Regency Heights-Detroit
19100 West Seven Mile Road, Detroit, MI 48219 · For profit - Individual · 168 certified beds · (313) 533-5002 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)
- lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0602), cited Dec 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- it has 2 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $19,321 in federal fines (most recent 2024-04-05)
- about 19% 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 | 1.7% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.7% | 5.4% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.1% | 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 | 0.9% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 2.9% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.6% | 19.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 93.7% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.2% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 7.3% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 2.1% | 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 | 90.8% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.3% | 24.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.8% | 11.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.56 | 1.84 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.02 | 1.64 | 1.80 | 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.
45.0% 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 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.5% 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 55 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 0.45 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 60% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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 | 45.0%CMS range 33.6–57.8 | 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 | 13.0%CMS range 9.4–17.1 | 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 | 54.5% | 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 | 63.6% | 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 | 47.3% | 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 | 95.5% | 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 | 100.0% | 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 | 100.0% | 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 | 1.1% | 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 | 7.8%CMS range 4.8–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 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 168 beds and averages 152.7 residents a day — about 91% occupied, or roughly 15 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 3.76 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.25 hrs/resident/day on weekends vs 3.97 on weekdays — 18% thinner on weekends. RN hours go from 0.44 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 35% 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.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · Gcited before2024-04-05 · 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 observations, interviews, and record review the facility failed to implement interventions to prevent pressure ulcers for one (R153) of 10 residents reviewed for pressure ulcers resulting in R153 developing an Unstageable Pressure Ulcer to her left hip. Findings include: According to the National Pressure Ulcer/Injury Advisory Panel (NPUAP); Unstageable Pressure Ulcer/Injury is full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (necrotic dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and…
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.
- Actual harm · Gcited before2023-02-16 · 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 interview and record review, the facility failed to implement interventions to prevent the development of a pressure ulcer and properly treat a pressure ulcer for one resident (R96) of five residents reviewed for pressure ulcer/injuries resulting in the development of a facility acquired Stage III pressure ulcer (Full-thickness loss of skin, in which adipose [fat] is visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present. Slough and/or eschar [dead skin tissue] may be visible.). Findings include: A review of the admission Record for Resident #96 (R96) revealed an initial admission date of 12/10/2020, readmission date of 12/6/2022, and discharge date of 2/10/2023. R96's diagnoses included congestive heart failure, cerebral infarction, gastrostomy status, ulcer of esophagus with bleeding, and Alzheimer's Disease. Review of R96's Minimum Data Set (MDS) assessments revealed the following: A Quarterly MDS assessment dated [DATE] revealed R96 had no pressure ulcers 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 · F2025-05-30 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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 an adequate supply of emergency food was available. Findings include: On 5/29/25 at 11:16 AM, an observation and interview regarding the facility's emergency food supply was conducted with Dietary Manager (DM) H. DM H provided a document titled, Emergency Planning Recommendations for your Facility which indicated in part the following: We suggest storing a minimum of a 3-day supply of non-perishable food on site. DM H agreed that non-perishable foods were shelf-stable (food stored at room temperature and able to last long periods without spoiling). This document included a disaster menu for Day 1, Day 2, and Day 3. The disaster menus for Day 1, Day 2, and Day 3 were compared to the shelf-stable food on hand. The following items were not available and not substitutable with other foods on hand: assorted 100% juices, high protein breakfast bars, shelf-stable milk, and canned potatoes. The following shelf-stable food items listed on the disaster menus were also not available but may, in an emergency, be…
