Boulevard Temple Care Center, LLC
2567 West Grand Boulevard, Detroit, MI 48208 · For profit - Individual · 124 certified beds · (313) 895-5340 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.8% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.9% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.5% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.3% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.7% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 1.2% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.6% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 7.1% | 19.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 91.2% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 5.1% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 24.2% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.5% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 77.2% | 79.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 37.4% | 24.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.4% | 11.7% | 12.0% | worse |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
39.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 39.1%CMS range 22.7–52.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 6.5–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 124 beds and averages 118.1 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.21 hrs/resident/day on weekends vs 3.81 on weekdays — 16% thinner on weekends. RN hours go from 0.53 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · J2023-01-31 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to perform life saving measures to a resident that was documented as a full code (When a person has no heartbeat and not breathing, CPR/cardiopulmonary resuscitation should be administered). This deficient practice resulted in an Immediate Jeopardy on [DATE] when nursing staff failed to perform CPR on R19 or call emergency services (911) when found with no heartbeat and was not breathing. This deficient practice placed all 95 residents at risk for the likelihood of serious injury, harm, and/or death from code status not being followed by staff. Findings include: Record review of R19's face sheet revealed admission into the facility on [DATE] with a pertinent diagnosis of benign neoplasm of meninges (tumors growing in membranes around the brain). According to the Minimum Data Set, dated [DATE], R19 had impaired cognition and was extensive assist with Activities of Daily Living (ADLS). Record review of Resident Code Status revealed a document that was signed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-15 · tag F0887 — isolatedEducate 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.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake 2706021.Based on interview and record review, the facility failed to obtain legal consent and failed to provide education for the Covid-19 vaccination for one resident (R101) out of three residents reviewed for immunizations. Findings include: Review of immunizations revealed an administration date of 12/12/2024 of the Covid-19 vaccination. Route of administration- Intramuscularly, Dose and Unit 0.5 ml, administered by Infection Preventionist (IP) A. Review of R101's Electronic Health Record (EHR) revealed: Immunization- SARS-COV-2 (COVID-19) Status-Complete-Consent Confirmed By, (IP) A, Confirmation Date 12/12/2024, Education Provided.On 04/15/26 at 2:30pm, Family Member B was interviewed regarding complaint about the administration of the Covid-19 vaccination. Family Member B stated, I would never consent to the Covid-19 immunization for R101 due to R101's medical condition. I did not give verbal or written consent for this immunization and R101 was unable to provide consent for himself. Family Member B also said that Covid-19 education was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-16 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to 2677888. Based on interview and record review, the facility failed to report an incident of injury of unknown source to the State Agency in a timely manner for one resident (R105), out of six residents reviewed for abuse, resulting in the potential for unresolved resident concerns. Findings include:The facility self-reported incident (FRI) was received on 11/11/25. The incident was discovered on 11/7/25. A review of the facility's 5-Day investigation documented in part the following: On 11/7/25 at approximately 9:15 AM, R105 went to the nurses station and showed the nurse her left arm. There was a bruise on her left arm. It was purplish in color and was 3 1/2 inches by 2 inches on the forearm above the elbow. R105 told the nurse that she woke up with the bruise. R105 could not give an explanation of how she received the bruise. Staff that worked on the days before 11/6/25 and 11/7/25 did not see a bruise on R105's arm. R105 did go out on a LOA (leave of absence) with her guardian. