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West Bloomfield Health and Rehabilitation Center

6445 W Maple, West Bloomfield, MI 48322 · For profit - Corporation · 172 certified beds · (248) 661-1600 Medicare & Medicaid certified

Call the home — (248) 661-1600 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Feb 20251 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
6777 W Maple Rd · (800) 436-7936 · Call to confirm hours
Pharmacy
6530 Farmington Rd · (248) 661-5333 · Call to confirm hours
Grocery
Kroger1.4 mi
33300 W 14 Mile Rd · (248) 737-7280 · Call to confirm hours
Park
6801 Drake Rd · (248) 451-1900 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased17.5%10.8%15.4%worse
Long-stay residents who lose too much weight5.5%5.4%5.4%typical
Long-stay residents with a catheter left in their bladder0.7%0.8%0.9%better
Long-stay residents with a urinary tract infection2.1%1.5%2.0%typical
Long-stay residents with depressive symptoms0.0%4.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.9%3.0%3.3%better
Long-stay residents whose ability to walk worsened20.1%12.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication27.7%19.4%18.9%worse
Long-stay residents given the seasonal flu vaccine87.8%95.0%95.3%typical
Long-stay residents with pressure ulcers4.1%5.1%4.7%better
Long-stay residents with worsening bladder/bowel control23.8%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.7%14.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.5%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine92.9%79.5%79.4%better
Short-stay residents rehospitalized after admission29.9%24.0%22.6%worse
Short-stay residents with an outpatient ER visit13.6%11.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.711.841.67worse
Long-stay outpatient ER visits per 1,000 resident days2.451.641.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ 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.

63.2% 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 573 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.2%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
55.1%U.S. median 56.6%
Met the expected recovery
0.50U.S. median 0.31
Therapy hours / resident / day
0.27hours / resident / day
Physical therapy
0.20hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 55.1% 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 254 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 33% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.2%CMS range 58.9–66.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 8.1–12.510.7%Oct 2022–Sep 2024no 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 discharge55.1%56.6%Oct 2024–Sep 2025CMS 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 discharge48.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge59.8%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting97.6%100.0%Oct 2024–Sep 2025CMS 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 discharge99.5%98.7%Oct 2024–Sep 2025CMS 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 stay0.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.8%CMS range 4.5–10.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.901.02Oct 2022–Sep 2024CMS 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

0.49
RN hours/ resident / day
1.60
LPN hours/ resident / day
2.30
Aide hours/ resident / day
4.39
Total nurse hours/ resident / day
0.16
RN hoursweekends
40.7%
Total nursing turnover
26.3%
RN turnover

How full it usually is: this home is certified for 172 beds and averages 129.8 residents a day — about 75% occupied, or roughly 42 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.39 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.30 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 3.69 hrs/resident/day on weekends vs 4.68 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.62 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% 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

4
deficiencies at the latest standard inspection (2025-04-10)
10
at the previous standard inspection (2024-02-28)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · Gcited before2024-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: MI00143972. Based on interviews and record reviews the facility failed to ensure the required assistance level for care was provided for one (R404) of two residents reviewed for falls, resulting in the resident to have fell from their bed, required a transfer to the hospital due to pain, and admitted with a lateral angulated fracture of the right femoral neck and multiple left rib fractures. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part . During the evening shift, the medical professional was changing her (R404's) undergarments. This activity required (R404's name) to be repositioned in the bed and required by protocol to have 2 people present to assist. The second person was unavailable at this time and the medical professional attending to (R404's name) took it upon herself to proceed without the additional member to assist her . The medical bed was positioned at the highest point and the medical professional commence 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 3002054Based on interview and record review, the facility failed to ensure interventions to prevent falls were completed and in place for one resident (R801) of two residents reviewed for falls. Findings include:On 5/12/26 a concern submitted to the State Agency was reviewed which alleged the facility failed to implement interventions to prevent a fall for R801. On 5/12/26 the medical record for R801 was reviewed and revealed the following: R801 was initially admitted to the facility on [DATE] and passed away on 4/29/26 with diagnoses including Neoplasm of Cardia and Neoplasm of Bladder. A review of R9801's MDS (minimum data set) with an ARD (assessment reference date) of 3/21/26 revealed R801 needed assistance from facility staff with most of their activities of daily living. R801's BIMS score (brief interview for mental status) was 13 indicating intact cognition.A review of R801's careplan revealed the following: Focus-admission .Fall Risk r/t (related to) Risk for Falls R/T…