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 before2025-05-30 · 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: 1. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, meatballs, corned beef, baked beans, and diced potatoes; 2. Ensure the caulking of the hand washing sink was in good repair; 3. Store an ice scoop in a clean and sanitary manner; and 4. Properly date-label food stored in a resident refrigerator. These deficient practices resulted in the potential for food-borne illness for the residents that eat from the kitchen and residents that reside on the first-floor unit. Findings include: On 5/27/25 at 8:36 AM, the initial tour of the kitchen began with Dietary Manager (DM) H. The following was observed inside of the walk-in cooler: a pan of previously cooked meatballs dated 5/24, a pan of previously cooked corned beef dated 5/26, a pan of previously cooked baked beans dated 5/26, and a pan of previously cook diced potatoes dated 5/26. DM H said staff did not complete a cooling log for these previously cooked food items. On 5/28/25 at 12:39 PM, Certified Nurse Aide (CNA) J…
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 before2025-05-30 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
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 consistent proper working order of the facility's walk-in freezer which had the potential to affect all residents that eat from the kitchen. Findings include: During the initial tour of the kitchen on 5/27/25 at 8:36 AM with Dietary Manager (DM) H, the internal temperature of the walk-in freezer was observed to be 9 ºF (Fahrenheit). A four-ounce cup of ice cream stored in the freezer was observed soft, not frozen solid. During a return visit to the kitchen on 5/29/25 at 11:16 AM with DM H present, the internal temperature of the walk-in freezer was 9 ºF. A four-ounce cup of ice cream stored in the freezer was soft, not frozen solid. The walk-in freezer door did not seal properly when closed. A noticeable gap was visible when the freezer door was closed which allowed cold air to escape. DM H stated, I never considered it (the freezer door not closing properly) being a concern because the meat was always frozen. We need to shop for a new freezer. On 5/30/25 at 1:56 PM during an interview, the Nursing…
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 · D2025-05-30 · 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 properly maintain residents' wheelchairs for two residents (R34 and R86), out of six residents reviewed for a safe and comfortable environment, resulting in resident discomfort and potential for the spread of harmful pathogens. Findings include: On 5/27/25 at 10:19 AM, R34 was observed asleep in bed. Both armrests of the wheelchair observed in R34's room were in disrepair. The covering on one armrest was severely frayed and only partially covered the foam underneath. There was no padding or covering on the other armrest which would result in the resident's arm positioned on bare metal. The covering on the back section of R34's wheelchair was partially missing exposing the foam underneath. On 5/27/25 at 12:51 PM, R86 was observed awake in her room sitting in a wheelchair. The covering on both armrests on R86's wheelchair were split and frayed, and the padding underneath was exposed. R86 said sometimes the armrests hurt her arms. On 5/30/25…
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 · D2025-05-30 · 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
Based on observation, interview, and record review, the facility failed to ensure that medications were administered in accordance to professional standards of practice for two (R12 and R17) of five residents reviewed for medication administration resulting in the potential for medication errors to occur. Findings include: On 5/28/25 at 8:28 AM Licensed Practical Nurse (LPN) C was observed to have two medications cups with pills inside stacked on top of each other on the medication cart. During inquiry LPN C said the medications were for two different residents, R12 and R17. R12's medication cup was on the top and R12's medication cup was underneath. LPN C said they were going to administer the medications to the residents and then sign them out because, It saves time to pull two resident's medications at the same time. Upon inspection of the medication cups it was determined that neither R12 or R17 had their entire 9:00 AM prescribed medications in the medication cups. LPN C said, I only put the packaged medications in the cups. Not the floor stock medications. LPN C acknowledged…
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 before2025-05-30 · 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 ensure that nail care was provided for one dependent resident (R107) of three reviewed for activities of daily living care (ADLs). Findings include: On 5/27/25 at 10:51 AM, 5/28/25 at 1:40 PM, and 5/29/25 at 12:14 PM, observations were made of R107's nails being one forth to one third of an inch above the tip of their thumb and multiple fingers. R107's nails were observed to be discolored with a light brownish appearance. R107 was interviewed multiple times about the length and appearance of their nails and did not respond to the surveyor's questions. On 5/29/25 at 12:16 PM, certified nurse assistant (CNA) A was interviewd and shown R107's nails. CNA A indicated that they needed to be trimmed and cleaned. On 5/29/25 at 12:31 PM, unit nurse manager/licensed practical nurse (UNM/LPN) B was interviewed about their expectations regarding nail care involving R107. UNM B indicated that they had noticed the condition of R107's nails yesterday and…
