Hartford Nursing & Rehabilitation Center
6700 W Outer Dr, Detroit, MI 48235 · For profit - Corporation · 188 certified beds · (313) 836-1700 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 18% of its spending goes to commonly-owned related companies
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 fell from 4 to 3 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 | 8.8% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.1% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.6% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.4% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.4% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.5% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 3.5% | 19.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 90.3% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.4% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 28.5% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.7% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 63.0% | 79.5% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.2% | 24.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 5.1% | 11.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.18 | 1.84 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.00 | 1.64 | 1.80 | better |
§ 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.
53.0% 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 201 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 20.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 83 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.68 therapist hours per resident per day in 2026Q1 — more than 91% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 48% 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 | 53.0%CMS range 45.1–59.3 | 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 | 13.9%CMS range 11.2–17.8 | 10.7% | Oct 2022–Sep 2024 | worse than 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 | 20.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 37.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 9.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 78.2% | 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 | 97.4% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 0.8% | 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 | 8.7%CMS range 4.9–12.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 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 188 beds and averages 170.1 residents a day — about 90% occupied, or roughly 18 beds typically open. It runs fairly full. 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 4.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.34 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 3.57 hrs/resident/day on weekends vs 4.24 on weekdays — 16% thinner on weekends. RN hours go from 0.30 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as 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 more than at the previous inspection — worsening. 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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2025-03-31 · 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 #MI00151498. Based on observation, interview and record review, the facility failed to utilize a two-person assist while turning and reposition a resident while performing care for one resident (R903) of three residents reviewed for accidents, resulting in a fall with injury. R903 sustained a right hip fracture that required surgical repair. Findings include: Review of an allegation received through the State Agency revealed the following: (R903) has a history of stroke and is paralyzed from the waist down. (R903) has been in a nursing/rehab facility for the past two years . On or about 3/21/25, (R903) brief was being changed by an employee, and (R903) fell out of the bed. (R903) was left on the floor for an unknown period of time and was yelling for help when the staff member ran out of the room to get help. (R903) fell when (R903) was being turned over to change, but it is believed there was only one staff member present when she was being changed, and (R903) should have two…
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 · F2026-01-29 · 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 maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include:On 1/27/2026 at 9:59 AM, observation of the walk-in cooler found an increased accumulation of black spotted debris on the top surfaces of the hard plastic shelving used to store food product. When asked how often the storage shelves get cleaned, Dietary Manager (DM) F stated they get power washed, but it's been so cold we have not been able to take them outside.On 1/27/2026 at 10:19 AM, an interview with DM F found that the clean utensil bin is cleaned weekly. Observation inside of the bin found an assortment of clean utensils stored among food crumbs and debris. Upon wiping the inside of the bin, it was found to be greasy. DM F stated that they will get it cleaned. On 1/27/2026 at 10:21 AM, an interview with DM F found that the tabletop slicer is used once or so a week to slice meat. When asked what the plastic cover over the slicer…
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 · F2026-01-29 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility.Findings include:On 1/27/26 at 10:25 AM observation of the kitchen serving room revealed a possible stagnant water line coming from the hand sink area down the wall near the steam tables. An interview with the Maintenance Director (MD) H found that he was unaware of the water line. An interview with the Dietary Manager G found she was unaware of what the water line was for and stated it was not something that kitchen staff use.On 1/27/26 at 1:11 PM observation of the Homebound unit soiled linen room revealed the hopper had brownish yellow water coming from the hot and cold-water fixtures on the over hopper faucet. Further observation found discolored water coming from the hopper sprayer.On 1/27/26 at 1:35…
