered regularly. The resident's weight was monitored daily due to CHF, but significant weight increases were not reported to the physician, nor were there any adjustments made to the diuretic medication. The resident's weight increased from 94.2 kg at admission to 106 kg by the time of re-hospitalization, with no documentation of provider notification or intervention. Interviews with the Nurse Practitioner (NP) and review of medical records revealed that the facility's Medical Doctor (MD) had noted the need for continued Lasix, but the medication was not consistently administered. The resident's cardiologist identified the lack of Lasix administration during a pacemaker check, leading to the resident's admission to the hospital for diuresis. The facility's failure to administer Lasix as ordered and to address significant weight changes contributed to the resident's deteriorating condition and subsequent hospitalization.
Plan Of Correction
F684 Element #1: Resident #49 physician orders and treatment reviewed and appropriate. Element #2: Residents that reside in the facility have the potential to be affected. Residents have been reviewed for significant change in condition with physician notification. Element #3: Licensed Nurses have been educated on the facility's Change in Condition Notification of Clinician policy. Element #4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s) will conduct weekly audits for residents who have significant change in condition physician communication. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5: The Administrator is responsible for sustained compliance.
Failure to Provide Adequate Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide preventative care consistent with professional standards for two residents at risk for pressure injuries. Resident #98, who had a history of pressure injuries and was assessed as being at mild risk, was observed multiple times in a wheelchair with improper positioning and without adequate pressure relief. The resident's blue boots, intended to reduce pressure, were often not securely attached, and the resident was left in the same position for extended periods, leading to a pressure ulcer on the right heel. Despite having a catheter, the resident was not repositioned or provided with adequate pressure relief, and catheter care was not performed during an observed transfer. Resident #65, also assessed as being at mild risk for pressure injuries, was observed spending most of his time in a wheelchair without a pressure-reducing cushion, as required by his care plan. The resident was seated on a hoyer sling instead, which does not provide the necessary pressure relief. Staff interviews confirmed the absence of a pressure-reducing cushion, and the resident was observed in the same position for extended periods without repositioning, increasing the risk of skin breakdown. The report highlights the facility's failure to adhere to care plans and professional standards for pressure ulcer prevention, resulting in inadequate care for residents at risk of pressure injuries. The lack of proper positioning, pressure relief, and adherence to care plans for both residents demonstrates a significant deficiency in the facility's care practices, potentially leading to worsening of existing pressure injuries and the development of new ones.
Plan Of Correction
Element# 1 Braden assessment for resident #65, and #98 have been completed, and interventions implemented based on identified risk areas. Element# 2 Residents at risk for skin breakdown have the potential to be affected. Resident Braden assessment identifying residents at risk have been reviewed as well as appropriate interventions in place. Element# 3 Licensed Nurses and CNAs have been educated on Pressure ulcer prevention including repositioning and support surface implementation. Element# 4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s), will conduct weekly observation audits to ensure appropriate skin interventions are in place. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element# 5 The Administrator is responsible for sustained compliance.
Deficiencies in Water Temperature Control and Resident Transfers
Penalty
Summary
The facility was cited for failing to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120°F. During a tour, it was observed that the hot water in the back 100 spa room reached 128°F, despite the presence of a point-of-use mixing valve intended to temper the water to a safe level. Interviews with maintenance staff revealed that the facility did not regularly monitor hot water temperatures to ensure they remained within safe limits, increasing the risk of injury to residents. Additionally, the facility failed to ensure safe chair-to-bed transfers for two residents. One resident, who required substantial assistance for transfers, was observed being transferred by a CNA without the use of a gait belt or assistance from a second staff member, contrary to the resident's care plan. The resident attempted to bear weight on a foot with a pressure wound during the transfer. Another resident, who required a mechanical lift for transfers, was observed being transferred with the hoyer sling improperly attached, risking the resident's safety. Interviews with staff confirmed the improper transfer techniques and the residents' need for specific assistance during transfers.
Plan Of Correction
DPS A Element #1 No residents were mentioned in the citation. Element #2 No residents have been identified at risk. 100 spa rooms are not currently utilized by facility residents. Element #3 Mixing valve in spa room 100 was removed and delimited. Spa room 100 hot water temperature post deliming was under 120 degrees. Facility Maintenance technician has been re-educated on appropriate safe water temperatures in patient care areas. Element #4 Facility Maintenance tech/Designee will complete 5 random weekly temperature checks in resident care areas. Any variances will be addressed at time of observation. Audits to be forwarded to facility QAPI for review and further recommendations. Element #5 The Facility Administrator is responsible for compliance. DPS B Element #1 Resident #98 and #65 have been re-evaluated to determine the amount of assistance needed to transfer safely. Resident care summaries have been updated to reflect current care needs. Element #2 All residents who require assistance with transfers have the potential to be affected by the same deficient practice. Element #3 Licensed nurses and certified nursing assistants have been re-educated on resident care plan/resident care summary regarding the amount of assistance required for a safe transfer and mechanical lift operation. Element #4 Under the direction of the Quality Assurance and Performance Improvement Committee, the Director of Nursing or designee(s) will conduct weekly observation audits of resident transfers including those that use mechanical lifts to assure the correct transfer technique followed. Audits will be forwarded to the Facility QAPI Committee for review and further recommendations. Element #5 The Director of Nursing is responsible for sustained compliance.
