Skip to main content
Complaint Investigation

Corewell Health Rehabilitation & Nursing Center -

October 1, 2025 · Stevensville, MI · 4368 Cleveland Ave
Citations 5
CMS Rating 1/5
Beds 111
Provider ID 235164
Healthcare Facility
Corewell Health Rehabilitation & Nursing Center -
Stevensville, MI  ·  View full profile →
Inspection Summary

Corewell Health Rehabilitation & Nursing Center - in Stevensville, MI — inspection on October 1, 2025.

Found 5 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Advertisement

Inspection Findings

FF0552
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Review of Order dated 5/9/25 for Resident #101, revealed, .Lorazepam (Ativan) tablet 0.5 mg Oral, nightly, Associated Diagnosis: Other insomnia.

Review of Order dated 5/29/25 for Resident #101, revealed, .Lorazepam (Ativan) tablet 0.5 mg Oral, Once, 1200.Associated Diagnosis: Other insomnia.Anxiety Disorder.Review of Order dated 6/4/25 for Resident #101, revealed, .Lorazepam (Ativan) tablet 0.25 mg Oral, 3 times daily, PRN (As needed).Associated Diagnosis: Anxiety Disorder.In an interview on 9/24/25 at 3:27 PM, Family Member/Durable Power of Attorney (DPOA) (FM) OO reported when Resident #101 was admitted to the hospital following a fall on 6/8/25, she was informed Resident #101 was being given Lorazepam at night which she was not aware Resident #101 had been receiving that medication. FM OO reported she did not give her permission for Resident #101 to take Lorazepam and because Resident #101 was so mobile she felt that Resident #101 should not have been put on that medication.Review of Psychotropic Medication Risk/Benefit Consent dated 4/17/25 revealed, no consent for the Lorazepam orders were completed and there was no signature.

The document only indicated FM OO was a participant as of 9/25/25. No documentation submitted to indicate consent was provided verbally. In an interview on 9/25/25 at 09:07 AM, Social Worker (SW) H reported consents for medications would be signed electronically by the decision maker or resident when admitted or when there was a change in medications where consents were needed. SW H reported she would be able to call the decision maker to obtain verbal permission from them with two person's present as witnesses. SW H reported also if the decision maker was not able to come to the building and electronically sign the document, the consent could be sent out to them for signature and social work would have to follow up for return. SW H reported there was not a standard of work process in place from corporate on consents. SW H was unable to locate notes for Resident #101 as well as notes which had indicated a conversation had been had with the decision maker for the prescribed lorazepam medications.During an observation and interview on 09/25/25 at 2:32 PM, Nurse Liaison C reported that there was no documentation in Resident #101's record that there was a verbal consent received for Lorazepam.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/01/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Corewell Health Rehabilitation & Nursing Center -

4368 Cleveland Ave Stevensville, MI 49127

SUMMARY STATEMENT OF DEFICIENCIES

Review of Your Rights and Protections as a Nursing Home Resident, revealed, .As a nursing home resident, you have certain rights and protections under Federal and state law that help ensure you get the care and services you need. Be Treated with Respect: You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose.

You have the right to decide when you go to bed, rise in the morning, and eat your meals. Be Free from Abuse and Neglect: You have the right to be free from verbal, sexual, physical, and mental abuse.If you feel you have been mistreated (abused) or the nursing home isn't meeting your needs (neglect), report this to the nursing home, your family, your local Long-Term Care Ombudsman, or State Survey Agency.

The nursing home must investigate and report all suspected violations and any injuries of unknown origin within 5 working days of the incident to the proper authorities.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/01/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Corewell Health Rehabilitation & Nursing Center -

4368 Cleveland Ave Stevensville, MI 49127

SUMMARY STATEMENT OF DEFICIENCIES

jeopardy to resident health or safety

the SBAR format.

Social Work Education: Social workers were previously educated on obtaining consent for psychotropic medications. On [DATE], one social worker was re-educated by the DON, and the second will be re-educated on [DATE].

Consultant Pharmacist Education: On [DATE], the consultant pharmacist was educated by the DON on the medication review process and verbalized understanding.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/01/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Corewell Health Rehabilitation & Nursing Center -

4368 Cleveland Ave Stevensville, MI 49127

SUMMARY STATEMENT OF DEFICIENCIES

Review of policy, Falls: Risk Screening, Prevention, and Post Fall Follow Up dated 7/21/24, revealed, .To outline the process to identify fall risk, interventions to prevent falls and patient or resident injuries, and to outline the required process for post fall follow-up for rehab and nursing centers .A patient fall is a sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can).

When a patient rolls off a low bed onto a mat or is found on a surface where you would not expect to find a patient, this is considered a fall. If a patient who is attempting to stand or sit and falls back onto a bed, chair, or commode, it is only considered a fall if the patient is injured .Care planning and evaluation will be completed by a licensed nurse who will initiate and update the plan of care and interventions to address risk for falls in the electronic health record (EHR) .Rehab and Nursing Centers: 1.

Assess the resident/patient for injury and circumstances surrounding the injury and determine if the resident/patient can be moved safely. In cases where the resident/patient may not be moved safely, contact appropriate medical providers, staff, or emergency medical response team for assistance. 2.

Evaluate and monitor resident by placing the post-fall assessment order. 3.

Check blood glucose for diabetic patients. 4.

Notify the appropriate individuals including the physician/designee and family members.5.

Review the resident's care plan and update as indicated incorporating interdisciplinary team feedback .

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/01/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Corewell Health Rehabilitation & Nursing Center -

4368 Cleveland Ave Stevensville, MI 49127

SUMMARY STATEMENT OF DEFICIENCIES

Advertisement

Federal health inspectors cited Corewell Health Rehabilitation & Nursing Center - in Stevensville, MI for a deficiency under regulatory tag F-F0690 during a complaint investigation conducted on 2025-10-01.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of Corewell Health Rehabilitation & Nursing Center -.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-28.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Stevensville, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Corewell Health Rehabilitation & Nursing Center - or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

Advertisement