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 before2026-01-29 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting all residents.Findings include: On 1/27/26 starting at 1:17 PM, an environmental tour was conducted in the homebound unit with the following observations:The faucet in resident room [ROOM NUMBER] was observed with only a pencil thin stream of hot water when in use. The faucet was loose to mount and was able to be moved around. The shower room found eight razors stacked on the sink basin. Further observation revealed spots of black accumulation on underside of the shower bed mat, and a wet washcloth on the floor.An observation of the janitor closet revealed that a chemical pre-dispensing system was in place and that staff leave the faucet on when not in use. This set up puts undue back pressure on the faucets internal atmospheric vacuum breaker (AVB) of which will ruin 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 · E2026-01-29 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
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 2720882.Based on observation, interview, and record review the facility failed to pass water in a timely manner to ensure adequate hydration for five residents (R94, R76, R18, R156, and R33) of seven residents reviewed for hydration, resulting in the potential for increased risk for dehydration.Findings include:During the initial screening process on 1/27/2026 between 10:00 a.m. and 2:00 p.m. multiple residents were observed with no water in their rooms or at bedside. These residents are as follows:R94.R94 was observed to be alert and was able to be interviewed. During an interview, R94 said there was no fresh water passed by the staff since about nine P.M. on the midnight shift. R94 pointed to a small, iced tea bottle and stated, I am glad I kept this tea bottle so I can get me some water out of the sink. I don't understand why they have not passed fresh water yet.According to the electronic medical record (EMR), R94 was admitted on [DATE] with diagnoses that included hemiplegia…
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 · E2026-01-29 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
This citation pertains to intakes 2656662 and 2661216Based on observation, interview, and record review, the facility failed to ensure meals were served at palatable temperatures in two of two records reviewed, resulting in decreased food consumption and potential nutritional decline.Findings Include:It was reported to the State Agency that food served to the residents was not at palatable temperatures.On 1/27/2025 at 11:57 AM, an interview with Dietary Manager F found that the facility has heated bases, but they are not in use for today's meal. Further observation found plates between 75F-85F with no visible plate warmer being utilized. When asked what she expects for hot food on the steam table, DM F stated that it should be at least 150F so that residents can get their food at 135F or higher.On 1/27/2025 at 12:09 PM, a regular test tray was plated and placed as one of the first meals on the C unit cart. On 1/27/2025 at 12:20 PM, the meal cart arrived on C unit with roughly 25 meal trays present. On 1/27/2025 at 12:37 PM, all trays were delivered, and the test tray was back in 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 · D2026-01-29 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 give information for Advance Medical Directives (AMD, the written instruction relating to the provision of health care) to one (R2) of two residents or their representatives reviewed for code status, resulting in R2's code status being changed to a full code (all possible life saving measures will be provided if the person's heart stops or they stop breathing).Findings include: On [DATE] at 2:30 PM, R2 was observed up in recliner chair watching TV. R2 was unable to be interviewed due to cognition status. On [DATE] at 2:50 PM, during interview with R2's Representative (RR1) they said they were not being included in decision making for R2. RR1 said they were not R2's Legal Guardian (LG) at this time and was currently trying to obtain it through the court system. RR1 said they did not know R2's code status had been changed to a 'full code' by the facility. According to R2's Electronic Health Record (EHR) RR1 was identified as R2's emergency…
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 before2026-01-29 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to transmit a Minimum Data Set (MDS) assessment for one (R173) of three residents reviewed for MDS assessment transmittal requirements.Findings include:During the MDS Assessment task R173 was identified to have a MDS assessment that was due over 120 days. On 1/28/26 a review of R173's Electronic Heath Record (EHR) revealed R173 discharged from the facility on 8/27/25. The MDS assessment for discharge status had not been transmitted to the CMS system at this time. On 1/28/2026 at 11:06 AM, during an interview with MDS coordinator (staff Q) R173's EHR was reviewed. Staff Q stated, We did not transmit the MDS yet. It's late. I will send it today. Staff Q said that the facility had undergone staff changes and some transmittals had been missed. On 1/29/26 at 2:10 PM the Nursing Home Administrator said the expectation is that MDS assessments will be sent timely in accordance with the federal regulations.