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 · D2025-05-30 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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 physician ordered lab draw (Keppra level) was completed for one resident (R84) reviewed for lab results, resulting in R84's physician being unaware that the ordered Keppra level was not completed along with the potential for an abnormal Keppra blood level go undetected and untreated. Findings include: Review of R84's Electronic Health Record (EHR) revealed the resident re-admitted to the facility on [DATE] with multiple diagnoses that included Chronic Kidney disease and Epilepsy (seizures). According to the physician's orders on 4/11/25, R84 was prescribed Keppra 750 milligrams (mg) twice a day. On 4/24/25, R84 was ordered to have a Keppra blood level drawn. As of 5/27/25 there was no Keppra level results available and no progress notes to indicate a Keppra level had been drawn. Further review of R84's EHR revealed the resident had no seizure activity in the facility. On 5/27/25 at approximately 1:00 PM the Director of Nursing (DON) reviewed…
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 before2025-05-30 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to accurately document one resident's (R93) code status in the electronic medical record (EMR) out of six residents reviewed for advanced medical directives (AMD), resulting in the potential for R93's choices not being followed. Findings include: Record review of R93's information page in the EMR documented in the code status area that resident was a Full Code (resuscitation would be performed in the event resident had no heartbeat or breathing had stopped). Record review of R93's Do-Not-Resuscitate Order revealed, I have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import. Further review of form revealed resident had signed the document on 7/8/24, as well as R93's attending physician. An interview was conducted on 5/27/25 at 11:10 PM with R93, it 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 · Dcited before2025-02-03 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 This citation pertains to intake MI00149633. Based on interview and record review, the facility failed to notify the Resident Representative (RR) of a diagnosis of pneumonia and physician's order for an antibiotic for one resident (R101) out of three residents reviewed for change in condition Findings include: It was reported to the State Agency that the facility did not notify the RR about the resident's medical condition. A review of the clinical record revealed R101 was initially admitted to the facility on [DATE] and discharged from the facility on 1/16/25. R101's diagnoses included Alzheimer's disease, dysphagia, and adult failure to thrive. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. Additional review of R101's clinical record documented in part the following: 1. Change in Condition Evaluation of 1/15/25 at 12:21 PM: Resident feels hot to touch, resident temperature documented. Physician recommended chest x-ray. R101's RR notified on 1/15/25 at 12:33 PM. 2. Nursing…
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 before2024-04-05 · 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 sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 142 residents who receive meal services (oral foods) out of the facility's total census of 153 residents. Findings include: In an observation on 4/3/24 at 11:23 a.m., Dietary [NAME] B touched a piece of cooked pork loin with bare hands while getting a temperature. Dietary [NAME] B picked up part of the pork loin and put it back in the pan without wearing gloves. CDM (Certified Dietary Manager) D instructed Dietary [NAME] B to put on gloves. In an observation on 4/3/24 at 11:24 a.m., Assistant [NAME] C removed gloves and did not perform hand hygiene before writing down temps in a book. In an observation on 4/3/24 11:50 a.m., Dietary [NAME] B removed gloves then walked to a drawer, opened it, and touched serving utensils. Dietary [NAME] B did not perform hand hygiene after glove removal. In an observation on 4/3/24 11:54 a.m., Dietary [NAME] B had gloved…
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 17 citations
- Potential for harm · Dcited before2024-04-05 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 immediately notify the family of a change in condition and subsequent transfer to the hospital for one (R55) of three residents reviewed for notification of change. Findings include: On 04/04/24 at 10:00 AM an observation of R55's room revealed an empty bed and recliner chair. Upon inquiry, Licensed Practical Nurse (LPN) J reported that R55 was sent out to the hospital prior to the start of her shift. On 04/04/24 at approximately 11:29 AM R55's Family Member (FM) #1 was observed at the nurse's station asking where R55 was. LPN I told FM #1 the resident (R55) was transferred to the hospital and another family member (FM#2) was aware. At this time FM#1 said, No, you never told us. This has happened 2 or 3 times now. They do not tell us. FM #1 then called FM #2 on his cell phone to verify if FM#2 had been notified of R55's change in condition and subsequent transfer to the hospital. FM #2 over the phone said, No, they didn't tell us. We found out because we went up there to visit and she (R55) wasn't there. Then…
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 · D2024-04-05 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to respond to concerns from residents about staff call light response times, resulting in dissatisfaction and unmet needs among 13 residents of 20 residents with the quality of care. Findings Include: On 4/4/24 at 1:55 PM a meeting was held with the members of the council. Residents presented concerns and dissatisfaction with call light response times. An anonymous resident commented about being told by staff to put a call light on before shift change because staff is busy. An anonymous resident gave an example of call light wait time explaining one day it took three and a half hours before a call light was answered. During the meeting of 20 residents, 13 residents raised their hands in response to the question of problems with call light response times. On 4/4/24 at 4:30 PM, record review of the