Regency at Grand Blanc
1330 Grand Pointe CT, Grand Blanc, MI 48439 · For profit - Limited Liability company · 138 certified beds · (810) 695-8920 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- it has 1 actual-harm citation
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- about 23% 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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 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, and staffing on its payroll (PBJ) submissions — 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 | 5 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 5 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 | 9.7% | 10.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.3% | 5.4% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.2% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 5.5% | 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 | 13.5% | 12.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 37.0% | 19.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.7% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.6% | 20.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.9% | 14.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.1% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.8% | 24.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 5.6% | 11.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.99 | 1.84 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.49 | 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.
65.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 663 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.4% 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 294 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 0.84 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% 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 | 65.0%CMS range 61.1–68.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.9%CMS range 9.7–14.7 | 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 | 54.4% | 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 | 61.6% | 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 | 52.0% | 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 | 98.7% | 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 | 96.1% | 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 | 99.0% | 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 | 1.5% | 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 | 1.5% | 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 | 7.0%CMS range 5.0–9.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 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 138 beds and averages 129.4 residents a day — about 94% occupied, or roughly 9 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 3.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.15 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 3.47 hrs/resident/day on weekends vs 4.13 on weekdays — 16% thinner on weekends. RN hours go from 1.33 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · Gcited before2025-04-17 · 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 Refer to Intake Numbers: MI00151742 Based on observation, interview, and record review, the facility failed to: 1.) provide services to prevent the development of new pressure ulcers consistent with professional standards, 2.) provide the appropriate skin care interventions to promote healing for two sampled residents (R304 and R306) of five residents reviewed with pressure ulcers, resulting in the development of avoidable pressure ulcer, delay in treatment and healing and potential for wound infection, pain, and complications. Findings include: Resident# 304 (R304) During the initial interview on 4/16/25 at 1:56 PM, R304 revealed he had recently developed a wound at the facility and stated he was not turned by staff as frequently as he should have been. According to the Record review conducted on 4/16/25 at 3:30 PM, R304 was [AGE] years old and admitted to the facility on [DATE] with the diagnosis of spinal stenosis at the lumbar region without neurogenic claudication and had surgical fusion of the spine…
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 before2026-04-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement interventions to prevent falls for one resident (Resident #3) of three residents reviewed for falls, resulting in a fall from bed.Findings include:This citation pertains to intakes 2971486 and 2985660.Resident #3 (R3):R3 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include rheumatoid arthritis, morbid obesity, inability to ambulate and primary generalized osteoarthritis.On 4/6/26 at 10:30AM, record review was conducted of a fall report from 03/26/26. On 03/26/26 at 14:00PM, Certified Nursing Assistant (CNA) C was providing care to R3 without the assistance of an additional staff member. CNA C rolled R3 away from and R3 kicked her right leg over the side of the bed, causing R3 to roll from the bed on to the floor. There was bruising noted to the right knee, ice was applied, the physician, responsible party and Director of Nursing (DON) were notified of the fall. X-rays of the right knee were ordered on 3/26/26…