- Potential for harm · D2026-01-29 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 accurately complete Minimum Data Set (MDS) assessments for two (R2 and R4) of three residents reviewed for MDS assessments. Findings include:R2 According to R2's MDS assessment dated [DATE] section P, R2 used a limb restraint less than daily. Review of R2's Electronic Health Record (EHR) did not reveal any orders, care plans, or documentation to support R2 used a limb restraint. 01/27/2026 11:06 AM R2 was observed lying in bed on left side using wedge bolster. There were no visible restraints on R2. There were no restraint devices in R2's room. At 2:30 PM R2 was observed up in recliner chair. There were no visible restraints on R2 or in the room. R2 was unable to be interviewed due to cognition status. At approximately 2:35 PM unit manager Licensed Practical Nurse (LPN) R was asked if there were any restraints in the facility. LPN R stated, There are no restraints in the facility. We do not use them. LPN R confirmed that R2 had never had…
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 · D2026-01-29 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 refer one (R158) of two residents reviewed, with a serious mental disorder, to the state designated authority for review of the pre-admission screening and resident review (PASARR) program. This resulted in the likelihood of decline related to unidentified needs. Findings include: Record Review of the Electronic Health Record (EHR) revealed no Level II PASARR completed by the facility since R158's admittance date on 8/1/25. On 01/27/2026 at 11:39 A.M., R158 was interviewed and reported that he does not receive behavior or psychiatric supports at this facility. On 01/27/2026 at 2:20 P.M., R158's record review revealed a diagnosis of PARANOID SCHIZOPHRENIA with no evidence of a Level II PASARR. Review of a Level I PASARR dated 8/1/25 which was completed by the referring hospital which denoted the following: a diagnosis of Schizophrenia, a history of previous mental health treatment and the routine prescription of the antipsychotic medication…
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 before2026-01-29 · 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 follow standards of practice for medication administration for one resident (R183) of four residents reviewed for medication administration. Findings include:On 01/27/2026, at approximately 10:05 AM, R183 was observed in their room. Three pills in a medication cup were observed on R183's bedside table. Upon inquiry, R183 said the nurse leaves them since they cannot swallow the pills all at once. R183 further said they are not sure what the pills are taken for, or what they are. A record review was completed on 1/28/2026 which revealed R183 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right side, muscle wasting and atrophy, hyperlipidemia, hypertension, gastro-esophageal reflux disease, depression, and insomnia. Section C of the Minimum Data Set with an Assessment Reference Date of 1/6/2026, revealed R183 scored a 15/15 on the Brief Interview for…
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 19 citations
- Potential for harm · Dcited before2026-01-29 · 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 Based on observation, interview, and record review, the facility failed to ensure two residents (R118 and R33) out of four residents reviewed for accidents had wheelchair footrests in place during wheelchair mobility.Findings include: R33 On 1/27/2026 at 10:25 a.m. R33 was observed sitting in a wheelchair and unable to answer questions about care. Observed both of R33's leg lifted off the floor with intervals of the left leg dropping to the floor while Licensed Practical Nurse (LPN) V propelled R33 without any footrest into the hallway. There was no footrest in the room or the closet. On 1/27/2026 at approximately 10:35: a.m. LPN V was interviewed regarding R33's footrest. LPN V was asked did the resident have footrests for the wheelchair for safety? LPN V stated, the resident do not have leg rests but I will call therapy to get some for her. The resident should have them for safety reasons. According to the electronic medical record (EMR), R33 was admitted into the facility on 2/10/2017 and readmitted on [DATE]…
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 before2026-01-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when 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 observation, interview, and record review, the facility failed to follow physician's orders to apply oxygen for one resident (R118) out of four residents reviewed for oxygen use.Findings include:On 1/28/2026 at 8:25 AM, R118 was observed sitting in the rehab wing day room in a wheelchair with a portable oxygen tank with Certified Nursing Assistant (CNA) actively assisting R118 with breakfast. R118 was observed not wearing the oxygen canula. R118 was observed coughing. R118 was unable to answer questions regarding care. Licensed Practical Nurse (LPN) I was asked how R118 was transported to the day room. LPN I said Certified Nursing Assistant (CNA) J pushed R118 in a wheelchair. When LPN I was asked if R118 should be on oxygen LPN I stated, Yes she just got out of isolation for Covid-19 and acknowledged R118 was not wearing the oxygen canula. LPN I checked R118's portable oxygen tank and said R118's tank was empty and proceeded to get R118 a new portable oxygen tank and applied R118's oxygen canula. 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.
