Above 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 Mymichigan Skilled Nursing Facility during CMS and state inspections, most recent first.
The facility failed to maintain an active plan to reduce the risk of legionella and other OPPP in the laundry room. Surveyors observed two unused spigots, two dead-end lines near the washers, and a dead-end water line with a filter near the desk area; Housekeeping Mgr C stated the fixtures and lines were not used, and Maintenance M stated only the ceiling-hung lines were flushed monthly while the other unused lines and spigots were not flushed.
The facility failed to document appropriate indications and behavior monitoring for psychotropic medication use for multiple residents. Records showed antidepressant, anti-anxiety, and antipsychotic medications ordered for residents with diagnoses such as dementia, depression, anxiety, stroke, and psychotic disturbance, but nursing notes and Behavior Management Team documentation often lacked resident behaviors, assessment, or justification for use. Staff interviews confirmed missing documentation and inconsistent understanding of the Behavioral Management process, and one resident’s consent reasons did not match the order indications.
Informed consent was not obtained before starting a resident on a psychotropic medication. The resident was cognitively intact, had anxiety and depression, and was receiving Buspar, Lamictal, and Lexapro, but the consent form only covered some of the psychotropic meds and did not include Lexapro. The SS RN and Administrator both confirmed consent should have been obtained before the medication was started.
A resident with bilateral foot drop contractures, impaired ROM, and dependence for care was not receiving therapy or restorative nursing services, and no care plan or order was in place for ROM, contracture management, or PRAFO boots. Staff documentation showed only unclear AROM entries, no PROM task, and no refusal documentation, while observations found the resident unable to move the ankles, reporting pain with gentle PROM, and not wearing the boots that were present in the room. Interviews confirmed therapy had not evaluated the resident for contracture management and the restorative RN, DON, and CNA staff could not explain how the resident’s ROM needs were being monitored or addressed.
A resident receiving Eliquis for a pulmonary embolus had no care plan or documented monitoring for signs or symptoms of bleeding or other adverse effects. The MDS RN confirmed the resident was on an anticoagulant, verified there was no anticoagulation care plan in the EMR, and stated there was no monitoring in place. The Administrator also acknowledged the concern, and the facility’s medication management policy did not address monitoring for adverse consequences of medication therapy.
Medication administration errors exceeded the 5% threshold after two errors were observed in 32 med passes. Two RNs administered bethanechol chloride to two residents without following the blister pack instruction to give it on an empty stomach; one dose was prepared while a food tray was present, and the other was given after breakfast. Both nurses were unsure of the medication-specific instructions, and the DON was informed of the errors.
The facility failed to respond to a call bell system for two residents, leaving them without assistance in the dining room. Despite ringing a manual silver bell, no staff responded until one resident yelled out. The call bell was out of reach, and staff did not adhere to the facility's policy requiring prompt response to call bells.
The facility failed to ensure safe wheelchair transport for two residents, who were observed being pushed without footrests, posing a potential risk for injury. Both residents were severely cognitively impaired and required assistance with daily activities. The DON acknowledged the need for foot pedals for safety, but the facility's policy did not address wheelchair transport.
A facility failed to implement policies for psychotropic medication use for a resident, leading to inappropriate treatment and lack of informed consent. The resident, with severe cognitive impairment and anxiety, was on Buspirone and Fluoxetine without mental health provider involvement. The facility did not effectively use non-pharmacological interventions or coordinate care with community mental health services.
The facility failed to date and label food items in the kitchen and resident areas, risking foodborne illness. Observations revealed undated hamburger buns, marshmallows, tangerines, and blueberries. The CDM and DON acknowledged the oversight, discarding the unmarked items. The facility's policy requires proper labeling and dating of food, which was not followed.
Inactive Water Lines and Unused Fixtures in Laundry Room
Penalty
Summary
The facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). During observation of the laundry room, two spigots on the dirty side were seen, and Housekeeping Manager C stated they were not used. Two dead-end lines coming down from the ceiling, located adjacent to the washers and not connected to anything, were also observed; Housekeeping Manager C stated they had not been used since she had been working there. In addition, a dead-end water line with what appeared to be a filter attached was observed near the desk area in the laundry room, and Housekeeping Manager C stated it had not been used since she had been working there. During interview, Maintenance Mechanic D stated the unused water lines hanging from the ceiling adjacent to the washers are flushed monthly, but the two unused spigots on the dirty side and the water line with the filter near the desk area are not flushed. The facility Water System Program and Risk Assessment states under dead legs/abandoned piping to remove piping and fixtures that are no longer used and to flush dead piping that is not removed. The report also cites CDC guidance dated January 3, 2025, stating to eliminate dead legs and flush low-flow piping runs and dead legs at least weekly.