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 before2026-01-07 · 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 This citation pertains to Intake Number 2697789.Based on observation, interview and record review the facility failed to complete thorough respiratory assessments for one resident (Resident #1) and establish a completed oxygen order for one resident (Resident #2). Findings Include:Resident #1:On 1/2/2026 at approximately 12:20 PM, an interview was conducted with Resident #1's daughter. She stated her mother admitted to the facility for strengthening after she fractured her tibia and fibula, while at the facility it was discovered she had pneumonia and utilized oxygen daily. Concern was expressed that as Resident #1's time at the facility progressed, she required increased oxygen supplementation. In addition, the two antibiotic courses did not appear to be effectively treating her pneumonia. When Resident #1 began the second antibiotic the facility was unable to get her breathing under control and her oxygen was consistently being increased to 4 Liters or higher. She stated they believe there was delay 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 · E2025-06-13 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure five residents' (#1,#7, #13, #37 and #42) wheelchairs/Amigos were regularly cleaned, sanitized and free from damaged areas of six reviewed for a homelike environment. Findings Include: During Resident Council held on 6/11/2025 at 10:20 AM, five residents' wheelchairs or amigos were observed to have packed substances in the crevices, worn cushions, and varying areas of dried on substances. When asked if their wheelchairs were cleaned on a regular basis, they stated they were not. None could recall when the last time their wheelchair had been cleaned. Review was completed of Resident #1, #7, #13, #37 and #42's wheelchair cleaning task log for the last 30 days. The documentation indicated their wheelchairs were being cleaned weekly, but observations made indicated they were not being consistently cleaned. The following was documented: Resident #1: Wheelchair was last cleaned on 6/5/2025. Resident #7: Wheelchair was last cleaned 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 · Ecited before2025-06-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 Resident #70 On 6/10/25 at 1:13 PM, an interview was completed with Resident # 70 in their room. The Resident was sitting up in their bed with the overbed tray positioned over the bed in front of them. A nebulizer machine was present on the dresser beside the bed. The nebulizer mask was sitting directly on the top of the dresser and was not contained. There was visible fluid in the medication cup chamber of the nebulizer mask. Record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder, depression, anxiety, and colostomy (surgically created opening in the abdomen allowing for the passage of stool into an external bag). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate to substantial assistance to complete Activities of Daily Living (ADLs) with the exception of set-up assistance for eating and oral hygiene. Review of Resident #70's care plans in the Electronic Medical Record…
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 before2025-06-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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) Maintain food preparation and kitchen equipment in a sanitary and good working condition and 2) Maintain a clean and sanitary environment (refrigerator, microwave and floor drains), resulting in an increased potential for food borne illness, with the potential to affect all residents who consumed oral nutrition. Findings Include: On 6/10/25 at 10:28 AM, a tour of the kitchen was completed with Certified Dietary Manager D the following was identified as areas of concern: Ice Machine: Puddle of water was observed being the ice machine. The drain grate was a dark orange/brown color on the slacks. The tubing from the back of the ice machine the filter connected on the wall was riddled with visible brown colored dust spanning the length of the tubing. Microwave: The inside of the door, sides and top of the microwave were splattered with unknown food particles. Cooks Refrigerator: Both corners of the refrigerator had dried food particles and smudges in various areas on the outside and inside of the door. Cereal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-13 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 dignity by not having the call lights accessible, extended call light response times, and not treating residents in a respectful manner for five residents (Res. #15, Res. #50, Res.#187, Res. #289, & Res.