- Potential for harm · D2026-01-29 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 obtain a Legal Guardian (LG) for one (R2) of one legally incapacitated resident resulting in R2 not having a court appointed legal guardian since 2024. Findings include:On [DATE] at 2:30 PM, R2 was observed up in recliner chair watching TV. R2 was unable to be interviewed due to cognition status. On [DATE] at 2:50 PM during interview with R2's Representative (RR1) they said they were not being included in decision making for R2. RR1 said they were not R2's Legal Guardian (LG) at this time and was currently trying to obtain it through the court system. RR1 said they had not been assisted by the facility to assist with Legal Guardianship paperwork. RR1 stated, I was told because I did not live in the same county as the facility, they had no way to help me. According to R2's Electronic Health Record (EHR) RR1 was identified as R2's emergency contact and representative. R2 had resided in the facility since [DATE] with multiple diagnoses that…
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 · D2026-01-29 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 the physician ordered diet was provided to one resident (R203) of two residents reviewed for diet and nutrition, resulting in the potential for the resident to aspirate or choke.Findings include: On 1/27/2026 at approximately 1:40 PM, R203 was observed in their room with their lunch meal tray. The meal ticket on the tray listed the diet order as a regular diet with a pureed texture. The following food was observed on the tray: chicken pot pie, bread roll, peas and carrots, and applesauce. The food was not in a pureed form. R203 began to remove the plastic wrap from the bread roll to consume it. At approximately 1:45 PM, the surveyor notified LPN A of the concern. Upon entering the resident's room, the nurse was asked to verify the diet order on the meal ticket and stated, it's pureed, but that's not pureed food. I'll remove it and get (R203) the correct food. A record review revealed that the resident was admitted to the facility…
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 · D2026-01-29 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 ensure one resident (R33) out of five residents reviewed for immunizations, was provided influenza and pneumococcal vaccination and education resulting in the potential for development and spread of influenza and pneumonia among vulnerable residents in the facility. Findings include:On 1/29/2026 at 10:00 AM, the Infection Preventionist (IP) O was interviewed and reported R33 did not have documentation of a current influenza or pneumococcal immunizations or refusals signed by the guardian.Review of the Electronic Health Record (EHR) for R33 revealed R33 admitted on [DATE] with diagnosis of transient cerebral ischemic attack, dementia and Alzheimer's disease. R33 did not have documentation to indicate that the influenza or pneumococcal vaccines were declined by the guardian or were contraindicated.On 1/29/2026 at 11:59 AM the Director of Nursing (DON) was interviewed and said R33's guardian should have been contacted to obtain consent 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 · D2026-01-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (R33) out of five residents reviewed for immunizations, was provided Covid-19 vaccination and education resulting in the potential for development and spread of Covid-19 among vulnerable residents in the facility. Findings include:On 1/29/2026 at 10:00 AM, the Infection Preventionist (IP) O was interviewed and reported R33 did not have documentation of a current Covid-19 immunization or refusal signed by the guardian.Review of the Electronic Health Record (EHR) for R33 admitted on [DATE] with diagnosis of transient cerebral ischemic attack, dementia and Alzheimer's disease. R33 did not have documentation to indicate that the Covid-19 vaccine was declined by the guardian or was contraindicated.On 1/29/2026 at 11:59 AM the Director of Nursing (DON) was interviewed and said R33's guardian should have been contacted to obtain consent or declination.Review of the facility policy titled Resident Covid-19 Vaccination dated 10/6/2025,…
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 · Ecited before2025-08-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 intakes 1227387 and 1227390.Based on interview and record review the facility failed to implement fall prevention interventions for one (R101) of three residents reviewed for accidents, hazards, and adequate supervision, resulting in multiple falls with the potential for injuries. Findings include:This citation pertains to intakes 1227387 and 1227390.Based on interview and record review the facility failed to implement fall prevention interventions for one (R101) of three residents reviewed for accidents, hazards, and adequate supervision, resulting in multiple falls with and without injury.Findings include:On 8/4/25 at 10:30 a.m. R101 was contacted via telephone regarding the allegations reported to the state agency. R101 said they experienced several falls when trying to get something off the floor, when needing to go to the bathroom independently, and after putting on and waiting for the call light to be answered. R101 said the nurses put the resident at the nurse's station all day…