Deficiencies in Catheter and Incontinence Care
Penalty
Summary
The facility failed to ensure proper care for two residents with indwelling foley catheters, leading to potential risks of catheter dislodgement, pain, and infection. Resident #98, who was at risk for compromised skin integrity due to impaired mobility and incontinence, was observed without proper catheter securement, causing her pain. The resident had been in her wheelchair for five hours without being toileted, contrary to her care plan, which required toileting every two hours. Additionally, during incontinence care, the catheter was not secured to her leg, and no catheter care was performed, despite the resident's complaints of discomfort. Resident #65, who had a catheter due to bladder outlet obstruction, also did not receive appropriate care. The resident's catheter was not secured with a leg strap as required, and during incontinence care, the CNA did not change gloves after contact with feces, potentially leading to cross-contamination. The CNA also failed to apply barrier cream after cleaning the resident, which is part of standard incontinence care. These deficiencies were observed during staff interviews and direct observations, highlighting lapses in catheter care and infection control practices.
Plan Of Correction
Element #1: For resident #65 and #98, securement devices have been provided per the plan of care. Element #2: Residents residing in the facility receiving assistance with incontinence care and/or have foley catheters have the potential to be affected. Element #3: Licensed nurses and certified nurse assistants will be re-educated to ensure incontinence care and foley catheter care are consistent with professional standards of practice. Element #4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Nurse Manager, or designee(s), will perform randomly weekly audits of dependent residents for appropriate foley catheter care and incontinence care. Weekly audits are to be submitted to the facility QAPI committee for review and further recommendations. Element #5: The Administrator is responsible for sustained compliance.
Failure to Monitor Oxygen Equipment for Resident
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of oxygen delivery equipment for a resident with chronic obstructive pulmonary disorder (COPD). Resident #16, who was severely cognitively impaired, was observed with an empty water bottle connected to her oxygen concentrator, which was still running. The oxygen tech responsible for maintaining the equipment reported that he was unable to perform the scheduled maintenance the previous week due to scheduling issues, resulting in a delay until the following Monday. Interviews with facility staff revealed inconsistencies in the understanding of responsibilities for monitoring the oxygen equipment. The Registered Nurse (RN) and Clinical Nurse Supervisor (CNS) indicated that nurses should monitor and replace empty water bottles as needed, while the Director of Nursing (DON) stated that she did not expect nurses to monitor the equipment, as an external company was responsible for it. This lack of clarity and oversight led to the deficiency in ensuring the oxygen delivery equipment was properly maintained for Resident #16.
Plan Of Correction
Element #1 Residents #16's oxygen delivery equipment water humidifier bottle has been replaced. Element #2 Residents residing in the facility requiring oxygen therapy have the potential to be affected. Their equipment has been inspected and serviced as identified. Element #3 Licensed nurses were re-educated on oxygen equipment usage and appropriate maintenance of equipment. Element #4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Nurse Manager, or designee(s), will conduct random weekly audits on residents who require oxygen therapy to ensure proper equipment is available and utilized. Element #5 The Administrator is responsible for sustained compliance.
Failure to Document Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the physician documented a review of pharmacy recommendations and follow-up actions for a resident, leading to potential medication side effects and unnecessary medications. The resident, who was cognitively intact, had several pharmacy recommendations that were not addressed by the physician. These recommendations included changing Lidoderm orders to PRN due to frequent refusals, re-evaluating the need for duplicate therapy with Elderberry Immune Complex and Vitamin C, and discontinuing Peri-Colace due to the use of Linzess. Further recommendations included improving glycemic control by adjusting insulin therapy and considering a gradual dose reduction of Zoloft, as required by federal nursing facility regulations. Despite these recommendations, the physician's response was left blank, with no signature or date, indicating a lack of follow-up on the pharmacy's suggestions. The facility's policy required that pharmacists report any irregularities to the attending physician, medical director, and director of nursing, with actions to be taken within specified timeframes. However, the physician did not review or sign the pharmacy recommendations for the resident, and the facility's nurse liaison acknowledged this oversight during an interview. This lack of documentation and follow-up on pharmacy recommendations resulted in a deficiency in medication management for the resident.