#391) of five residents reviewed for dignity and respect and call light response times, resulting in fear of abandonment, isolation and decreased socialization and the potential for falls or accidents. Findings include: Resident #15 (R15) Dignity During the initial tour on 06/10/25 at 1:11 PM, Resident #15 was observed eating popcorn in bed in his room. During the initial interview, R15 revealed that he could not see any more since he was diagnosed with Glaucoma; he is now blind. When asked if he had access to his call light, he said he would often feel around his bed to find it but could not find the call light button. During an observation on 6/10/25 at 1:12 PM, Nurse M, assigned to R15, found the call light on the floor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-13 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide advanced written notification of a room change and obtain consent for one resident (Resident #70) of one resident reviewed, resulting in a cognitively intact resident not being informed of and/or provided the rationale for a room change prior to their room being moved. Findings include: Resident #70: On 6/10/25 at 1:13 PM, an interview was completed with Resident # 70 in their room. When queried if they had been in this room since they were admitted to the facility, Resident #70 verbalized they were in a different room before. Resident #70 was queried regarding the room change and stated, I just came back, and all my stuff was gone. I was mad. When queried if they were notified of the room change and the reason for the change prior to their personal items being moved to a different room, Resident #70 stated, No. When asked where they were when their personal items were relocated, Resident #70 revealed they thought they were in therapy. Resident…
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 before2025-06-13 · 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 Resident #18 (R18): Accidents On 06/12/25 at 12:34 PM, a review of R18's Electronic Medical Record (EMR) was conducted. R18 was [AGE] years old, admitted to the facility on [DATE] under hospice care with the diagnosis of Congestive heart failure, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Vascular Dementia, Difficulty in Walking, weakness, and End Stage Renal Disease ESRD)in addition to other diagnoses. R18's Minimum Data Set (MDS) assessment, dated March 15, 2025, revealed a Brief Interview for Mental Status score of 07/15. A score of 0-7 indicates that the individual has severe cognitive impairment. The R18's plan of care, dated 2/12/25, did not include ensuring safety and monitoring body placement in a chair or bed after the Resident's dialysis or when up on a chair unsupervised. R18 goes to dialysis treatment three (3) times a week and has a functional ability deficit requiring assistance with self-care and mobility. R18 required substantial/maximum assistance with a 2-person assist for bed mobility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-13 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 timely respond to two residents' (#28 and #47) pharmacy recommendations of five residents reviewed for unnecessary medications. Findings Include: Resident #28: On 6/13/2025 at 9:30 AM, a review was conducted of Resident #28 medical records, and it indicated she readmitted to the facility on [DATE] with diagnoses that included, Chronic Respiratory Failure, Major Depressive Disorder, Adjustment Disorder, Anxiety and Gastro-Esophageal Reflux Disease. Further review was conducted and yielded the following: On 6/13/2025 at approximately 10:45 AM, a review was conducted of Resident #28's Medication Regime Reviews (MRR) from August 2024 - May 2025. The following was found: January 13, 2025: (Resident #28) receives Eliquis 5 mg BID and Aspirin Low Dose 81 mg daily. Her last HBG is noted at 8.543 on 1-3-25. Please reevaluate the continued use of their combination therapy and perhaps stop using ASA therapy . Practitioner B accepted the recommendation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-13 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure policies and procedures were operationalized for safe bedside medication storage for two residents (# 70 and # 81) of two residents reviewed resulting in a lack of assessment for self-administration of medications, medications stored at bedside, and lack of staff knowledge of medication administration. Findings include: Resident #70: Record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder, depression, anxiety, and colostomy (surgically created opening in the abdomen allowing for the passage of stool into an external bag). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate to substantial assistance to complete Activities of Daily Living (ADL) with the exception of set-up assistance for eating and oral hygiene. On 6/10/25 at 1:13 PM, an interview was completed with Resident # 70 in their room.…
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 14 citations
- Potential for harm · D2025-04-17 · 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 Intakes Numbers MI00151425 and MI00151742. Past Non-Compliance (PNC) was identified at the facility during the investigation of the allegation and was accepted by the survey team upon exit from the facility for this citation. Following discussion with the State Manager, Past Non-Compliance was accepted with a Compliance Date of 3/28/2025. Based on the interview and record review, the facility failed to immediately notify the emergency contact regarding the resident's change in condition, which resulted in hospitalization for one resident (R#302) and delayed notification for one resident (R#301) after a fall of six residents reviewed for notification of changes. Findings include: Resident #301 (R301): A review of Resident #301's medical record conducted on 4/16/25 at 3:30 PM revealed Resident #301 (R301) was [AGE] years old and admitted to the facility on [DATE], with a diagnosis of Dysphagia, Malignant Neoplasm of the Bronchus or Lung, and Hemiplegia and Hemiparesis following Cerebral…