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-16 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes 2628767 and 2674347. Based on interview and record review, the facility failed to timely submit documentation of completed investigations to the State Agency for alleged resident-to-resident sexual abuse for two residents (R101 and R102) and alleged resident-to-resident physical abuse for two residents (R102 and R103) out of six residents reviewed for abuse, resulting in the potential delay for opportunities to implement corrective measures and interventions. Findings include: R101, R102A facility self-reported incident (FRI) was received by the State Agency (SA) on 8/8/25. The FRI documented that on 8/8/25 at approximately 2:30 PM, it was witnessed that R102 was in his wheelchair rolling towards his room. R101 was in her wheelchair rolling in the direction of R102. When the two residents rolled past each other, R102 reached his arm over to move R101's head towards him and then R102 kissed R101 on the mouth. R102 then rolled to his room and R101 rolled to the dining room. R101…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-16 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were administered properly and per physician's orders for one resident (R108) of three residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not taken or administered properly. Findings include: In an observation and interview on 12/15/25 at 9:35 AM, R108 was awake and lying in bed. While grimacing and holding her stomach, R108 said her stomach hurts. R108 said she reported her stomach pain to Certified Nurse Aide (CNA) J. On 12/15/25 at 9:37 AM, CNA J indicated that she told Registered Nurse (RN) I that R108 was in pain. On 12/15/25 at 9:45 AM, RN I denied being informed that R108 was in pain. RN I and the State Surveyor went into R108's room. R108 again stated that she had pain in her stomach. While in R108's room, seven unidentified oral medications were observed on R108's overbed table; two tablets were loose…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2635308.Based on observation, interview, and record review, the facility failed to properly secure a television for one resident (R101) out of four residents reviewed for accidents resulting in R101 receiving a head injury.Findings include:On 10/8/2025 at 10:15 AM R101 was observed seated in a wheelchair in the common area with a bump on her forehead. When R101 was asked about the bump she was unable to explain how she received it.Record review of R101's Electronic Health Record (EHR) revealed she was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease and Dementia.Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R101 had severe cognitive impairment with a Brief interview for Mental Status (BIMS) score of one out of 15 and was dependent for mobility except for eating where she required set up.On 10/8/2025 at 11:10 AM, Certified Nursing Assistant (CNA) B was interviewed and said she was assigned to work with R101 when the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-17 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00153561. Based on observation, interview and record review the facility failed to ensure adequate supervision for one resident (R902) out of one resident with severe cognitive impairment, resulting in three residents (R901, R903, and R904) verbalizing lack of privacy and security. Findings include: Record review of allegation sent to State Agency revealed R902 had entered R901's room several times without invitation. An interview was conducted on 6/17/25 at 11:04 AM with R901 on the second floor of facility, it was reported that R902 at the time that the allegation was reported, had wandered into the resident's room multiple times. R902 would pick up and look at resident's belongings and had covered the resident with blankets while in the bed. R901 further reported not feeling safe when R902 would enter the room. Record review of 901's electronic medical records revealed admission into the facility on 6/27/23 with a pertinent diagnosis of paraplegia (paralysis). According to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-05-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Properly date-label food in the freezer; 2. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, macaroni and cheese; 3. Recognize unpasteurized shell eggs were used for the preparation of over easy eggs; 4. Ensure kitchen staff properly used hair restraints; and 5. Ensure pans were allowed to air dry before stacking. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: On 5/12/25 beginning at 8:40 AM, the initial tour of the kitchen began with Dietary Aide (DA) O and the following was observed in the reach-in freezer: three undated opened bags of French fries and one undated opened bag of chicken. The following was observed inside of the walk-in cooler: One half-size pan of previously cooked macaroni and cheese dated 5/11 and 5/14. One opened case of shelled eggs dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-05-14 · tag F0850 — failed to provide social-work services — widespreadHire a qualified full-time social worker in a facility with more than 120 beds.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to employ a qualified social worker on a full-time basis to meet the psychosocial, mental, and behavioral health care needs of residents in a facility with more than 120 beds. This deficient practice had the potential to affect all residents that reside within the facility. Findings include: An interview was conducted on 5/12/25 at 1:30 PM with the Director of Nursing. It was reported that the facility did not have a social worker available. An interview was conducted on 5/13/25 at 1:30 PM with the Nursing Home Administrator (NHA). It was reported that the facility had 124 beds online. It was further reported that the facility does not currently employ a full-time social worker and has not had one since the week of Easter (April 21, 2025). During a phone interview on 5/14/25 at 1:45 PM the Medical Director reported no knowledge that the facility did not have a full-time social worker available at this time. Review of facility policy Social Service Program dated 9/7/2023, it was documented, The facility will provide medically…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-14 