Regency at Shelby Township
7401 22 Mile Road, Shelby Township, MI 48317 · For profit - Corporation · 116 certified beds · (586) 580-5500 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2023
- 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
- about 18% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 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 | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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 | 19.8% | 10.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.3% | 5.4% | 5.4% | better |
| 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 | 1.2% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.0% | 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 | 4.0% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 23.8% | 12.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.0% | 19.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 71.1% | 95.0% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 2.1% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.6% | 20.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.2% | 14.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.1% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 96.9% | 79.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.9% | 24.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 5.7% | 11.7% | 12.0% | 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.
54.8% 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 455 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 43.9% 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 198 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 0.71 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% 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 | 54.8%CMS range 49.8–58.7 | 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 | 12.9%CMS range 10.6–14.9 | 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 | 43.9% | 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 | 48.0% | 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 | 42.4% | 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 | 99.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 96.8% | 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 | 1.9% | 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 | 6.6%CMS range 4.4–9.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.82 | 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 116 beds and averages 109.8 residents a day — about 95% occupied, or roughly 6 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 3.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 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 3.20 hrs/resident/day on weekends vs 4.03 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.86 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2023-07-26 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes: MI00135903 and MI00135359. Based on observation, interview, and record review, the facility failed to provide an environment free from verbal abuse, physical abuse, and neglect from staff to resident for one of one sampled resident (R51) reviewed for abuse resulting in, abuse, neglect and the likelihood of mental anguish using the reasonable person concept. Findings include: A review of Intake called into the State Agency: MI00135903 revealed the following, (R51) had called Certified Nursing Assistant (CNA L) an '[expletive]' and [they] replied, 'no you are an [expletive]' .(R51) and (CNA L) exchanged verbal remarks back and forth and then (CNA L) slapped (R51) on (their) bare bottom and said to (them), who is your daddy? . On 7/24/23 at 10:00 AM, R51 was observed lying in bed and asked about the incident that took place on 3/13/23 between them and CNA L. R51 explained that they have problems with their memory, and did not remember the incident. A review of R51's 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 · Dcited before2026-05-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2992237.Based on observation, interview and record review, the facility failed to ensure interventions were implemented and care provided timely for three residents (R903, R904, and R906) of seven reviewed for care plan implementation and care needs. Findings include: R906On 05/05/26 at 9:30 AM, R906 was observed laying on their back in bed. R906's legs were slightly flexed at the knees and the heels rested on the bed. A Pressure Relieving Ankle Foot Orthotic (PRAFO) boot was on an armchair to the right of the bed. R906 reported they had a wound to the left heel and needed help to put the boot on, and staff had not come in, and the boot had not been applied that morning. When asked if they could move about in the bed, the resident reported they had limited movement of the left leg. At 11:55 AM, R906's heels and the PRAFO boot were in the same position as before. The heels rested on the bed. A review of the active physician orders in the electronic medical record (EMR) documented…