Council Meeting Notes revealed on 3/19/24 a note was made stating in part, . (residents) discussed answering call lights not being answered in a timely manner. On 4/5/24 at 9:30 AM the Activities Director L was interviewed and 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 · D2024-04-05 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure accurate information for transfer was communicated to the receiving hospital for one (R55) of two residents reviewed for discharges and transfers. Findings include: On 04/04/24 at approximately 10:00 AM Licensed Practical Nurse (LPN) J reported that R55 was sent out to the hospital prior to the start of her shift and was unaware of the circumstances that required R55 to be transferred to the hospital. On 04/04/24 at 11:30 AM, R55's Electronic Health Record (EHR) was reviewed. An order dated 4/4/24 at 7:27 AM indicated R55 was to be sent to the hospital for abnormal labs. A 'Transfer Form' dated 4/4/24 at 7:37 AM documented 'transfer details' that were dated 3/12/24 and indicated that R55 was sent out to the hospital for 'shortness of breath'. There was no corresponding progress note for 04/04/24 to indicate any additional medical information was provided to the receiving hospital. On 04/04/24 at 11:42 AM upon inquiry, Nurse Practitioner (NP) K said she ordered R55 to be transferred to the hospital for abnormal labs…
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 · D2024-04-05 · 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 observation, interview and record review, the facility failed to apply splinting devices for two (R23 and R62) of eight residents reviewed for limited range of motion, resulting in the potential for increased joint contracture, loss of range of motion and increased pain. R23 On 4/03/24 at 10:39 AM R23's was observed in bed with left hand clenched into a fist. On 4/04/24 at 11:34 AM R23 was observed in bed with left hand clenched into a fist no carrot, or towel roll in hand. On 4/04/24 at 3:15 PM R23 was observed in bed with left hand clenched into a fist with no carrot or towel roll in left hand. Review of R23's Electronic Health Record (EHR) revealed the most recent admission to facility on 4/19/2022 with diagnosis that included Alzheimer's disease, diffuse traumatic brain injury, and hemiplegia and hemiparesis left side. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment and dependent for activities of daily living (ADLs). Review of R23's April 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 · D2024-04-05 · 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 date a respiratory water bag for one (R62) of two residents reviewed for oxygen use. Findings include: On 4/03/24 at 9:57 AM, R62's water bag for tracheostomy oxygen humidification was observed in use with no date labeled on bag. On 4/04/24 at 8:15 AM, R62's water bag for tracheostomy oxygen humidification was observed in use with no date labeled on bag. On 4/4/24 at 1:14 PM, R62's water bag for tracheostomy oxygen humidification was observed in use with no date labeled on bag. On 4/04/24 at 1:47 PM Licensed Practical Nurse (LPN) H was interviewed and said the water bag is used to humidify the supplemental oxygen to R62's tracheostomy and should be dated so that staff are aware when it was last changed. On 4/05/24 at 1:51 PM the Director of Nursing (DON) was interviewed and agreed R62's water bag should be dated to ensure when the bag was initially used and changed. Review of R62's Electronic Health Record (EHR) revealed admitted 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 · Dcited before2024-04-05 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 interview and record review the facility failed to ensure complete and accurate documentation was maintained in an Electronic Health Record (EHR) for three residents (R23, R62, and R55) of 30 residents reviewed for accurate medical records resulting in inaccurate and incomplete medical records with inadequate care delivery. Findings include: R62 Review of R62's EHR revealed admitted to facility on 5/5/2023 with diagnosis that included chronic respiratory failure, contractures to right and left elbows, and traumatic brain injury. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment. Review of R62's April Medication Administration Record (MAR) revealed that elbow braces bilateral on 4 to 6hrs daily on at 10 AM one time a day on at 10 AM off between 2 PM and 4 PM daily were applied on dates 4/1/2024 through 4/4/2024 by Licensed Practical Nurse (LPN) F. R23 Review of R23's EHR revealed most recent admission to facility on 4/19/2022 with diagnosis that included alzheimer's…
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 · D2024-04-05 · 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 two residents (R126 and R87) out of five residents reviewed for immunizations, were provided influenza vaccination and education resulting in the potential for the development and spread of influenza among vulnerable residents in the facility. Findings include: On 4/5/2024 at 11:00AM the Infection Preventionist (IP) A was interviewed and reported the following residents did not have documentation of a current influenza immunization or refusal: -Review of the Electronic Health Record (EHR) for R126 admitted on [DATE] with diagnosis of respiratory failure, heart failure. R126 did not have documentation to indicate that the influenza vaccine was offered or was contraindicated. -Review of the EHR for R87 revealed admitted on [DATE] with diagnosis of urinary tract infection and dementia. R87 did not have documentation to indicate that the influenza vaccine was offered or was contraindicated. On 4/5/2024 at 1:12 PM the Director of Nursing (DON) 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 · D2024-04-05 · 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 intake MI00141524. Based on interview and record review, the facility failed to thoroughly investigate an injury of unknown origin and unexpected death for one (R162) of two resident reviewed for abuse. Findings include: The State agency received a complaint that R162 was found expired in her room on the floor with an injury of unknown origin to the back of her head. A review of R162's closed Electronic Health Record (EHR) revealed that on [DATE] at approximately 7:45 AM the resident was observed laying on her left side on the floor in front of her bed and determined to be expired. There was no additional progress note or total body assessment that documented the condition of the resident's head or body. R162 was receiving palliative care (medical care focusing on pain relief) and had a 'Do Not Resuscitate' order. There was no Accident and Incident (A&I) report for [DATE] in the resident's EHR. On [DATE] at 11:22 AM the facility's 'Safety Coordinator' Licensed Practical Nurse (LPN) H…