    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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2026-03-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 2696425 .Based on interview and record review, the facility failed to ensure medication was available for administration per Physician's order, utilize the reserve supply of medication for administration and accurately document administration of medication in the medical record for one resident (R903) of two residents reviewed for medication administration. Findings include:On 3/9/26 a concern submitted to the State Agency was reviewed which alleged R903 was not provided their medications according to the Physician's order. On 3/9/26 the medical record for R903 was reviewed and revealed the following: R903 was initially admitted to the facility on [DATE] and had diagnose including Muscle weakness and Low back pain. A review of R903's MDS (minimum data set) with an ARD (assessment reference date) of 11/23/25 revealed R903 needed assistance from facility staff with most of their activities of daily living. R903's BIMS score was 15 indicating intact cognition.A review of R903's care…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-04-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: 04/09/25 11:20 AM, during an observation of the kitchen with Food Service Director (FSD) B, the following items were observed: The ceiling vent cover near dish machine and above a clean dishware rack, was observed with a thick layer of dust. There were 2 trays of clean coffee cups, with the open side facing up, on the rack underneath the soiled vent. Wen queried as to why the cups were stored uncovered with the open side up, FSD B stated we're getting ready to use them According to the 2017 FDA Food Code section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. According to the 2017 FDA Food Code section 4-903.11…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-10 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure timely and accurate advanced directive documentation were in place for four (R29, R47, R48 and R71) out of eight reviewed for advanced directives. Findings include: R47 On 4/8/25 at approximately 10:31 AM, R 47 was observed in their room. The resident was alert and able to answer questions appropriately and noted that they had been at the facility for a few years and expressed no concerns. A review of R47's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: chronic kidney disease and congestive heart failure. A review of R47's Minimum Data Set (MDS) (1/2/25) revealed the resident had a BIMS score of 12/15 (moderately impaired cognition). The resident was noted as FULL CODE. Continued review of R47's clinical record revealed the following: 8/4/22: Advanced Directive: Patient received a packet of information about Advanced Directives .An Advanced Directive Information &…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-10 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain the confidentiality of medical information for one (R110) of four residents reviewed for dignity. Findings include: On 4/8/25 at 12:02 PM, R110 was observed sitting in a wheelchair in a sitting/dining room located behind the nurse station. Another resident was observed sitting in the area of the nurse station. Licensed Practical Nurse (LPN) G was observed standing between the other resident and the nurse station and projecting loudly, asking R110 if they wanted a Tylenol. R110 explained they did. On 4/8/25 at 12:05 PM, LPN G was observed sitting in front of a computer at the nurse station and appeared to be having a conversation with R110, who was still seated in the room behind the nurse station. LPN G said loudly, It's your Colchicine, for your gout. R110 asked if they had gout. LPN G replied, Yes. During the entire exchange, the other resident was sitting in the hallway between LPN G at the nurse station and R110 in the 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-10 · tag F0806 — failed to honor food preferences — isolated
    Ensure 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 two (R273 and R272) of four residents reviewed for dietary services, received meals according to their preferences. Findings include: R273 On 4/8/25 at 9:27 AM, R273 was observed lying on their bed. A meal tray, consisting of a plate of untouched scrambled eggs, a broken up blueberry muffin and a bowl of oatmeal was observed on the over-bed table across R273. R273 was asked about their mostly untouched breakfast. R273 explained they did not like eggs. Observation of the meal ticket revealed near the top of the ticket NO EGGS was highlighted in yellow. On 4/8/25 at 12:32 PM, observation of R273's lunch tray revealed a bowl of mixed vegetables, milk, coffee and a cookie. R273 was asked if that was all they had received for lunch. R273 explained they had received an egg salad sandwich and the aide had removed it. Observation of R273's lunch meal ticket revealed NO EGGS highlighted in yellow and 1 Egg Salad S/W was listed. R273 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-11 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #'s MI00147219 and MI00149909 Based on observation, interview and record review, the facility failed to ensure multiple allegations of verbal and physical employee to resident abuse were reported to the State Agency (SA) for two (R404 and R401) of three residents reviewed for abuse. Findings include: R404 A complaint was filed with the SA that read in part, .on 1/27/25, (R404) got into a fight with a nurse's aide possibly named (Certified Nursing Assistant - CNA D) . (R404) was hit