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 before2025-11-20 · 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 follow physician orders for three residents (R56, R119 and R117) out of three reviewed for quality of care. Findings include:R56 On 9/22/2025 at 1:15 PM, R56 was observed sitting up in a wheelchair. A gauze wrap and bandage were observed on their right lower extremity (RLE). The bandage was noted to be dated 9/18/2025. A review of the medical record revealed that R56 was admitted into the facility on 5/24/2025 with the following medical diagnoses, Moderate Protein-Calorie Malnutrition and Peripheral Vascular Disease. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated an impaired cognition. R56 also required staff assistance with bed mobility and transfers. Further review of the physician orders revealed an active wound care order for the right lateral lower leg that was to be changed every Tuesday, Thursday, and Saturday and as needed if missing 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 · D2025-11-20 · 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
Based on observation, interview, and record review, the facility failed to implement interventions for pressure ulcer healing for one resident (R89) out of three reviewed for pressure ulcers. Findings include:On 9/22/2025 at 10:16 AM, R89 was observed lying in bed. Their feet were hanging off the bed, with the head of bed (HOB) flat and they were laying on their back with no positioning devices in place. A green positioning wedge was observed in the chair next to the bed.A review of the medical record revealed that R89 was admitted into the facility on 9/11/2025 with the following medical diagnoses, Pressure Ulcer of Sacral Region, Stage 4 (Full-thickness skin and tissue loss with exposed muscle or bone in the ulcer) and Moderate Protein-Calorie Malnutrition. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R89 also required staff assistance with bed mobility and transfers.Further review of the physician orders revealed the following, Ordered: 9/11/2025.Order: Verify wedge pillow is 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 · D2025-11-20 · 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
Based on observation, interview and record the facility failed to ensure medications were labeled and dated when opened in one of four medication carts. Findings include: On 09/22/2025 at 4:49 PM, the Spring Hill medication cart two was reviewed with Registered Nurse (RN) D. Two insulin lispro vials were not dated on the vial, for one active resident and one discharged resident, and a 100-50 MCG/ACT fluticasone-Salmeterol inhaler did not have a resident identifier, nor a date opened. On 09/24/2025 at 12:55 PM, the Director of Nursing (DON) reported the nurse should label the carton and the actual medication in case the carton is lost or damaged. A review of the identified medications on drugs.com documented: for the lispro insulin - Store the vial in a refrigerator or at room temperature and use within 28 days; and for the fluticasone/salmeterol - Write the date you opened the foil pouch in the first blank line on the label. Write the use by date in the second blank line on the label. That date is 1 month after the date you wrote in the first line.A review of the facility policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-12 · tag F0919 — failed to provide a working call system — widespreadMake sure that a working call system is available in each resident's bathroom and bathing area.
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 respond to residents needs(call lights) in a timely manner for one resident (R81 and R47) and two resident rooms (rooms [ROOM NUMBERS]) fourteen reviewed for call light response. Findings include: R81 On 9/10/24 at 9:59 AM, R81 was interviewed in their room with their daughter present and ask about the care and services they were receiving at the facility. Both R81 and their daughter indicated that call light wait times, Can be long, up to forty five minutes during the early morning and on weekends. A review of R81's electronic medical record (EMR) revealed R81 was originally admitted to the facility on [DATE] with diagnoses that included, aftercare following knee joint prosthesis and weakness. R81's most recent minimum data set assessment (MDS) dated [DATE] revealed R81 had an intact cognition and required partial to moderate assistance with all activities of daily living (ADLs) other than eating and oral hygiene. On 9/12/24 at 3:15 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
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 practice proper infection control practices in a contact isolation room and properly store nebulizer/C-Pap (non-rebreather) mask for five residents (R36, R223, R221, R74, and R11) reviewed for infection control. Findings include: R36 On 9/10/2024 at 12:06 PM, the call light for R36 was seen activated. R36 was noted to be on contact precautions. A sign, as well as personal protective equipment (PPE) was observed on the door. On 9/10/2024 at 12:07 PM, Maintenance Assistant (MA) B was observed going into the room. MA B did not don/doff any PPE, nor perform hand hygiene upon exiting the room. A review of the medical record revealed R11 admitted into the facility on 9/4/2024 with the following diagnoses, Chronic Respiratory Failure with Hypoxia and Major Depressive Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R11 also required staff assistance with bed mobility and transfers. On 9/12/2024 at 9:44 AM, an interview…