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 · Ecited before2024-11-22 · 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 ensure resident equipment was cleaned and sanitized sanitary equipment for 14 of 14 residents that resided on the third floor. Findings Include: On 11/22/24 at 9:00AM, a shower chair was observed in the hallway with visible dried feces. In addition, the sit to stand machine (device used for positioning residents) was noted to be soiled with dirt and food particles. On 11/22/24 at 9:10 AM, LPN A was queried concerning who was responsible for cleaning the resident's equipment. LPN A indicated the equipment should have been cleaned by the midnight shift. LPN A further indicated the equipment should have been cleaned after each use to prevent cross contamination. On 11/22/24 at 9:20 AM, the Nursing Home Administrator, (NHA) was shown the shower chair while she was rounding on the unit. The Administrator reiterated after observing the shower chair the facility was responsible for cleaning the equipment and the equipment should be cleaned after each use and on the midnight shift. A request for the facility's policy…
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 · D2024-11-22 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 maintain the cleanliness of a geriatric recliner for one (R78) of two residents reviewed for clean, comfortable and homelike environment. Findings include: On 11/20/24 at 6:17 a.m. R78 was observed in the common area of the unit sitting in a geriatric recliner. R78 appeared very anxious, restless, and confused. R78 legs were bent, and the lower part of the recliner was observed with dried food, dust, and candy wrappers. The left side of the recliner had dried brownish colored drip stains and the top of the recliner had a dried white substance. On 11/22/24 at 12:37 p.m. R78 was again observed in the common area of the unit sitting in the geriatric recliner. The recliner was observed with dried food, dust, stains, and trash as observed on 11/20/24. On 11/22/24 at 1:09 p.m. the Assistant Director of Nursing (ADON G) was asked to observe R78's recliner. ADON (G) was then interviewed about the cleaning of wheelchairs and recliners. ADON (G)…
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 before2024-11-22 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 ensure a Minimum Data Set (MDS) assessment was completed and transmitted to CMS (Center for Medicare and Medicaid) within 14 days after completion for one (R54) reviewed during the Resident Assessment review, resulting in inaccurate tracking of resident assessments (admission, quarterly, and discharge). Findings include: On 11/22/24 at 12:01 p.m., review of the clinical record revealed R54 had an admission MDS assessment with an assessment reference date (ARD) of 7/1/24. This MDS documented that it had been Completed (7/10/24); locked and accepted on 7/23/24. R54 discharged from the facility on 7/19/24. Review of the discharge MDS assessment revealed the assessment was not completed or submitted which was indicated on the resident assessment as MDS Record over 120 days. Review of the MDS tracking located in the MDS tab in the electronic medical record read, Next Tracking/discharge: Discharge- ARD: 7/19/24, 112 days overdue. On 11/22/24 at 1:17 p.m.,…
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 · D2024-11-22 · 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 timely ADL (Activities of daily living) care to include nail care and beard care for one resident (R28) of three residents reviewed for ADL care resulting in dissatisfaction with care. Findings include: On 11/20/24 at 9:07 AM R28 was observed in bed with long fingernails with debris and an unkempt beard. R28 stated I could use a shave and get my nails cut. On 11/21/24 at 8:41 AM R28 was observed with long fingernails with debris and an unkempt beard. Record review of R28's Electronic Health Record (EHR) revealed admitted to facility on 1/28/22 with pertinent diagnosis of hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) following cerebral infarction (stroke) affecting right dominant side. Review of the Minimum Data Set (MDS) dated [DATE] for R28 revealed a Brief interview for Mental Status (BIMS) of 13/15 intact cognition and substantial/maximum assistance for personal hygiene. On 11/21/24 at 2:08 PM R28 was…