Psychotropic medications lacked documented justification and behavior monitoring
Penalty
Summary
The facility failed to ensure appropriate indications for the use of psychotropic medications for five residents reviewed for chemical restraints. The deficiency was identified during interview and record review and involved residents receiving antidepressant, anti-anxiety, and antipsychotic medications without documentation showing behaviors, monitoring, or justification for use in the records reviewed. The facility’s Behavior Management Monitoring Policy stated the Behavioral Management Committee was to monitor psychoactive medication use weekly and determine whether there was justification for initiation of such medications, with the Social Worker reviewing progress notes and care plans before committee review. For one resident, the record showed sertraline was ordered for depression, and the care plan addressed psychotic drug use, psychosocial well-being, mood, and loneliness, but nursing notes from 4/3/26 through 4/13/26 contained no entries of resident behaviors, assessment, monitoring, or documentation of justification for the medication. For another resident with diagnoses including stroke, confusion, and psychotic disorder with delusions and skin picking, orders included Lexapro, Remeron, and Buspirone, but nursing notes from 3/16/26 through 4/10/26 contained no documentation of targeted behaviors, assessment, or monitoring, and no justification for the psychoactive medications was found. A third resident with dementia, psychotic disturbance, mood disturbance, and anxiety had orders for sertraline and Aricept, but the only two Behavior Management Team notes found contained no documentation of behaviors, and nursing notes from 3/26/26 through 4/5/26 showed only two entries of swatting at staff, which Social Service stated was not enough to justify psychoactive medications. A fourth resident with cerebral infarction, anxiety disorder, and dependence for ADLs had orders for lorazepam every 6 hours and buspirone three times daily, but nursing notes from admission through 4/14/26 contained no documentation of behaviors, an implemented mood management plan, or monitoring of behaviors, and Social Service stated no documentation for psychoactive medications could be found. For the fifth resident, the record showed diagnoses of dementia and depression, with psychotropic medications including fluoxetine, buspirone, and olanzapine; staff acknowledged the listed indications for Buspar and Zyprexa were not acceptable. Consent forms listed reasons for use that did not match the order indications, and documentation of behaviors was limited to two episodes of crying/tearfulness and sad/worried facial expression in the Point of Care history. During interview, Social Service RN E stated she was not aware of a Behavioral Management committee and was not familiar with the facility policy, and the Administrator stated there was room for improvement.
Informed Consent Not Obtained for Psychotropic Medication
Penalty
Summary
The facility failed to implement and operationalize policies and procedures to ensure informed consent was obtained before starting psychotropic medication therapy for one resident. Resident #2 was admitted with diagnoses including generalized anxiety disorder and depression, was cognitively intact, and required moderate to total assistance with ADLs except for supervision/setup for oral care and eating. The resident’s care plan identified risk for adverse consequences from psychotropic medications, and the MAR showed the resident was receiving Buspar, Lamictal, and Lexapro. Record review showed an Informed Consent/Risk Benefit Analysis form signed by the resident’s DPOA and a facility RN for Lamictal, Buspar, and Hydroxyzine, but the physician signature area was blank and Lexapro was not included on the consent. During interview, the Social Service RN confirmed the consent did not include Lexapro and stated a consent had not been completed for it, although it should have been obtained prior to initiation. The Administrator also stated consent should have been obtained before therapy began. A policy or procedure related to informed consent for psychotropic medication therapy was requested but not provided by the end of the survey.