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 · D2024-09-12 · 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 interview, and record review, the facility failed to ensure one resident (R25) was catheterized (straight cathed-tube inserted into the bladder to help drain urine) timely out of one reviewed for dignity, resulting in the potential for feelings of sadness. Findings include: On 09/11/24 at 2:27 PM, an interview with R25 occurred and R25 stated Because I am one of the youngest ones here, I try not to cause trouble. I was up by 5:00 AM and cathed for my doctor's appointment. Upon returning from the appointment at 1:00 PM, I asked the nurse to cath me again because it was hurting. I had to wait until 3:00 PM. I was really upset and sad about waiting so long to be cathed. It made me feel sad like the nurses don't care about me or how I feel. A review of R25 medical record revealed they were admitted into the facility on 7/23/24 with diagnoses of Scoliosis, Insomnia, Hypertension, and Neuromuscular Dysfunction of Bladder. A review of R25's Minimum Data Set (MDS) assessment dated [DATE] revealed, R25's Brief…
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 · D2024-09-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one resident (R56) of three residents reviewed for accommodation of needs with a comfortable bed, resulting in feelings of dissatisfaction and discomfort. Findings include: On 9/10/24 at 2:58 PM, R56 was observed in bed with their feet on the end of the bed on the bed board, a pillow was underneath their feet. R56 was observed to be obese and their was very little room in the bed on either side of their body. R56 was interviewed about the comfort of their bed and indicated they were uncomfortable and dissatisfied with their bed. R56 stated, Can you talk to them about getting me a better bed. On 9/10/24 at 3:05 PM, Certified Nurse Assistant (CNAG) entered R56's to provide them with fresh water and was asked about R56's bed. CNA G stated, We need better beds. On 9/11/24 at 10:46 AM, R56 was observed in bed on their back with very little room in the bed on either side of their body. R56 stated, I cannot move in this bed. Once they…
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 before2024-09-12 · 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 develope a comprehensive care plan for one (R103) out of six residents reviewed for care plans. Findings include: On 9/10/24 at 10:20 AM, 2:05 PM, and 4:22 PM, and on 9/11/24 at 8:29 AM, 9:52 AM, 12:05 PM, 1:23 PM, and at 4:22 PM, R103 was observed lying in bed and a back brace was observed in R103's room. On 9/12/24 at 8:49 AM, R103 was observed standing in the hallway with their walker. Certified Nurse Assistant (CNA) C stated, Where is your back brace, you need to have it on at all times. CNA C was then observed applying R103's back brace. A review of R103's medical record revealed they were admitted to the facility on [DATE] with a diagnosis of Wedge compression fracture of fifth lumbar vertebra, subsequent encounter for fracture with routine healing. A review of R103's Brief Interview for Mental Status revealed a score of four, indicating cognitive impairment. A review of R103's physician orders revealed an active order which…
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 · D2024-09-12 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to revise a care plan to reflect interventions for wandering behaviors for one resident (R76) out of one reviewed for behaviors. Findings include: On 9/10/24 at 10:13 AM, R76 was observed lying in bed sleeping soundly. On 9/10/24 at 4:00 PM, R76 was observed sitting up in bed watching television. On 9/10/24 during a confidential resident council, three residents discussed R76 wandering and behaviors at night. One resident stated, I have complained about (R76) coming into to room at all hours of the night. R76 doesnt pay attention to 'stop signs' on doors or if door is closed. I have to yell for the staff to come and help. R76 hits the staff and is difficult with them as well. A review of the record revealed R76 was admitted into the facility 02/05/24 with following diagnoses: Alzheimer's Disease, Dementia, Hyperlipidemia, Catatonic Schizophrenia and Depressive disorder. A review of the Minimum Data Set (MDS) assessments on 8/14/24 revealed, Brief Inverview Mental Status assessment score was 00 indicating…