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 · D2025-04-17 · 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 pertains to Intake Number MI00150768. Based on interviews and record review, the facility failed to ensure appropriate wound treatment, assess, monitor, and establish a care plan for one resident (Resident #301), who sustained a laceration on the left lower extremity after a fall, of three sampled residents reviewed for skin care treatments. Findings include: Resident #301 (R301): According to the review of Electronic Medical Records (EMR)conducted on 4/16/25 at 3:30 PM, R301 was [AGE] years old and admitted to the facility on [DATE], with a diagnosis of Dysphagia, Malignant Neoplasm of the Bronchus or Lung, and Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non-dominant side in addition to other diagnoses. While at the facility, he had multiple falls on 2/14/25, 2/25/25 and 2/26/25. R301's Brief Interview for Mental Status (BIMS) was 12/15 assessed on 2/9/2025. A score of 12 indicates moderate cognitive impairment. Scores between 8 and 12 are generally classified as…
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 before2024-07-31 · 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 Intake Number MI00145466. Based on interview and record review, the facility failed to provide adequate and appropriate interventions, evaluate and revise interventions to prevent the development and healing of pressure wounds for one resident (Resident #1) of three residents reviewed for pressure wounds, resulting in Resident #1 developing a pressure wound to the right and left heel area and the right and left buttock, worsening of the wounds and the potential for pain, infection and deterioration in health and wellbeing. Findings include: Resident #1: A review of Resident #1's medical record revealed an admission into the facility on 3/18/24 and discharge to acute care hospital on 5/7/24 with diagnoses that included traumatic hemorrhage of cerebrum, chronic kidney disease Stage 2 (mild), heart disease, difficulty in walking, weakness, contusion of scalp, and multiple fractures of ribs, left side, pedestrian on foot injured in collision with motor vehicle. A review of Resident #1'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 · D2024-06-04 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 residents' rights were being honored for one resident (Resident #21) of 2 sampled residents reviewed for residents' rights, resulting in the facility staff refusing to provide Resident #21 with requested dietary wishes. Findings include: Resident #21(R21): Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected R21 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included atrial fibrillation(irregular heart rate), recent pneumonia, urinary tract infection within past 30 days, gastroesophageal reflux disease, hypertension(high blood pressure), chronic obstructive pulmonary disease and depression . The MDS reflected R21 had a BIMS (cognitive assessment tool) score of 10 which indicated her ability to make daily decisions was moderately impaired. The MDS reflected eating or oral hygiene were not assessed related to, Not attempted due to medical condition or safety condition.…
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 · D2024-06-04 · 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 one resident (Resident #115) of 26 residents reviewed. Findings include: Resident #115: Review of the medical record revealed Resident #115 (R115) was admitted to the facility on [DATE] with diagnoses that included moderate protein-calorie malnutrition. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/18/24 revealed R115 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R115's medical record revealed they had a pressure ulcer to their coccyx and left heel. On 05/30/24 at 1:29 PM, R115 was observed in their room, reclined in a high back wheelchair. R115 appeared to be sliding out of the wheelchair. R115 reported they had wounds on their bottom and their heel. R115 reported their bottom hurts horrible. There was a wheelchair cushion and dycem (non-slip material) observed on the bed and not in the wheelchair. At…
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 · D2024-06-04 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake 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 observations, interviews, and record reviews, the facility failed to effectively clean and maintain the carpet in room [ROOM NUMBER], resulting in the increased likelihood for cross-contamination, bacterial harborage, odor and decreased air quality. Finding include: During an interview on 5/30/24 at 2:10 PM, Confidential Family Member(CFM) T reported that a loved one was originally admitted into room [ROOM NUMBER] that had carpet and had very strong odor of urine. CFM T reported loved one was moved out of the room, however, another resident is currently in room and odor was still present and reported felt sorry for resident. During tour of