The Vardell Report.Optalis Health and Rehabilitation of Three Rivers

Across 12 inspections from August 2023 to June 2026, state surveyors documented 77 findings at Optalis Health and Rehabilitation of Three Rivers; 77 have a recorded correction; CMS lists 3 enforcement actions in the window.

Inspections

12

2023–2026, complaint and standard

Findings

77

Deficiencies cited by state inspectors

Corrected

77

Of 77 findings, with a recorded correction date

Penalties

3

2 fines; payment not published, 1 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Jun 302026

   Complaint investigation

   4 findings

   • F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Level GActual harmCorrected Jul 27, 2026
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Jul 27, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jul 27, 2026
   • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Jul 27, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Apr 22026

   Complaint investigation

   4 findings

   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level FNo actual harm, potential for moreCorrected Apr 24, 2026
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Apr 24, 2026
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jun 5, 2026
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected May 8, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Dec 32025

   Standard health inspection

   14 findings

   The same visit included a complaint investigation.

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jan 10, 2026
   • F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Jan 10, 2026
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level ENo actual harm, potential for moreCorrected Jan 10, 2026
   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Jan 10, 2026
   • F584Honor 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.Level ENo actual harm, potential for moreCorrected Jan 10, 2026
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jan 10, 2026
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Jan 10, 2026
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jan 10, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jan 10, 2026
   • F659Provide care by qualified persons according to each resident's written plan of care.Level DNo actual harm, potential for moreCorrected Jan 10, 2026
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jan 10, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jan 10, 2026
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jan 10, 2026
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Jan 10, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Oct 222025

   Complaint investigation

   2 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Oct 31, 2025
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Oct 31, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Oct 82025

   Complaint investigation

   8 findings

   • F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Level GActual harmCorrected Oct 31, 2025
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Oct 31, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Oct 31, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Jul 292025

   Complaint investigation

   3 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Aug 25, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 25, 2025
   • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Aug 25, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Feb 212025

   Complaint investigation

   5 findings

   • F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Level GActual harmCorrected Mar 18, 2025
   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Mar 18, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Apr 15, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Mar 18, 2025
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Mar 18, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Oct 242024

   Complaint investigation

   1 finding

   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Oct 29, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. Oct 12024

   Standard health inspection

   17 findings

   The same visit included a complaint investigation.

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Oct 29, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Oct 29, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Oct 29, 2024
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Oct 29, 2024
   • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Oct 29, 2024
   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Oct 29, 2024
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Oct 29, 2024
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Oct 29, 2024
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Oct 29, 2024
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Oct 29, 2024
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Oct 29, 2024
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Oct 29, 2024
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Oct 29, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Oct 29, 2024
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Oct 29, 2024
   • F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level DNo actual harm, potential for moreCorrected Oct 29, 2024
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Oct 29, 2024

   Enforcement Action

   Denial of payment imposed February 21, 2025. Status: Closed, April 15, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 1, 2024, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $9,110 imposed October 8, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 1, 2024, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $17,345 imposed October 8, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 1, 2024, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

10. May 302024

    Complaint investigation

    3 findings

    • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Jun 21, 2024
    • F567Honor the resident's right to manage his or her financial affairs.Level DNo actual harm, potential for moreCorrected Jun 21, 2024
    • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Jun 21, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

11. Jan 42024

    Complaint investigation

    3 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level ENo actual harm, potential for moreCorrected Feb 9, 2024
    • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected Feb 9, 2024
    • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Feb 9, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

12. Aug 22023

    Standard health inspection

    13 findings

    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Aug 30, 2023
    • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Aug 30, 2023
    • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Aug 30, 2023
    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Aug 30, 2023
    • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Aug 30, 2023

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Dignity and Resident Rights, Cited in Four Inspections

   Inspectors cited F550 in August 2023, October 2024, December 2025 and April 2026. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232424242425252525252626F550 across all 12 inspections, oldest to newest
2. 2

   Care Plans, Cited in Four Inspections

   Inspectors cited F656 in August 2023, October 2024, October 2025 and December 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232424242425252525252626F656 across all 12 inspections, oldest to newest
3. 3