Failure to Maintain ROM and Coordinate Restorative Services for a Resident With Bilateral Foot Drop Contractures
Penalty
Summary
The facility failed to provide appropriate care to maintain and/or improve range of motion for a resident with bilateral foot drop contractures. Resident #6 was admitted with diagnoses including diabetes mellitus, a saddle embolus of the pulmonary artery, and right and left foot drop contractures. The resident was cognitively intact, had impaired ROM in both lower extremities, and was dependent on staff for bathing, toileting, and transferring. The MDS indicated the resident was not receiving therapy or restorative nursing services, and the EMR did not contain a care plan or HCP order related to the bilateral foot drop contractures, ROM, or restorative nursing services. Record review showed the resident had previously expressed a desire for therapy to strengthen the legs and improve bilateral foot drop, and later stated a desire to be able to stand. Documentation also showed staff applied boots to the resident’s feet, but the resident complained of pain and requested removal after approximately two minutes. The resident’s restorative nursing assessment from July 2025 documented a ROM program with exercises and a goal to maintain current function, but also noted repeated refusal and discharge from restorative nursing services. Despite this, the resident’s point-of-care documentation from March 2025 through October 2025 reflected only AROM entries, with no task for PROM or PRAFO boot application, no clear description of what AROM was being completed, and no documentation of refusals. During observation, the resident was seen in bed with both feet positioned downward, and when asked to move the ankles, the resident stated they could not. The resident also stated they wanted staff to work with and move their ankles and joints so they would not become stiffer. CNA staff attempted gentle PROM with minimal movement and the resident verbalized pain with the attempt. The resident had PRAFO-style contracture boots in the room, but they were not being worn. Interviews with the restorative RN, DON, therapy director, and other staff confirmed the resident was not receiving restorative nursing services, therapy had not evaluated the resident for contracture management, there was no care plan for the boots or contractures, and staff could not explain how the resident’s contractures were being assessed or managed without therapy input.
Lack of Monitoring for Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure adequate monitoring for potential adverse consequences of anticoagulation therapy for one resident receiving Eliquis 5 mg twice daily for a saddle embolus of the pulmonary artery. The resident’s record showed diagnoses including diabetes mellitus and bilateral foot drop with contractures, and the MDS indicated the resident was cognitively intact and required moderate to total assistance with ADLs except oral care and eating. Review of the HCP orders, MAR, TAR, and EMR documentation showed no documentation of monitoring for signs or symptoms of bleeding or other potential side effects related to the anticoagulant medication. The resident also did not have a care plan related to anticoagulation therapy or monitoring. During interview, the MDS RN confirmed the resident was receiving an anticoagulant, stated residents should have a care plan that includes monitoring, and verified there was no care plan in place for this resident. The RN further stated there was no monitoring in place and that a care plan would be implemented. The Administrator acknowledged awareness of the concern and stated it was being addressed, and also indicated the facility did not believe it had a specific policy or procedure for monitoring potential adverse consequences of anticoagulant medication therapy. Review of the facility’s Medication Management Policy and Procedure did not include information related to monitoring for signs or symptoms of potential adverse consequences of medication therapy.
Medication Administration Error Rate Exceeded 5%
Penalty
Summary
The facility failed to keep the medication administration error rate below 5% after two medication errors were identified during 32 medication pass observations, resulting in a 6.25% error rate. The errors involved bethanechol chloride for two residents, both of whom had blister pack labels stating, "Take on an empty stomach." For one resident, RN K prepared the medication while the resident’s food tray was visible on the overbed table in front of them, then was questioned before administration and did not initially recognize the instruction on the blister pack. RN K stated they were unsure of the facility policy for medications with specific administration instructions and said they would still give the medication. The DON later instructed to hold the medication and inform the doctor. For the second resident, RN J prepared bethanechol chloride from the blister pack and administered it after the resident had already eaten breakfast. RN J did not review the empty-stomach instruction until after administration and stated they would need to look up the medication, noting they were giving it at the scheduled time and would speak with the DON because the administration times might need to be adjusted. The DON was informed and acknowledged the medication error. Facility policy required medications to be administered in a safe, accurate manner and directed staff to read the label on each medication three times and use an approved reference when unfamiliar with the medication’s pharmacology, side effects, or contraindications.
Failure to Respond to Call Bell System
Penalty
Summary
The facility failed to ensure that a call bell communication device was responded to for two residents, resulting in them being seated in the dining room with a silver metal service bell that was rung with no response from facility staff. During an observation, Resident #9 was found thirsty, with a wet brief, and wanting to lay down. Despite ringing the bell multiple times, no staff responded, even though two staff members were seated nearby. It was only after Resident #9 yelled out that a CNA responded and provided a glass of water. The CNA indicated that the resident would yell out if she needed something, suggesting a lack of reliance on the call bell system. Further observations revealed that the dining/TV room had a manual silver call bell placed out of reach of both Resident #9 and Resident #72, with no staff present. The facility's 'Emergency/Call Bell' policy requires call bells to be within reach and staff to respond promptly, which was not adhered to. Additionally, a manual silver call bell in the Resident/Family visitor lounge was also not responded to when rung by the state surveyor, indicating a systemic issue with the call bell response in non-centralized areas.