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 · D2023-12-05 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
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 MI139413 & MI140760. Based on interview and record review, the facility failed to (1) obtain authorization to manage personal funds (social security check), (2) properly manage a trust account, and (3) follow the guidelines to become the appropriate representative payee for one resident (R701) of three residents reviewed for resident rights, resulting in the resident and the family expressing anger and frustration of not having control over personal funds. Findings include: On 12/5/23 at 11:44 a.m. the complainant was contacted via telephone regarding the allegation of the facility taking R701's personal funds without permission. The complainant said R701 no longer resides in the facility and transferred to another facility due to owing the facility a large bill. The complainant also said the facility fraudulently became the resident's representative payee through social security to have all R701's money to come to the facility. The complainant became very angry and stated, How…
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 · D2023-12-05 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 MI139413 & MI140760. Based on interview and record review, the facility failed to obtain authorization to use resident funds (social security) for one resident (R701) of one reviewed for misappropriation of funds resulting in the facility use of resident funds for a five month period of time without the resident's consent. Findings include: On 12/5/23 at 11:44 a.m. the complainant was contacted via telephone regarding the allegation of the facility taking R701's personal funds without permission. The complainant said R701 no longer resides in the facility and transferred to another facility due to owing the facility a large bill. The complainant also said the facility fraudulently became the resident's representative payee through social security to have all R701's money to come to the facility. The complainant became very angry and stated, How are they able to just take someone's money without their authorization. (R701) has other obligations to pay. Because they took all 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 before2023-02-16 · 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: 1. Remove expired, undated, unlabeled food from the kitchen walk-in cooler and resident refrigerators; 2. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, baked beans and BBQ ribs; 3. Properly seal frozen food items; 4. Ensure pans were clean and allowed to air dry before stacking and storage; 5. Ensure the use of beard guards of staff working in the kitchen; 6. Accurately document the walk-in freezer temperatures; 7. Ensure ladles were stored properly to prevent contamination; 8. Adequately clean kitchen surfaces; 9. Remove expired liquid nutrition supplements from active stock; 10. Properly store ice scoops in a sanitary manner; and 11. Properly clean in and around an ice machine. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: On 2/13/2023 beginning at 9:48 AM, the initial tour of the kitchen was conducted with Dietary Manager…
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 · F2023-02-16 · 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 This citation includes two deficient practice statements. Deficient Practice #1. Based on observation, interview, and record review, the facility failed to maintain three resident rooms (101, 116, and 120) reviewed for the environment, resulting in an unsafe and an unclean environment. Findings include: During environmental observations, the following was noted: On 2/13/23 at 10:02 am, in room [ROOM NUMBER] a telephone jack wires were observed to be exposed out side of the wall socket and a flap of wallpaper was lifted exposing dry wall on the bottom left corner of the PTAC (portable terminal air conditioning unit). On 2/13/23 at 11:08 am, a 3x3 crack in the vinyl flooring exposing a cement slab was observed on the left side R71's bed in room [ROOM NUMBER]. Further investigation of the crack on the floor reveaked it to have rough, ragged edges. On 2/13/23 at 11:50 am, in room [ROOM NUMBER] the bathroom sink was observed to have rust in the sink bowl and rust running in a downward direction from the overflow…
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 before2023-02-16 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
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 the second floor ice machine was maintained in a safe and sanitary operating condition, resulting in the ice machine not being protected against contamination from sewage or other sources of contamination, potentially effecting all residents consuming ice from this machine. Findings include: During an observation and interview on 2/16/2023 at 12:43 PM with Maintenance Director D, the drain line from the second floor ice machine was observed to not have the required minimum one-inch air gap (an unobstructed vertical space between the end of the drain line and the flood rim of the floor drain). On 2/16/2023 at 3:20 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and they reported there was not. 5-202.13: An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least…