   Protection From Abuse and Neglect, Cited in Three Inspections

   Inspectors cited F600 in January 2024, July 2025 and October 2025. This citation covers whether residents are protected from abuse and neglect by anyone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232424242425252525252626F600 across all 12 inspections, oldest to newest
4. 4

   Reporting Suspected Abuse, Cited in Three Inspections

   Inspectors cited F609 in January 2024, October 2024 and October 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232424242425252525252626F609 across all 12 inspections, oldest to newest
5. 5

   Citation F628, Cited in Three Inspections

   Inspectors cited F628 in October 2025, October 2025 and June 2026. The agency describes it this way: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232424242425252525252626F628 across all 12 inspections, oldest to newest
6. 6

   Care Plan Timing and Review, Cited in Three Inspections

   Inspectors cited F657 in August 2023, October 2024 and April 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232424242425252525252626F657 across all 12 inspections, oldest to newest
7. 7

   Citation F745, Cited in Three Inspections

   Inspectors cited F745 in July 2025, October 2025 and June 2026. The agency describes it this way: Provide medically-related social services to help each resident achieve the highest possible quality of life. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232424242425252525252626F745 across all 12 inspections, oldest to newest
8. 8

   Medication Labeling and Storage, Cited in Three Inspections

   Inspectors cited F761 in August 2023, October 2024 and February 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232424242425252525252626F761 across all 12 inspections, oldest to newest
9. 9

   Kitchen and Food Safety, Cited in Three Inspections

   Inspectors cited F812 in August 2023, October 2024 and December 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   232424242425252525252626F812 across all 12 inspections, oldest to newest
10. 10

    Infection Control, Cited in Three Inspections

    Inspectors cited F880 in August 2023, October 2024 and December 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242425252525252626F880 across all 12 inspections, oldest to newest
11. 11

    Residents Taking Their Own Medication, Cited in Two Inspections

    Inspectors cited F554 in October 2024 and December 2025. This citation covers whether a resident who keeps and takes their own medication has been assessed as safe to do so. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242425252525252626F554 across all 12 inspections, oldest to newest
12. 12

    Citation F561, Cited in Two Inspections

    Inspectors cited F561 in August 2023 and October 2024. The agency describes it this way: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242425252525252626F561 across all 12 inspections, oldest to newest
13. 13

    Citation F602, Cited in Two Inspections

    Inspectors cited F602 in May 2024 and February 2025. The agency describes it this way: Protect each resident from the wrongful use of the resident's belongings or money. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242425252525252626F602 across all 12 inspections, oldest to newest
14. 14

    Investigating Alleged Violations, Cited in Two Inspections

    Inspectors cited F610 in January 2024 and October 2025. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242425252525252626F610 across all 12 inspections, oldest to newest
15. 15

    Citation F627, Cited in Two Inspections

    Inspectors cited F627 in October 2025 and June 2026. The agency describes it this way: Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242425252525252626F627 across all 12 inspections, oldest to newest
16. 16

    Help With Daily Living, Cited in Two Inspections

    Inspectors cited F677 in August 2023 and October 2024. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242425252525252626F677 across all 12 inspections, oldest to newest
17. 17

    Quality of Care, Cited in Two Inspections

    Inspectors cited F684 in February 2025 and July 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242425252525252626F684 across all 12 inspections, oldest to newest
18. 18

    Accident Hazards and Supervision, Cited in Two Inspections

    Inspectors cited F689 in October 2024 and October 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242425252525252626F689 across all 12 inspections, oldest to newest
19. 19

    Respiratory Care, Cited in Two Inspections

    Inspectors cited F695 in August 2023 and December 2025. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242425252525252626F695 across all 12 inspections, oldest to newest
20. 20

    Medical Records, Cited in Two Inspections

    Inspectors cited F842 in October 2025 and April 2026. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242425252525252626F842 across all 12 inspections, oldest to newest
21. 21

    Citation F883, Cited in Two Inspections

    Inspectors cited F883 in October 2024 and December 2025. The agency describes it this way: Develop and implement policies and procedures for flu and pneumonia vaccinations. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242425252525252626F883 across all 12 inspections, oldest to newest
22. 22

    Citation F921, Cited in Two Inspections

    Inspectors cited F921 in May 2024 and October 2024. The agency describes it this way: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    232424242425252525252626F921 across all 12 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How do staff learn each resident’s preferences, and how is a complaint about dignity handled?