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 · D2024-11-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to include one resident (R93) out of four residents reviewed for limited ROM in the restorative program. Findings include: On 11/20/24 at 12:38 PM, R93 was interviewed while in bed and stated, I'm not getting therapy or any exercises. I was supposed to get exercises after therapy finished. Record review of Electronic Health Record (EHR) revealed R93 admitted to the facility on [DATE] with diagnoses that included acquired absence of right leg below knee, absence of left leg below knee. Review of the Minimum Data Set (MDS) dated [DATE] for R93 revealed a Brief interview for Mental Status (BIMS) 15/15 intact cognition and substantial/maximal assistance for transfers. Record review of the physical therapy discharge summary note dated 11/1/24 revealed RNP/FMP (restorative nursing program/functional maintenance program): to facilitate maintaining current level of performance and in order to prevent decline, development of an instruction in the following RNP has…
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 before2024-11-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when 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 observation, interview, and record review the facility failed to ensure respiratory care equipment was stored in a sanitary manner for one resident (R276) out of two residents reviewed for respiratory care resulting in the potential for respiratory infections. Findings include: On 11/20/24 at 10:23 a.m. R276 was observed sitting in a wheelchair, in the room. R276 was alert, oriented to person, place, situation, and able to make all needs known. On the nightstand, a CPAP machine (A continuous positive airway pressure device used for treating sleep apnea disorders.) mouthpiece and tubing was observed loosely wrapped around machine with the mouthpiece resting on the nightstand's surface uncovered. R276 was queried about the uncovered mouthpiece and stated, The other places have always given something to put over it to keep from getting dirty but not here. It has fallen on the floor. I just pick it up and put back on the table. Sometimes they clean it in the morning but not before I put it on at night. 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.
- Potential for harm · D2024-11-22 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
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 routine dental services were provided to one resident (R63) of three residents reviewed for routine dental services, resulting in unmet oral health needs, discomfort, and loss of dignity. Findings include: On 11/20/24 at 9:45 a.m. was observed in bed resting. R63 presented as alert, oriented to person, place, and situation. R63 stated, I don't like the food here. I get soft food because I have trouble chewing. I asked to see a dentist, but no one has said anything about an appointment to see one. R63 pulled the bottom lip down and exposed two teeth (no other teeth except the two shown). R63 stated, I want these last two teeth pulled so I can get dentures and go back to a regular diet. I'm not eating like I want to. I eat more outside food. I want to gain more weight, but I can't if I'm not eating. If I can get them pulled, I will grin from ear to ear like a [NAME] cat. R63 confirmed being in the facility for about two months. Review…
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 before2024-03-07 · 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 MI00143137. Based on interview and record review the facility failed to ensure an x-ray for one resident (R906) was completed in a timely manner. Findings include: During an interview on 3/7/24 at 11:00 AM with R906, it was reported that a fall occurred when entering the facility on 3/5/24 at approximately 5:45 PM. R906 further reported that an x ray was done, This morning. Record review of electronic medical records (EMR) revealed admission into facility on 3/5/24. According to the Brief Interview for Mental Status (BIMS) dated 3/6/24, R906 was Cognitively Intact. During an interview on 3/7/24 at 9:45AM with Attending Physician (AP) A, it was reported that an x ray was ordered on the evening of 3/5/24. Record review of Physician Orders documented: X ray of left leg, left knee, and left hip dated 3/5/24 at 9:19 PM. On 03/07/2024 at 10:02 AM, Licensed Practical Nurse (LPN) B, reported that an order was received from AP A on 3/5/24 and was entered into the resident's electronic medical record (EMR). It was further reported that it was a stat…
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 before2024-03-07 · 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