facility on 6/04/24 at 10:20 AM, very strong pungent odor of urine noted outside room [ROOM NUMBER]. room [ROOM NUMBER] was noted to have carpet on floor. During an interview on 6/04/24 at 10:25 AM, Housekeeping staff (HK) U reported had worked at the facility for about three years. HK U reported history of foul odor in areas with old carpet because odor can not 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 · Dcited before2024-05-22 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 Citations pertains to Intake Number MI00137732. Based on interview and record review, the facility failed to ensure that one resident (Resident #112), who was at risk of aspiration pneumonia was given tube feeding per physician's order (rate per hour), resulting in a doubled rate of feeding per hour (130 ml/hr vs the ordered at 65ml/hr), which resulted in an episode of emesis, and the likelihood of fluid overload. Resident #112: Review of the Face Sheet, Minimum Data Set, dated 6/23, Physician orders dated 6/6/23, nutritional care plan dated 6/7/23 and Dietary notes dated 6/23. The resident was [AGE] years old, alert and responsible for self, a full code, and admitted to the facility on [DATE]. The resident's diagnosis included, extradural and subdural abscess, sepsis, morbid obesity, Dysphagia (difficulty swallowing), weakness, reduced mobility and had a history of COVID-19 with respiratory failure. Review of the Physician order dated 6/6/23, stated Enteral Feed Order (tube feeding) two times a day infuse…
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 before2023-05-12 · 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 1) Failed to ensure that food temperatures were completed; 2) Failed to ensure proper drying techniques for cleaned dishes; 3) Failed to ensure that food items were labeled and discarded properly; 4) Failed to ensure that a clean and calibrated thermometer was used; 5) Failed to ensure proper raw meat preparation and 6) Failed to ensure that hand hygiene was performed, resulting in the likelihood of cross contamination, resident illness with the potential for hospitalization for a total census of 125 residents. Findings include: On 5/05/23, at 9:54 AM, Kitchen observation was conducted along with Registered Dietician F Assistant Administrator B as follows: The reach in refrigerator had the following opened items that were noted to not have open dates: almond milk 32 oz 1/2 gallon of 2% milk 2 gallons of whole milk carton of 2% lactose free milk carton of thickened milk The walk-in refrigerator was noted to have 1 large open bag of lettuce with no open date observed. RD F removed the bag of lettuce off the shelf looked…
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 before2023-05-12 · 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 Based on observation, interview and record review, the facility failed to implement appropriate interventions and ensure adequate supervision for two residents (Resident #23 and Resident #69), resulting in continued unwitnessed falls with injuries of lacerations and broken teeth for Resident #69 and with the likelihood of further and/or more serious injuries. Findings include: Resident #69: On 5/10/23, at 1:56 PM, Resident #69 was sitting in their wheelchair in the hallway near the nurses station. Resident #69 had steri-strips over her right eyebrow covering a laceration approximately 1 centimeter long. There were dark purple, burgundy colored areas noted to her right eye and eye lid. Resident #69 offered that they fell over their own feet. On 5/10/23, at 3:30 PM, a record review of Resident #69's Electronic Medical Record (EMR) revealed an admission on [DATE] with a readmission on [DATE] with diagnoses that included History of falling, Parkinson's disease and Intracranial injury. According to the most recent…
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 · E2023-05-12 · tag F0806 — failed to honor food preferences — patternEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 residents' food preferences were honored and food temperatures were maintained during meal service for Resident #76, Resident #228 and nine residents who attended the Resident Council meeting, resulting in, residents' food being cold upon arrival on multiple occasions and the facility not allowing residents who choose to dine in their rooms the opportunity to select their meals prior to the meals being served. Findings include: Resident Council Meeting: During Resident Council on 5/9/2023 at 1:30 PM, attendees were queried regarding the facility's dining service. The nine attendees expressed concern with the temperature of their food upon arrival. They stated many times it barely warm and/or cold. They continued they would like a wider variety of food that is culturally inclusive based on the makeup of the facility. They unanimously expressed dissatisfaction with not being allowed to select their meal choices if they eat in…