   Dignity and Resident Rights: cited in four inspections, most seriously at level D.

2. 02

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in four inspections, most seriously at level E.

3. 03

   What happened after the abuse or neglect citation, and what changed in training or supervision?

   Protection From Abuse and Neglect: cited in three inspections, most seriously at level E.

4. 04

   How are staff trained to report suspected abuse or neglect, and who reports it to the state?

   Reporting Suspected Abuse: cited in three inspections, most seriously at level E.

5. 05

   What changed after F628 was cited, and how do you check it now?

   Citation F628: cited in three inspections, most seriously at level D.

6. 06

   How often are care plans revised, and who takes part in the review?

   Care Plan Timing and Review: cited in three inspections, most seriously at level D.

7. 07

   What changed after F745 was cited, and how do you check it now?

   Citation F745: cited in three inspections, most seriously at level D.

8. 08

   How are medications stored and secured, and who checks the medication carts?

   Medication Labeling and Storage: cited in three inspections, most seriously at level E.

9. 09

   May we see the kitchen, and what do your own sanitation checks look like week to week?

   Kitchen and Food Safety: cited in three inspections, most seriously at level F.

10. 10

    Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

    Infection Control: cited in three inspections, most seriously at level E.

11. 11

    How do you decide whether a resident may keep and take their own medications?

    Residents Taking Their Own Medication: cited in two inspections, most seriously at level D.

12. 12

    What changed after F561 was cited, and how do you check it now?

    Citation F561: cited in two inspections, most seriously at level D.

13. 13

    What changed after F602 was cited, and how do you check it now?

    Citation F602: cited in two inspections, most seriously at level D.

14. 14

    When an allegation is made, who investigates it, and how are residents protected in the meantime?

    Investigating Alleged Violations: cited in two inspections, most seriously at level E.

15. 15

    What changed after F627 was cited, and how do you check it now?

    Citation F627: cited in two inspections, most seriously at level G.

16. 16

    How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

    Help With Daily Living: cited in two inspections, most seriously at level E.

17. 17

    How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

    Quality of Care: cited in two inspections, most seriously at level D.

18. 18

    What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

    Accident Hazards and Supervision: cited in two inspections, most seriously at level G.

19. 19

    Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

    Respiratory Care: cited in two inspections, most seriously at level D.

20. 20

    How can a family request a resident’s records, and how are they kept accurate?

    Medical Records: cited in two inspections, most seriously at level D.

21. 21

    What changed after F883 was cited, and how do you check it now?

    Citation F883: cited in two inspections, most seriously at level D.

22. 22

    What changed after F921 was cited, and how do you check it now?

    Citation F921: cited in two inspections, most seriously at level E.

23. 23

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Insufficient nursing staff was cited in October 2024.

24. 24

    What led to the 2025 fine, and has it been paid?

    A $9,110 civil money penalty was imposed October 8, 2025. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Michigan state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Michigan state survey agency

  Inspection Aug 2, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Michigan state survey agency

  Inspection Jan 4, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Michigan state survey agency

  Inspection May 30, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Michigan state survey agency

  Inspection Oct 1, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Michigan state survey agency

  Inspection Oct 24, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Michigan state survey agency

  Inspection Feb 21, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Michigan state survey agency

  Inspection Jul 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Michigan state survey agency

  Inspection Oct 8, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Michigan state survey agency

  Inspection Oct 22, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Michigan state survey agency

  Inspection Dec 3, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Michigan state survey agency

  Inspection Apr 2, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Michigan state survey agency

  Inspection Jun 30, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 235395

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.