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide follow-up to the (Department of Community Health/ form 3877/78) during annual review and to ensure the form was submitted to the local Community Mental Health Services Program (CMHSP) for a level two OBRA (Omnibus Budget Reconciliation Act) evaluations annually for six (R28, R48, R77, R96, R97 and R99) of six residents reviewed for Preadmission Screening/Annual Resident Review (PASARR). Findings include: R28 A clinical record review revealed R28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia, Psychotic Disorder with Hallucination, Adjustment Disorder with Depressed Mood and Pulmonary Fibrosis. According to the Minimum Data Set (MDS) assessment dated [DATE], R26 scored a 00/15 on the Brief Interview for Mental Status (BIMS) score which indicated severely impaired cognition. Further review of the most current 3877 triggered the need for a 3878 form to be completed. R48 A clinical record review revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-14 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to revise the care plan for one (R97) of one resident reviewed for updated care plans when a resident diagnoses was corrected and changed. Findings include: Review of the Electronic Medical Record (EMR) revealed R97 was originally admitted on [DATE], with a readmission on [DATE] with pertinent diagnoses of Post Traumatic Stress Disorder. Further review revealed a Brief Interview for Mental Status score of 15/15 indicated intact cognintion. A review of the care plan revealed a focus of Post Traumatic Stress Disorder. On 5/13/2025 a review of the care plan was made with the Minimum Data Set (MDS) Nurse S regarding R97's diagnoses of Post Traumatic Stress Disorder. MDS Nurse S revealed a Psychiatric Evaluation dated 11/26/24 without a diagnosis of Post Traumatic Stress Disorder and that a correction had been made on the MDS at that time. Further review of the EMR revealed a care plan with an initiation date of 9/19/2024 by Social Services and a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2025-05-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide one to one meal assistance for one resident (R24) out of five residents reviewed for nutrition. Findings include: On 5/12/25 at 1:10 PM, staff were observed delivering a meal tray to R24's room. The tray was set up and staff left the room. Continued observation made until 1:21 PM, staff entered the room and only opened R24's ice cream package and then left the room. Review of R24's dietary slip documented resident was 1:1 (one to one) for meal assistance. On 5/12/25 at 1:38 PM, an interview was conducted with Certified Nursing Assistant (CNA) T who reported, I tried to feed her, but she often feeds herself. On 5/13/25 at 9:10 AM, staff were observed delivering a meal tray to R24. The tray was set up and staff then left the room. Continued observation until 9:20 AM, no staff were present to provide one-on-one assistance with meal. Record review of R24's electronic medical records (EMR) revealed admission into the facility on 3/7/22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that medications were not left at resident bedside for two (R93 and R108) of thirty-three residents reviewed regarding medications found at bedside. Findings include: On 5/12/2025 at 10:58 AM, during an observationn and interview, R108 was observed retrieving a yelow/orange capsule from the bedside table. R108 placed the capsule into thier mouth and sipped water from their water cup. An inquiry was made, what was that you just took? R108 replied, it was gabapentin. A review of R108's Electronic Medical Record (EMR) revealed R108 was admitted on [DATE] with the following pertinent diagnoses of Huntington's Disease (a progressive neurologic deterioration). Further review revealed a Brief Interview of Mental Status score of 14/15 indicated intact cognition. Further review of the EMR for R108 revealed the resident had an active order for gabapentin 300 mg. On 5/12/25 at 11:25 AM, during observation and interview with R93, a medicine cup…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-09 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI00146539 and MI00146638. Based on interview and record review, the facility failed to ensure staff to resident verbal abuse did not occur for one resident (R102) and physical abuse did not occur for two residents (R103 and R106) out of four residents reviewed for abuse. Findings include: R102 - A review of the facility's investigation documentation submitted to the State Agency documented in part that on 8/8/24 at around 8:15 AM, Certified Nurse Aide (CNA) G was passing out juice to residents in the main dining room on the 2nd floor. CNA G asked R102 if she wanted a juice, and she said yes. CNA G proceeded to give her juice. Once CNA G turned around to serve another resident, R102 hit CNA G in the neck two times. After CNA G was hit, she immediately reacted by shouting profanity at the resident. CNA H was able to hold the hand of R102 from hitting CNA G (again). CNA G did walk away and the nurse on duty walked CNA G to the nurse manager's office. R106 and R102 - A review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-09 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to submit an incident of resident-to-resident abuse and the 5-day investigation to the State Agency involving two residents (R102 and R106). Findings include: Review of R102's progress note of 8/12/24 at 12:35 PM documented in part the following: Resident observed hitting another resident (R106) while sitting in wheelchair in dining room. Writer separated