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 · Dcited before2024-09-12 · 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 follow up on physician's orders to scheduled an appointment for one resident (R30) of one resident reviewed for consultation. Findings include: On 09/10/24 at 9:30 AM, R30 was observed sitting on the side of his bed watching television. When asked about concerns with care, R30 stated Yes. I have not seen the wound doctor lately due to my old sore and I have a rash on my side that really itches and burns. A review of R30's medical record revealed a physician's note dated 8/28/24 stating Resident was seen for the Chief Complaint: Requesting dermatology consult. Patient was seen today at their request for rash to the back of left hip and left groin. Resident also reports that it has been on the back for a long time, so this is not new for this patient. The areas appear round and raised, but no scaly or dry skin noted. Resident does report that they are itchy, sore and sometimes burns. They are very difficult to see. Resident states that 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 · D2024-09-12 · 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 provide services to maintain the functional abilities of one (R70) out of one resident reviewed. Findings include: On 9/10/24 at 9:34 AM, R70 was observed lying in bed. R70 was asked if they had any concerns about their care. R70 explained they can no longer get out of bed as much as they used to and now need help with bathing. R70 explained they were previously getting therapy which was helping them perform their hygiene care and they were getting stronger but now they are on restorative care but haven't been getting it and cannot do anything without help now. 09/11/24 11:51 AM R70 was observed in the bathroom sitting in their wheelchair at the sink. R70 explained it takes them a long time to get washed up because they are much weaker since not receiving therapy. A review of R70s electronic medical record (EMR) revealed they were admitted to the facility on [DATE] with the following diagnosis: Hypothyroidism unspecified. A review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-12 · 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
Based on observation, interview, and record review, the facility failed to properly store an oxygen tank for one resident (R221) out of five reviewed for respiratory care. Findings Include: On 9/10/2024 at 10:20 AM, R221 was observed sitting in their room and was receiving oxygen via a nasal cannula. R221 stated they had recently arrived at the facility and needed oxygen continuously. In the corner of the room an oxygen tank was observed freestanding. No stand or cart was noted in the room. A review of the medical record revealed R22 admitted into the facility on 9/9/2024 with the following medical diagnoses, Lung Cancer and Chronic Obstructive Pulmonary Disease (COPD). A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. On 9/10/2024 at 10:31 AM, Certified Nursing Assistant (CNA) R was asked about the oxygen tank was in R221's room without a stand. CNA R stated they were going to get a stand immediately. A review of a facility policy titled, Oxygen Storage and Assembly noted the following, Oxygen…
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 · D2024-09-12 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
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 obtain physician orders for colostomy (an opening through the skin) care for one resident (R11) out of one reviewed for colostomy care. Findings include: On 9/10/2024 at 10:00 AM, R11 was observed laying in bed. R11 stated they were about to get up and get ready for lunch. R11 stated they needed their colostomy emptied. R11 stated they have had a colostomy for quite some time. R11 stated the staff does empty it, but they have to remind them. A review of the medical record revealed that R11 admitted into the facility on 9/4/2024 with the following diagnoses, Chronic Respiratory Failure with Hypoxia and Major Depressive Disorder. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R11 also required staff assistance with bed mobility and transfers. The MDS assessment also noted R11 had an colostomy. Further review of the physician's order and task guide did not reveal an order for colostomy care, including changing. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-12 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide ongoing behavioral health services for one resident (R27) out of eight reviewed for behavioral health. Findings include: On 9/10/24 at 10:00 AM, R27 was observed in bed. R27 explained they used to get out of bed into their wheelchair but does not feel like getting out of bed anymore because they are worried about their son whom they have been supporting financially and is now running out of money to support. On 9/11/24 at 11:24 AM, during an interview, Social Worker (SW) P was asked if they were aware of R27s mood and concerns regarding their son. SW P explained they were aware and they talked to accounts receivable and informed R27 of how much money was left over after they paid the facility. SW P also explained that they provided R27 with the name and phone number of a church and called R27s older son. On 9/12/24 at 11:59 AM, R27 was observed in bed awake with the blinds closed and staring at the wall. R27 was observed to 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 · F2023-07-26 · 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 ensure food items were labeled and stored at the appropriate temperature, failed to maintain sanitary conditions, failed to ensure staff donned a beard restraint, and failed to ensure handwashing to prevent cross contamination. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 7/24/23 between 8:45 AM-9:15 AM, during an initial tour of the kitchen with Culinary Manager A, the following items were observed: In the dry storage room, the flour, sugar, bread crumbs and oatmeal bins were all observed to be unlabeled with the contents inside. Culinary Manager A confirmed the bins should be labeled. According to the 2017 FDA Food Code section 3-302.12 Food Storage Containers, Identified with Common Name of Food, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT,…
