Staffing
CMS publishes a 3-star staffing rating for this facility.
RN staffing was 0.39 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceAsk Trust Hub Network
CMS overview
No proprietary TrustHub score. These ratings are published separately by CMS.
Facility information
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Decision guide
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
CMS publishes a 3-star staffing rating for this facility.
RN staffing was 0.39 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceThe latest standard inspection on Jul 17, 2025 cited 7 deficiencies.
View inspection evidenceCMS-published records list 5 ownership or control parties.
CMS records show an ownership change effective April 2022.
View ownership evidenceOwnership & operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
SeniorTrustHub found evidence connecting this facility to:
Ownership
These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.
Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Apr 1, 2022
Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 50%
Association date reported to CMS: Apr 1, 2022
Individual · CORPORATE OFFICER
Association date reported to CMS: Apr 1, 2022
Individual · W-2 MANAGING EMPLOYEE
Association date reported to CMS: Apr 1, 2022
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 0 across MI.
Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.
Inspections & deficiencies
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 17, 2026)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Mar 17, 2026)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 29, 2025)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 29, 2025)
Provide safe and appropriate respiratory care for a resident when needed.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Sep 29, 2025)
No health-deficiency rows were deterministically linked to this inspection.
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 25, 2025)
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 25, 2025)
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 25, 2025)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 25, 2025)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 25, 2025)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 25, 2025)
Provide and implement an infection prevention and control program.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 25, 2025)
Keep all essential equipment working safely.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jun 16, 2025)
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 9, 2025)
Keep all essential equipment working safely.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Apr 15, 2025)
No health-deficiency rows were deterministically linked to this inspection.
No health-deficiency rows were deterministically linked to this inspection.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 21, 2024)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 21, 2024)
Ensure services provided by the nursing facility meet professional standards of quality.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 21, 2024)
Provide enough food/fluids to maintain a resident's health.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 21, 2024)
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 21, 2024)
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 21, 2024)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 21, 2024)
Provide and implement an infection prevention and control program.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 21, 2024)
Educate 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.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Aug 21, 2024)
No health-deficiency rows were deterministically linked to this inspection.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 6, 2023)
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 6, 2023)
Provide activities to meet all resident's needs.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 6, 2023)
Penalties & enforcement
No penalty records were found for this provider in the currently loaded CMS Penalties dataset.
Questions to ask
Facility history
10 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
RN staffing decreased from 0.45 to 0.35 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.
0.45 → 0.35
CMS · Reported in a source release · View related evidence
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
7 deficiencies were recorded.
CMS · Recorded event date · View related evidence
1 deficiency was recorded.
CMS · Recorded event date · View related evidence
2 deficiencies were recorded.
CMS · Recorded event date · View related evidence
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
9 deficiencies were recorded.
CMS · Recorded event date · View related evidence
3 deficiencies were recorded.
CMS · Recorded event date · View related evidence
An ownership change was recorded. New organization: DOUGLAS MI OPCO LLC.
DOUGLAS INVESTMENTS & ASSOCIATES, LLC → DOUGLAS MI OPCO LLC
CMS · Recorded event date · View related evidence
Staffing
CMS staffing rating: 3 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.779 | 3.079 |
| RN categories | 0.448 | 0.248 |
Contract staff accounted for 4% of reported nursing hours included in this quarter calculation.
PBJ reports zero combined RN-category hours on 3 days with a positive MDS census in this quarter.
Reported RN-category hours per resident day were 0.062 higher than the prior loaded quarter.
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 3.537 | 0.453 | 0.979 | 2.105 | 0% | 91 |
| 2025Q3 | 3.597 | 0.351 | 1.109 | 2.137 | 0% | 92 |
| 2025Q4 | 3.632 | 0.328 | 1.05 | 2.255 | 0.2% | 92 |
| 2026Q1 | 3.576 | 0.39 | 1.046 | 2.14 | 4% | 90 |
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
Planned evidence layers
These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.
Trust participation
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