residents. Writer asked resident what happened. Resident (R102) stated that she didn't like (R106) and that (R106) had called her a b*h. Writer asked resident (R106) what happened and (R106) stated that resident rolled her wheelchair beside hers and started hitting her. Writer asked resident (R106) was she hurt, and resident stated no. Resident (R102) removed from dining room area and into hallway with nurse aide present. Writer notified unit manager and administrator. Writer called and left message with resident's husband. Review of R106's progress note as clarified by the Nursing Home Administrator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00145800. Based on interview and record review, the facility failed to ensure proper care was provided as indicated on the resident care guide for one resident (R101) dependent on staff for performance of activities of daily living (ADL). Findings include: On 5/20/24 at 2:36 PM, the facility filed a Facility Reported Incident that alleged on 5/19/24, R101 stated Certified Nurse Aide (CNA) C was rough while providing her care. A review of R101's clinical record documented an initial admission date of 5/23/22 and readmission date of 6/29/24. R101's diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), unspecified dementia, major depressive disorder, conductive hearing loss, and morbid obesity. A Minimum Data Set, dated [DATE] documented severe cognitive impairment, frequent incontinence of bowel and bladder, and dependence upon staff for toileting hygiene. Review of R101's care plans documented in part the following: Focus: (R101) has a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-09 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intake MI00146939. Based on interview and record review, the facility failed to ensure the proper medications were provided to a resident (R104) discharged from the facility. Findings include: It was reported to the State Agency that R104 was sent home from the facility with another resident's medications. A review of the clinical record for R104 documented an admission date of 8/30/24 and discharged date of 9/9/24. R104's diagnoses included hypertension and Down's syndrome. On 10/8/24 at 10:48 AM, Home Care Nurse (HCN) D was interviewed and said R104 was sent home from the facility with medications that were labeled with someone else's name. HCN D said there were about six different medications that were labeled with R105's name. On 10/8/24 at 10:55 AM, the Resident Representative (RR) for R104 was interviewed and listed the following medications that were sent home with R104 but labeled with R105's name: amlodipine 10mg, atorvastatin calcium, esomeprazole magnesium, donepezil 10mg, levetiracetam 750 mg, baclofen 10mg, and divalproex 500 mg. A review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-04-18 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to store delivered food stock properly, resulting in a potential for contamination and deterioration of food products. Findings include: On 4/16/2024 at 9:26 A.M. during an observation of the kitchen, delivered food stock was observed stored on the floor outside of the walk-in refrigerator. At 10:10 A.M. Approximately 15-20 cases of assorted refrigerated and dry goods were stacked on the floor waiting to be stored. Dietary Manager E who was present and cleaning the walk-in refrigerator was queried concerning the delivery days for food stock and indicated Tuesday and Thursday. On 4/18/2024 at approximately 9:00 A.M. during an observation of the facility's dumpster area, food stock was delivered into the kitchen and placed on the floor. The delivered food items consisted of a combination of 15-20 cases of food items that required refrigeration and canned food products. At 11:20 A.M. the delivered food stock was observed in the same place without being stored off the floor or placed on a Dollie (device used to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-18 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a homelike environment for one resident (R74) of eight residents reviewed for comfortable, homelike environments. Findings include: Review of the admission Face Sheet documented R74 was admitted to the facility on [DATE], with diagnoses that included: osteomyelitis, hypertension, amputation of left lower limb and diabetes mellitus. According to the minimum Data Set (MDS) dated [DATE], R74 had a BIMS (Brief Interview for Mental Status) of 15 indicating intact cognition and required one-person physical assist to perform Activities of daily living (ADL's). On 4/16/24 at 10:30 A.M. and 4/17/24 at 9:00 A.M., during an observation of resident 74's room, the ceiling above the television and hand sink was observed with a gaping hole (approximately 4 x 5 inches wide) with surrounding broken plaster. On the opposite side of the room underneath the window another hole was observed. Two large cans were placed close to each area where the holes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-18 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to: maintain cooking equipment and the physical environment in the kitchen in a safe and sanitary manner, repair five rooms and the dining area on the 5th floor, clean the inner spaces of handrails on the fourth and fifth floor and ensure the elevator doors had a smooth, cleanable surface. This deficient practice had the potential to affect all 104 residents that resided within the facility. Findings include: On 4/17/24 at 1:30 P.M. during an observation in the kitchen the cooking equipment (deep fat fryer) Pitco Frialator, the Vulcan stove, South bend double