Plan Of Correction
Drug Regimen Review Element #1: Resident #15 has not had any negative outcomes related to observation. Resident #15's Pharmacy Recommendations have been reviewed by the facility provider, and new orders have been placed as deemed appropriate by the provider. Element #2: Residents residing in the facility have the potential to be affected. Element #3: The facility provider that is designated to complete Drug Regimen Review has been re-educated on the facility medication management policy. The medication management policy has been reviewed by the Director of Nursing and Administrator and deemed appropriate. Element #4: The Director of Nursing/designee will complete a random monthly audit on the completion of Drug Regimen Review recommendations. Variances will be corrected at the time of observation. Audits will be forwarded to the facility QAPI committee for further review and recommendations. Element #5: The Administrator is responsible for sustained compliance.
Failure to Provide Required Emergency Lighting in Generator ATS Room
Penalty
Summary
The facility failed to maintain its generator in accordance with NFPA 110 requirements. During an observation, it was found that there was no battery back-up light installed in the electrical room containing the generator Automatic Transfer Switch (ATS), as required by NFPA 110, section 7.3. This deficiency was identified through direct observation and confirmed in an interview with the Maintenance Technician at the time of discovery. The lack of a battery back-up light in the generator ATS room could potentially affect all occupants of the facility, as it would result in no emergency lighting in the event of a generator failure, leaving no lighted access to emergency equipment. The report does not mention any specific residents or staff affected at the time of the deficiency, nor does it provide details about their medical history or condition.
Failure to Maintain Self-Closing Doors in Hazardous Storage Areas
Penalty
Summary
Surveyors observed that the facility failed to ensure proper protection of hazardous areas as required by Life Safety Code (LSC) 19.3.2.1. Specifically, on two separate occasions, it was found that the doors to the Therapy storage closet and the 100 back hall storage closet (used for emergency food and water storage) did not self-close to a positive latch. These deficiencies were identified during direct observation and confirmed through interviews with the Maintenance Technician present at the time. The report notes that these failures could potentially affect 20 occupants in the event of a fire not being contained to the hazardous area. No information about corrective actions or follow-up measures is included in the report, and there are no details provided about specific residents or their medical conditions at the time of the deficiency.
Smoke Barrier Door Failed to Self-Close Due to Improper Alignment
Penalty
Summary
The facility failed to provide smoke barrier doors that were self-closing or automatic-closing as required by Life Safety Code (LSC) 19.3.7.8 and Chapter 7. During an observation, it was found that the north cross-corridor door leaf at the 100 front hall near room 121 was not plumb, causing it to bind on the floor. This condition prevented the door from releasing upon activation of the fire alarm and from closing sufficiently to maintain the minimum clearance necessary for proper operation in accordance with LSC 7.2.1.8.2. These findings were confirmed during an interview with the Maintenance Technician at the time of discovery.
Inadequate Supervision Leads to Resident's Choking Death
Penalty
Summary
The facility failed to ensure the safety and provide adequate supervision for a resident with a history of dysphagia and choking incidents, resulting in the resident choking on food and subsequently dying. The resident, who had a history of dementia, oropharyngeal dysphagia, and larynx cancer, was on a specialized diet due to his condition. Despite being educated on the risks of not adhering to the recommended diet, the resident chose to eat foods that were not suitable for his condition. The facility did not implement sufficient interventions to ensure his safety while eating, especially when he chose to eat in his room. The resident's care plan indicated that he should eat in communal dining areas for increased supervision, but this was not consistently enforced or documented in the Resident Care Summary. During a COVID-19 outbreak, the main dining room was closed, and the resident was allowed to eat in his room without adequate supervision. Staff members were not fully aware of the resident's need for increased supervision during meals, and there were no additional safety measures in place when he ate alone in his room. On the day of the incident, the resident was found unresponsive in his room after choking on a piece of steak. Despite efforts to resuscitate him, he was declared dead, and the cause of death was determined to be choking. The facility's lack of consistent supervision and failure to implement necessary safety interventions contributed to the resident's death.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 205 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stevensville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royalton Manor, Llc | 2.3 mi | ★★★★★ | 5 | 0 |
| Coventry House Inn | 2.5 mi | ★★★★★ | 14 | 0 |
| West Woods Of Bridgman | 7.7 mi | ★★★★★ | 53 | 1 |
| The Orchards At Niles | 18.1 mi | ★★★★★ | 20 | 0 |
| Niles Care Center, Llc | 19.7 mi | ★★★★★ | 33 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Corewell Health Rehabilitation & Nursing Center -.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.