Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
West Woods of Bridgman
Bridgman, MI · 92 certified beds · Last Life Safety survey August 20, 2025
CMS Certification Number 235625 · first certified November 2006
Ownership
Operated by THE PEPLINSKI GROUP · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MI
29 citations — more than 89% of the 422 certified nursing homes in MI. Compared within MI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 16 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: August 2026 to October 2026. This facility’s last Life Safety survey was August 2025. Facilities in MI are typically surveyed 12–14 months after the last one (median 13), measured over 723 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
9 of the 29 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
8 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 29 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in MI, and nationally. Surveyors differ markedly between states, so the MI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 29 |
| Median facility in MI | 14 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 28, 2023 | 7 |
| August 22, 2024 | 6 |
| August 20, 2025 | 16 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | 2 | 2025-08-20 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-08-20 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2025-08-20 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2024-08-22 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2025-08-20 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2025-08-20 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2024-08-22 |
| E-0007 | Address patient/client population and determine types of services needed. | 1 | 2025-08-20 |
What the citations cover
- Emergency Preparedness Deficiencies 9
- Smoke Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Services Deficiencies 3
- Other 5
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 9 |
| Smoke Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Services Deficiencies | 3 |
| Egress Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 20, 2025 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (September 17, 2025) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (September 17, 2025) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (September 17, 2025) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (September 17, 2025) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (September 17, 2025) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (September 17, 2025) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (September 17, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (September 17, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (September 17, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (September 17, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 17, 2025) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (September 17, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 17, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (September 17, 2025) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (September 17, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 17, 2025) |
August 22, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 25, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 25, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (September 25, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 25, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 25, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (September 25, 2024) |
June 28, 2023 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (July 27, 2023) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (July 27, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 27, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 27, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 27, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 27, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 27, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.