Deficiency in Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure safe wheelchair transport for two residents, resulting in them being pushed in wheelchairs without footrests, which poses a potential risk for injury. Resident #7 was observed being pushed by Activity Staff L without footrests. This resident, admitted with diagnoses including dementia, anxiety, a left hip injury, and a bone density disorder, was assessed as severely cognitively impaired and required substantial assistance with daily activities. Despite being noted as independent with wheelchair mobility, the care plan indicated a risk of falls due to a history of falls and weakness. Similarly, Resident #17 was observed twice being pushed by CNA M without footrests. This resident, also severely cognitively impaired, required substantial to total assistance with daily activities and had a history of repeated falls. The Director of Nursing acknowledged that foot pedals should always be used for safety when pushing residents in wheelchairs, but the facility's policy on transportation guidelines did not address wheelchair mobility or transport. The observations and interviews highlight a deficiency in adhering to safety protocols for wheelchair transport within the facility.
Failure to Implement Psychotropic Medication Policies
Penalty
Summary
The facility failed to implement and operationalize policies and procedures for psychotropic medication use for a resident, resulting in a lack of appropriate diagnoses and indications for treatment, a lack of Gradual Dose Reductions (GDR), and the potential for ineffective and inappropriate treatment. The resident, who was observed to be severely cognitively impaired and required substantial assistance with daily activities, was taking psychotropic medications Buspirone and Fluoxetine without appropriate documentation of informed consent and without being seen by a mental health provider. The resident's care plan included interventions such as attempting GDR and using non-pharmacological interventions, but these were not effectively implemented. The resident was admitted with diagnoses including dementia without behavioral disturbance and anxiety, and was deemed incompetent to make medical decisions. Despite this, the facility obtained a signed consent form from the resident for Prozac after they were deemed incompetent, and the consent form lacked necessary physician documentation. The facility's Social Services Designee and Director of Nursing were unable to provide explanations for the lack of appropriate consent and the absence of mental health provider involvement. Interviews with facility staff revealed that the resident frequently cried and was easily upset, with a history of trauma, but no specific behavioral health services or treatments were provided. The facility did not have a mental health provider on-site and relied on community mental health services, which the resident did not attend due to the Durable Power of Attorney's concerns about the resident's fear of leaving the facility. The facility's failure to coordinate care and obtain necessary documentation from community mental health services further contributed to the deficiency.
Failure to Date and Label Food Items
Penalty
Summary
The facility failed to ensure proper dating and labeling of food items in the kitchen and resident areas, which could lead to foodborne illness. During an inspection, it was observed that kitchen food items, such as hamburger buns and marshmallows, were not dated with received or use-by dates. The Certified Dietary Manager (CDM) acknowledged that these items should have been dated and discarded the unmarked items. Additionally, thermometers in the kitchen refrigerators were not placed correctly, potentially affecting temperature accuracy. In the resident pantry refrigerator, food items brought in by family members, such as tangerines and blueberries, were not labeled with use-by dates, contrary to the facility's policy. The Director of Nursing (DON) confirmed that these items should have been dated and discarded them. The facility's policy requires that food brought in from outside be labeled with the resident's name, room number, and date, and discarded if not consumed within three days. The lack of proper labeling and dating of food items in both the kitchen and resident areas indicates a failure to adhere to established food safety protocols.
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Illustrative
What surveyors actually found near you
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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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Standish
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Sterling | 8.5 mi | ★★★★★ | 6 | 0 |
| Huron Woods Nursing Center | 19.6 mi | ★★★★★ | 15 | 0 |
| The Villa At West Branch | 23.7 mi | ★★★★★ | 1 | 0 |
| Gladwin Pines Nursing And Rehabilitation Center | 26.2 mi | ★★★★★ | 16 | 0 |
| Gladwin Nursing And Rehabilitation Community | 26.3 mi | ★★★★★ | 14 | 0 |
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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.