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 · E2023-07-26 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within 14 days after completion for four (R59, R95, R103, and R107) of four residents reviewed for resident assessment transmission, resulting in potential for inaccurate tracking of resident assessment, admission and discharges. Findings include: A review of R59's MDS assessments noted, R59 was admitted on [DATE] and discharged on [DATE]. The list of assessments completed revealed, Entry [DATE] accepted, Admission/Medicare 5 day accepted [DATE]. R59 discharged home on [DATE]. R59's medical record did not reveal a completed and submitted discharged MDS assessment. A review of R95's MDS assessments noted, R95 was admitted on [DATE] and discharge [DATE]. The list of MDS assessments complotted revealed, Entry [DATE] entry, Admission/Medicare 5-day [DATE]. R95 discharged to the hospital on [DATE]. R95's medical record did not reveal a completed and submitted…
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 · E2023-07-26 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 This citation pertains to Intake MI00133827. Based on observation, interview and record review the facility failed to ensure care needs were met timely for five sampled Residents (R24, R41, R65, R234, R236) of six reviewed for activities of daily living needs, resulting in dissatisfaction with the care provided, a delay in care needs being met and the potential for unmet care needs. Findings include: R65 On 7/25/23 at 2:40 PM, the call light was observed to be activated for R65. R65 was observed lying on their back, and explained that they had decided to remain in bed today, as their stomach was uncomfortable due to constipation. R65 explained that their brief had not been changed all day and that this is the reason their call light was on. R65 was asked if the padding underneath them was wet, and they responded with, I think so. Along with Certified Nurse Assistant (CNA) R R65's brief was checked. Upon CNA R pulling R65's covers off them, a strong pungent smell of urine permeated the room. The brief 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 · D2023-07-26 · 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 MI00137843. Based upon interview and record review, the facility failed to provide timely notification of a fall with injury to the family member/responsible party of one (R481) of five residents reviewed, resulting in family member/responsible party not knowing right away that the resident fell and causing a delay in the opportunity to participate in medical decisions regarding care and treatment. Findings include: Review of the facility record for R481 revealed an admission date of 06/13/23 with diagnoses including Dementia, Hypoglycemia, Diabetes Mellitus and Acute Kidney Failure. The Minimum Data Set (MDS) assessment dated [DATE] indicated R481 required maximum/total assistance for self care. Additional review of the facility record pertaining to R481's reported fall revealed a Certified Nurse Assistant (CNA) found the resident on the floor of their room on 06/16/23 and the resident was found to have a bump next the left eye and no further obvious injury upon further…
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 before2023-07-26 · 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 MI00133827. Based on observation, interview, and record review the facility failed to re-check a blood glucose level (amount of sugar circulating in the blood) after an insulin administration for one resident R433 of two reviewed for change in condition, resulting in the potential for continued blood sugar instability and diabetic complication. Findings include: On 7/25/23 at 9:23 AM, R433 was observed in bed and asked how the midnight shift care was. R433 stated that they had a really high blood sugar of 517 around 9:30 PM. R433 continued and stated that they were given 12 units of insulin. R433 was asked what their blood sugar read after the 12 units, R433 stated, The Nurse did not come back and check it. I didn't get checked again until this morning and it was 321. A review of R433's medical record revealed, R433 was admitted to the facility on [DATE] with diagnosis of Type II Diabetes. A review of R433's Minimum Data Set (MDS) assessment noted, R433 with an intact cognition…
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 before2023-07-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two Deficient Practice Statements. Deficient Practice #1. This citation pertains to Intake MI00131868. Based on interview and record review, the facility failed to assess, implement and ensure safe interventions were in place for one resident (R231) of five reviewed for accident/hazards, resulting in a fall. Findings include: A review of an Intake called into the State Agency revealed, A few days after (R231's) arrival, the nurse helped (the resident) to a chair. Left. (R231) slid out of the chair and fell. A review of R231's record revealed that the resident was admitted into the facility on 9/14/22 and discharged to the hospital on [DATE]. R231's medical diagnoses included Gas Gangrene (foot), Dysphonia (Hoarse Voice), Heart Failure, Kidney Disease, Peripheral Vascular Disease, Osteomyelitis (foot), Weakness, and Difficulty in Walking. A review of R231's progress notes revealed: -9/15/2022 .Physician - Plan of Care Review: .Ulcer to left heel .Assessment/Plan: .Rehab services for gait…