This citation pertains to intake MI00142795. Based on interview and record review the facility failed to provide adequate supervision during care for one resident (R905) out of three residents reviewed for ADL (Activities of Daily Living) resulting in a fall with injury. Findings include: During an interview on 3/7/24 at 10:15 AM with a Concerned Family Member (CFM) D, it was reported that R905 had fallen out of bed while care was provided by staff. Record review R905's Nurses Notes dated 2/16/24 at 7:12 AM it was documented, during patient care resident fell from bed. During an interview on 3/7/24 at 1:09 PM with Unit Manager (UM) E, it was reported that when Certified Nursing Assistant (CNA) F was providing care, R905 was moved away from CNA F while in bed resulting in the resident falling out of bed. When asked if this fall could have been prevented, UM E responded, If the resident had been pulled toward the staff member or positioned in the middle of bed it could have prevented the fall. When asked if the resident received an injury from the fall, UM E reported that R905 had 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 · Ecited before2023-09-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation relates to intake MI00129792. Based on observation, interview, and record review the facility failed to provide a functional designated hand washing sink in resident room [ROOM NUMBER]'s restroom, and a safe and sanitary environment in the facility's Cardiac and C-unit's soiled utility rooms resulting in the increased potential for harm. Findings include: On 9/20/2023 between 10:35 AM and 11:10 AM, during an environmental tour of the facility, the Cardiac and C-unit's soiled utility rooms were observed with visible debris and dark colored liquid in their hoppers, along with a strong odor present in the room. On 9/20/2023 at 11:07 AM, while in the C-unit's soiled utility room with Housekeeper, staff C, the surveyor inquired on the current state of the hopper in the room to which they replied, I don't know why someone would leave it like this. There is a sign from maintenance telling staff not to use this sink right above it. During this time frame on the same environmental tour of the facility, lift…
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 · D2023-09-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 has two deficient practice statements. Deficient Practice Statement #1. This citation pertains to Intake MI00139389. Based on observation, interview, and record review, the facility failed to ensure prescribed medications octreotide acetate injection (used to treat severe diarrhea) and triamcinolone acetonide ointment (used to treat various skin conditions) were provided in a timely manner for two residents (R102 and R121) reviewed for quality of care, resulting in resident frustration, and the potential for unmet care needs. Findings include: It was reported to the State Agency that the facility failed to administer medications as ordered. Resident #102 - A review of the admission record for Resident #102 (R102) documented an admission date of 8/21/2023 with diagnoses that included bladder cancer. A Minimum Data Set assessment dated [DATE] documented intact cognition and the presence of an ostomy. Physician orders for R102 included: Octreotide acetate injection solution 500 mcg/ml. Inject 0.6 ml…
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 · D2023-09-21 · 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 This citation pertains to Intakes MI00136145 and MI00138771 Based on interview and record review, the facility failed to provide timely treatment and interventions to promote the healing of pressure ulcers for three residents (R151, R168, and R163) out of seven residents reviewed for wound care, resulting in the potential for worsening of the pressure injury. Findings include: It was reported to the State Agency that facility staff did not provide adequate care for pressure wounds. Resident #151 - A review of the admission Record for Resident #151 (R151) documented an initial admission date of 7/14/2023 and readmission date of 8/10/2023. R151's diagnoses included cancer of the larynx, adult failure to thrive, chronic respiratory failure with hypoxia, peripheral vascular disease, atrial fibrillation, and type 2 diabetes mellitus. A Minimum Data Set (MDS)assessment dated [DATE] documented intact cognition and no pressure or venous ulcers. Physician orders documented: 1. Apply Santyl ointment nickel thick 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.
“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 | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 3 of 5 | 3.2 | -0.2 vs chain |
| Quality measures | 5 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 05/16/2005 |
| QAZI, MOHAMMAD | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/16/2005 |
| CIENA HEALTHCARE MANAGEMENT INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/20/2025 |
| BELL, LAKEISHA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/04/2013 |
| GALLMORE, KENNETH | 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 05/16/2005 |
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 $4.2M paid to related parties — landlords or management companies under common ownership — equal to about 18% 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.
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 235177. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-29, 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.