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 · D2023-02-16 · 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 ensure the legal representative formulated an Advance Directive to grant and/or withhold life sustaining treatment (Cardiopulmonary Resuscitation/CPR, Artificial Nutrition/Peg Tube, Artificial Hydration/ IV, and Diagnostic Testing) according to their wishes upon admissions, quarterly review, and/ or significant change for 1 resident (R62) of 4 sampled residents reviewed for advance directives, resulting in the potenital for denial of the resident's right to have life sustaining or withheld decisions honored. Findings include: On [DATE] at 10:44 a.m. R62 was observed resting in bed. R62 was also observed to be nonverbal and unable to make needs known. On [DATE] at 10:07 a.m. review of the clinical record documented R62 was admitted into the facility on [DATE] with diagnoses that included encephalopathy and dementia. According to admission Minimum Data Set assessment dated [DATE] R62 was severely cognitive impaired, had no speech, and…
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 · D2023-02-16 · 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 Based on observation, interview, and record review, the facility failed to implement a comprehensive care plan for a prosthetic shrinker sleeve (an elastic sock made to control swelling, promote healing, and assist in shaping an amputated leg to fit an artificial leg) for one resident (R467) out of two residents reviewed for rehab services, resulting in no established goals and interventions related to shrinker sleeve use and the potential for a delay in rehabilitation. Findings include: During an observation and interview on 2/13/2023 at 4:19 PM, Resident #467 (R467) was awake and sitting in his bed. R467 verbalized a concern regarding the lack of progress and follow up he was experiencing regarding the use of his prosthetic leg. A prosthetic shrinker sleeve was observed on R467's bedside table. A review of the admission Record for R467 documented an admission date of 1/20/2020 and readmission date of 1/30/2023. R467's diagnoses included orthopedic aftercare following surgical amputation, type 2 diabetes…
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 before2023-02-16 · 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 perform nail care for one resident (R64) and provide timely incontinence care for one resident (R151) out of 31 residents reviewed for dependent activities of daily Living (ADLS), resulting in unkempt nails, body odor, and in the potential for skin breakdown and poor self esteem of the resident. Findings include: Resident #64 Record review of R64's face sheet revealed admission into the facility on [DATE] with a pertinent diagnosis of dementia. According to the Minimum Data Set (MDS) dated [DATE], R64 had impaired cognition and was provided extensive assist with most Activities of Daily Living (ADLS). During an observation and interview on 02/13/23 at 02:41 PM, R64 was observed in bed with long jagged fingernails with a buildup of dark brown debris on the underside of nails. Resident was asked if it was a preference to have long nails, R64 nodded yes. When asked if it was a preference to have nails clean, R64 said Yes. During an…
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 · D2023-02-16 · 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 Based on observation, interview, and record review, the facility failed to implement skin care treatments for 3 residents (R58, R74, and R135) of 3 reviewed for non-pressure related skin conditions resulting in discomfort, untimely wound care, and the potential for further harm to skin integrity and wound degradation. Findings include: Resident #58 On 2/13/23 at 11:38 a.m. R58 was observed resting in bed with heel protectors on both feet. Further observation revealed a white bandage dressing on the left foot covering the heal and ankle with a date of 2/10/23. On 2/13/23 at 3:22 p.m. review of the clinical record documented R58 was initially admitted into the facility on 2/21/22 and readmitted 10/2022 with diagnoses that included unspecified soft tissue disorder of pressure multiple sites and dementia. According to the quarter Minimum Data Set assessment (MDS) dated [DATE], R58 required total two-person assistance with activities of daily living. The assessment also documented R58 had a diabetic foot ulcer with…
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
$19,321 in federal fines across 1 penalty.
- $19,321 — penalty dated 2024-04-05
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
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 | 3 of 5 | 3.2 | -0.2 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
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 |
|---|---|---|---|
| QAZI, MOHAMMAD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/1998 |
| KHAN, ANIS | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/1998 |
| CIENA HEALTHCARE MANAGEMENT INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/20/2025 |
| RAFIE, RAMIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| REED-SYLTE, CHRISTINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/23/2017 |
| MOHAMMAD A QAZI LIVING TRUST DATED 09/26/97 | Organization | ADP OF THE SNF | since 08/01/1998 |
CMS files one row per role, so the 14 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 $4.3M paid to related parties — landlords or management companies under common ownership — equal to about 19% 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 235452. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-30, 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.