oven, the panel between the fryer and grill and the back splash behind the stove were covered with layers of old, yellow colored grease and ash. The side panel of the stove had pieces of food embedded in the glue-like grease mixture that could not be removed even after observing staff cleaning the equipment daily. The walls and ceilings throughout the kitchen, dish room and preparation areas were observed with chipped paint, crumbling, missing plaster, large…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to consistently implement interventions (a properly functioning specialty mattress) for one (R57) of seven residents reviewed for pressure ulcer care when R57's specialty mattress resulting in the potential for continued impaired skin integrity. Findings include: On 4/16/24 at 1:15 PM R57 was observed laying in bed. An Alternating Pressure Relief machine was secured on the foot board of the resident's bed with cords connected to the mattress lying on the resident's bed. There were no lights on the machine's display panel and the mattress was deflated and flat even though it was plugged into the electrical socket. The resident appeared to be lying flat on the metal bed frame. When R57 was asked about his mattress he said, Yeah, they know its not working. It's been like this for a couple days now. They put it in TELS or something like that. I'm supposed to get a new one today. On 4/17/24 at 11:25 AM R57 was observed laying on his bed. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-18 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure one (R2) of five residents reviewed for limited range of motion received appropriate services and equipment to maintain or improve mobility. Findings include: R2 On 4/16/24 at 1:25 PM, R2 was observed in bed with bilateral upper arm contractures (tightening of the muscles, tendons, skin, and nearby tissue that causes the joints to shorten and become stiff) at both elbows and right wrist joint. No splints were observed. R2 was asked about the arm contractures and replied, I've been like this since I got here. I did have splints, but they lost them a while back and are supposed to get me new ones. I haven't had any therapy for a while. I don't know when I had it last. The resident denied pain or discomfort at this time. On 4/17/24 at 10:47 AM, R2 was in bed with both arms contracted at the elbow and right wrist. No splints were observed. R2 reported that therapy had been in yesterday and were ordering new splints. No therapy had been performed on the resident. The resident denied having any pain or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-18 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to facilitate a psychiatric evaluation as prescribed for one (R11) of five sampled residents reviewed for unnecessary medications, resulting in the potential for psychosocial disorders to go unaddressed and to exacerbate. Findings include: Record review of the Electronic Medical Record revealed R11 admitted to facility on 10/27/2023 with pertinent diagnosis of unspecified dementia. According to the Minimum Data Set (MDS) dated [DATE], R11 had severe cognitive impairment with a Brief Interview of Mental Status (BIMS) of 3/15. On 12/14/2023 a physician order was written for Escitalopram Oxalate Tablet 10 MG was ordered Give 1 tablet by mouth one time a day for Dementia with Behavior issues/Depression. On 12/21/2023 a physician order was written for Psych consult Dx: evaluation of behaviors and medication. Review of the pharmacist consultation report dated 3/7/2024 revealed R11 had received an antidepressant, Escitalopram 10 mg q day (everyday) for dementia…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Infection Control protocols were followed during care for two residents (R58 and R91) of five reviewed for Infection Control when appropriate protective personal equipment (PPEs) was not applied during direct care. R58 was positive for Covid-19 and R91 was prescribed to have Enhanced Barrier Precautions (EBP). Findings include: According to the facility's policy last revised on 3/26/24, EBP is used to prevent the transmission of CDC targeted multidrug-resistant organisms (MDROs). EBP is indicated for residents with any of the following; 1) infection of colonization with CDC-targeted MDRO or 2) a wound or indwelling medical device even if the resident is not known to be infected or colonized with a MDR) and should remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at higher risk. A. Health care personnel caring for resident on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CIENA HEALTHCARE/LAUREL HEALTH CARE — 81 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.8 | +0.2 vs chain |
| Health inspection | 3 of 5 | 2.5 | +0.5 vs chain |
| Staffing | 4 of 5 | 3.2 | +0.8 vs chain |
| Quality measures | 3 of 5 | 4.0 | -1.0 vs chain |
The other 80 homes this chain runs (chain average 2.8★, per CMS)
Showing 40 of 80; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| KHAN, ANIS | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2009 |
| QAZI, MOHAMMAD | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2009 |
| CIENA HEALTHCARE MANAGEMENT INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/19/2025 |
| BRADFORD, CARNEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/29/2023 |
| DEAN, FLORA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| MOHAMMAD A QAZI LIVING TRUST DATED 09/26/97 | Organization | ADP OF THE SNF | since 12/01/2009 |
CMS files one row per role, so the 13 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235498. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.