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 · D2023-07-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 MI00131868. Based on interview and record review, the facility failed to document the replacement of an indwelling urinary catheter and a nursing assessment after reported abnormal findings for one resident (R231) of one reviewed for catheters, resulting in a delay in the evaluation and treatment of urinary complications. Findings include: A review of Intake called into the State Agency revealed, On 10/4/22 (R231) had (their) catheter changed and whoever changed it did not know what they were doing. (R231) bled and was in terrible pain for 4 hours until the staff decided to take (them to the hospital) to get it fixed. A review of R231's record revealed that the resident was admitted into the facility on 9/14/22 and discharged to the hospital on [DATE]. R231's medical diagnoses included Gas Gangrene (foot), Obstructive and Reflux Uropathy, Dysphonia (Hoarse Voice), Heart Failure, Kidney Disease, Peripheral Vascular Disease, Osteomyelitis (foot), Weakness, and Difficulty 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 · D2023-07-26 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to serve food in a palatable manner and in an appetizing appearance for one sampled resident (R100) and seven confidential group residents, resulting in dissatisfaction during meals. Findings include: On 7/25/23 at 2:02 PM, the residents that attended the resident council meeting were asked about the food served at the facility and explained, Kitchen doesn't have enough help, the food is cold a lot and doesn't look appetizing. On 07/24/23 at 10:23 AM, R100 was interviewed during initial resident screening and reported that the food is, in his opinion, poor. R100 reported the quality of the food has declined since their original admission and that the facility seems to be buying cheaper food including the example that they used to have real cheeseburgers that people liked and now the burgers are baked in the oven. R100 reported that the hot food is consistently too cold. Review of the facility record for R100 revealed an admission date 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 before2023-07-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, a facility staff person failed to don appropriate personal protective equipment (PPE-items such as gloves, gowns, protective eye wear, etc.) when entering a room for one (R48) of two residents in transmission based precautions (TBP-precautions used for patients who may be infected with certain infectious diseases) reviewed for infection control compliance, resulting in the potential for the spread of infection. Findings include: Review of the facility record for R48 revealed an original admission date of 09/20/18 with the most recent admission being 07/13/23 with diagnoses that included Diverticulitis of the Large Intestine, End Stage Renal Disease (requiring renal dialysis) and Polyneuropathy. The Minimum Data Set (MDS) assessment dated [DATE] indicated R48 required set up assistance for eating and maximum assistance with most daily care otherwise. The Brief Interview for Mental Status (BIMS) assessment score of 14/15 indicated intact cognition. On 07/24/23 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.
“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 | 4 of 5 | 2.8 | +1.2 vs chain |
| Health inspection | 4 of 5 | 2.5 | +1.5 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 |
|---|---|---|---|
| CIENA MICHIGAN OPERATIONS GROUP LLC | Organization | DIRECT OWNERSHIP INTEREST | since 06/30/2022 |
| 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 11/12/2015 |
| CIENA HEALTHCARE MANAGEMENT INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/25/2025 |
| MAZE, REBECCA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/26/2015 |
| MOHAMMAD QAZI 2022 CHILDREN'S TRUST UAD 5-4-2022 | Organization | ADP OF THE SNF | since 06/30/2022 |
| ALATASSI, MALAZ | Individual | ADP OF THE SNF | since 01/01/2025 |
| DEUTSCH, NEAL | Individual | ADP OF THE SNF | since 09/07/2015 |
| GARDINA, ANNA | Individual | ADP OF THE SNF | since 09/07/2015 |
CMS files one row per role, so the 16 rows in the source record cover these 10 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.
4 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 $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MI
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Michigan Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 235710. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-20, 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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