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 before2023-05-12 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 label the enteral nutritional solution (nutrition provided by means of a percutaneous endoscopic gastrostomy tube-PEG tube), and the infusion tubing set and maintain a clean and sanitary environment for the tube feeding equipment for one resident (Resident #100) of two residents reviewed for enteral feeding, resulting in the potential for food borne illness related to ingesting contaminated enteral feeding solution. Findings include: Resident #100: A review of Resident #100's medical record revealed an admission into the facility on [DATE] with diagnoses that included cerebral infarction (stroke), left upper arm contracture of muscle, atrial fibrillation, heart failure, aphasia, speech and language deficits, hemiplegia and hemiparesis, dysphagia, and gastrostomy status. A review of the Minimum Data Set assessment, dated 3/12/23, revealed the Resident had severely impaired cognition, needed extensive assistance with activities of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-12 · 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 that nebulizer equipment and Continuous Positive Airway Pressure (CPAP) equipment were maintained in clean and sanitary condition for two residents (Resident #18 and Resident #253) of nine residents reviewed for oxygen needs, resulting in the potential for respiratory infection. Findings include: Resident #18: A review of Resident #18's medical record revealed an admission into the facility on 7/22/14 and readmission on [DATE] with diagnoses that included heart failure, cough, chronic sinusitis, anxiety disorder, depression, obesity, and functional quadriplegia. A review of the Minimum Data Set (MDS) assessment revealed the Resident had intact cognition and needed extensive assistance with bed mobility, dressing, toilet use and personal hygiene. Further review of Resident #18's medical record revealed an order for Ipratropium-Albuterol Solution, 3 ml (milliliters) inhale orally every 6 hours as needed for SOB (shortness of breath)…
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 · D2023-05-12 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1) Follow professional standards of care with the administration of insulin; 2) Follow a physician's order to remove a lidocaine patch; 3) Ensure pharmacy follow-up on ordered medication; and 4) Ensure that medication was ordered following physician evaluation and recommendations for three residents (Residents #25, Resident #29 and Resident #76) of six residents reviewed for medication administration, resulting in medical conditions going untreated and the potential for exacerbation of signs and symptoms of diagnoses. Findings include: Resident #25: A review of Resident #25's medical record revealed an admission into the facility on [DATE] with a readmission on [DATE] with diagnoses that included heart failure, fall, cyst of kidney, lower abdominal pain, diabetes, chronic obstructive pulmonary disease, polyneuropathy, chronic pain and pain in right knee. A review of the Minimum Data Set assessment revealed the Resident was cognitively…
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.
- No harm found · C2026-01-22 · tag F0658 — failed to meet professional standards of care — widespreadEnsure 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 This citation pertains to Intake Number 2710871. Based on the interview and record review, the facility failed to maintain complete, accurate, and timely clinical documentation for one resident (Resident #301) of 3 residents reviewed for accuracy and timeliness of clinical documentation. Findings include:Resident #301 (R301): According to the Electronic Medical Record review, R301 was admitted to the facility on [DATE] and expired there on [DATE]. A Medical Examiner's (ME) Report dated [DATE] revealed R301 was [AGE] years old with a past medical history consisting of a recent hip fracture with repair at the hospital (mentioned initials of the hospital), Diabetes Mellitus, Dementia, Anxiety Disorder, Coronary Angioplasty with stents, and Malignant Neoplasm of the eye in addition to other diagnoses. Due to the R30's medical history and his recent hip fracture, a suspicion of foul play was ruled out, and the cause of death was ruled a natural death. An interview with Nurse A was conducted by phone on [DATE] at 3:00…
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 | 5 of 5 | 2.8 | +2.2 vs chain |
| Health inspection | 3 of 5 | 2.5 | +0.5 vs chain |
| Staffing | 5 of 5 | 3.2 | +1.8 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 |
|---|---|---|---|
| MOHAMMAD A QAZI LIVING TRUST DATED 09/26/97 | Organization | INDIRECT OWNERSHIP INTEREST | since 06/30/2022 |
| QAZI, MOHAMMAD | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 06/30/2022 |
| KHAN, ANIS | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/26/2013 |
| CIENA HEALTHCARE MANAGEMENT INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/25/2025 |
| MICHELSON, RYAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/17/2018 |
| PACKEY, DREW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/26/2013 |
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 $5.1M paid to related parties — landlords or management companies under common ownership — equal to about 23% 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 235666. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-13, 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 →
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