with a fist on the top of the head, shoulder, and in (their) chest area during the incident . the nurse's aide got scratched while (R404) was trying to defend (themselves) . other staff were made aware of this incident . On 2/11/25 at 9:30 AM, R404 was observed lying in their bed. R404 was asked if there had been an incident between themselves and an employee at the facility. R404 explained when they were first admitted into the facility and did not know how things were done there, they had asked their…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00146824 Based on interview and record review, the facility failed to report an allegation of abuse (from R902) to the State Agency within the required timeframe for one (R905) of one residents reviewed for abuse, resulting in the potential for unidentified or continued abuse. Findings include: A complaint was filed with the State Agency alleging R902 was permitted to sign themself out of the facility after being evaluated as a threat to themself and others. Clinical record review revealed R902 was admitted to the facility on [DATE] with the medical diagnoses: Multiple Sclerosis (nerve damage to the spinal cord and brain), generalized muscle weakness, hypertension, atrial fibrillation (abnormal heart rate). R902 has a self-care deficit related to their musculoskeletal impairment and right hemiplegia (weakness) and uses a motorized wheelchair. R902 Psychological diagnoses include schizoaffective disorder, (a mix of schizophrenia symptoms includes hallucinations, delusions, and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-17 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00146824. Based on interview and record review, the facility failed to ensure additional and revised interventions were in place for one (R902) of one reviewed for behavior, resulting in the potential to exacerbate and further disrupt other residents (including R903, R904). Findings include: A complaint was filed with the State Agency alleging R902 was permitted to sign themselves out of the facility after being evaluated as a threat to themselves and others. Clinical record review revealed R902 was admitted to the facility on [DATE] with the medical diagnoses: Multiple Sclerosis (nerve damage to the spinal cord and brain), generalized muscle weakness, hypertension, atrial fibrillation (abnormal heart rate). R902 has a self-care deficit related to their musculoskeletal impairment and right hemiplegia (weakness) and uses a motorized wheelchair. R902 Psychological diagnoses include schizoaffective disorder, (a mix of schizophrenia symptoms includes hallucinations, delusions, and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-17 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00146824 Based on interview and record review, the facility failed to maintain and provide complete clinical records for one (R902) reviewed of one, resulting in the facility staff and providers not having access to all pertinent information to care for the resident. Findings include: A complaint was filed with the State Agency alleging R902 was permitted to sign themselves out of the facility after being evaluated as a threat to themselves and others. Clinical record review revealed R902 was admitted to the facility on [DATE] with the medical diagnoses: Multiple Sclerosis (nerve damage to the spinal cord and brain), generalized muscle weakness, hypertension, atrial fibrillation (abnormal heart rate). R902 has a self-care deficit related to their musculoskeletal impairment and right hemiplegia (weakness) and uses a motorized wheelchair. R902's Psychological diagnoses include schizoaffective disorder, (a mix of schizophrenia symptoms includes hallucinations, delusions, and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · D2024-05-29 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 citaiton pertains to intake #MI00144557. Based on interview and record review, the facility failed to ensure appropriate consents for treatment were made for one resident (R801) of three residents reviewed for consents, resulting in feelings of frustration. Findings include: On 5/29/24 at 11:47 AM, a review of R801's clinical record was conducted and revealed they originally admitted to the facility on [DATE] and most recently re-admitted on [DATE]. R801's diagnoses included: multiple sclerosis, anorexia, chronic ulcer of foot, and a left ischium/buttock pressure ulcer (diagnosis added 4/14/24). Continued review of R801's record revealed a progress note dated 3/19/24 that read, .Capacity eval (evaluation) done today and pt (patient) was deemed incompetent (not able to make complex medical decisions). Pt's DPOA (Durable Power of Attorney) is now in effect . A review of R801's Skin/Wound Notes by Wound Care Nurse Practitioner 'B' revealed the following: A note dated 4/23/24 which indicated a surgical wound…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-29 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 #MI00144557. Based on interview and record review, the facility failed to ensure notification of changes for one resident (R801) of three residents reviewed for notification of changes, resulting in feelings of frustration. Findings include: On 5/29/24 at 11:47 AM, a review of R801's clinical record was conducted and revealed they originally admitted to the facility on [DATE] and most recently re-admitted on [DATE]. R801's diagnoses included: multiple sclerosis, anorexia, chronic ulcer of foot, and a left ischium/buttock pressure ulcer (diagnosis added 4/14/24). Continued review of R801's record revealed a progress note dated 3/19/24 that read, .Capacity eval (evaluation) done today and pt (patient) was deemed incompetent (not able to make complex medical decisions). Pt's DPOA (Durable Power of Attorney) is now in effect . A review of R801's Skin/Wound Notes by Wound Care Nurse Practitioner 'B' revealed a note dated 3/20/24 that read, .was found to have developed a wound on his…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-02-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen: Findings include: On 2/26/24 at approximately 8:45 AM, an initial tour of the kitchen was conducted with Dietary Manager (DM) L. Observations were made in the large walk-in freezer and revealed the following items were open and undated: One open Pierogi bag, on open box of Morning Star Burgers, unboxed chicken patties in a plastic bag, one bag of opened shrimp and a wrapped piece of turkey breast. DM L was asked as to the facility policy for labeling and dating open food. DM L noted that the food items should have been dated when opened with a use by date. Following the observation in the walk-in freezer, observations were made in the dish washing area. DM L was asked to run the dish machine. At that time DM L placed a pot with a test strip on the dish machine. The color changing temperature test strip was not indicating the dish in the dish machine had reached a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-28 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow protocols for residents on contact/droplet precautions and utilize correct infection control practices and protocols for disposing of contaminated Personal Protective Equipment (PPE) (R15, R83, R50, R5, R54) residents reviewed for COVID-19 (Coronavirus Disease 2019). This had the potential to affect all 130 residents who resided in the facility. Findings include: On 2/26/24 at approximately 9:00 AM, the Director of Nursing (DON) provided a list of residents who were currently on transmission based precautions. A review of the list revealed R50, R54, R15, R5, and R83 were positive for COVID-19 and were on Contact and Droplet Isolation Precautions (isolation precautions implemented for patients with known or suspected infections that could spread by contact or droplets in the air). On 2/26/24 at 10:40 AM, R50 and R54's door and R15 and R5's door was observed with signage that indicated the residents were on contact/droplet…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-28 · tag F0849 — pattern
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 ensure coordination of care for hospice services for two residents (R#'s 22 and 105) of three residents reviewed for hospice services resulting in the potential for unmet care needs at the end of life. Findings include: A review of a facility provided policy titled, Hospice Referral-Services Agreement issued 2/2023 was conducted and read, Policy: The facility will coordinate and provide care in cooperation with Hospice staff for all residents that have elected the Hospice benefit. The facility will provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility . On 2/26/24 at 12:00 PM, a review of R22's hospice binder was conducted and revealed they admitted to hospice on 8/4/23. The documentation contained in the binder at that time was limited to a consent for services, a log 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · tag F0551 — isolated
    Give the resident's representative the ability to exercise the resident's 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 an authorized person consented to vaccinations for one resident (R97) of five residents reviewed for consents resulting in the potential the inappropriate initiation of treatments and services. Findings include: On 2/27/23 at 8:46 AM, a review of R97's clinical record was conducted and revealed R97 was admitted to the facility on [DATE] with diagnoses that included: diabetes, obesity, schizoaffective disorder, major depressive disorder and adjustment disorder. A review R97's most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12/15 indicating mild cognitive impairment. A review of R97's admission packet was conducted and revealed R97 designated family member 'E' (in-law) as their Responsible Party. Continued review of R97's records revealed Social Work quarterly progress notes that indicated R97 had no durable power of attorney or legal guardian, nor had they been…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-28 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure medications were administered according to professional standards of practice for one (R6). Findings include: On 2/27/24 at 7:41 AM, Nurse P was observed preparing medications for R6. Nurse P started the medication pass with obtaining vital signs and R6's blood sugar. Nurse P then prepared R6's morning medications (all of R6 pills were placed in a cup). Nurse P then prepared R6 MiraLAX however, Nurse P stated that she needed to reorder the medication and Nurse P stated she would not administer it because R6 did not have their own (designated bottle). Nurse P was then asked was MiraLAX a house stock medication which Nurse P replied, Yes, but I like to order patient specific medications. The MiraLAX was not given. Nurse P administered the medications that were pulled and R6 consumed them. Nurse P returned to her cart and signed out all of the medications via Electronic Medical Record (EMR). A record review revealed that all medications that nurse P had pulled were confirmed and administered correctly.…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practices. Deficient Practice #1 Based on observation, interview and record review the facility failed to ensure a Doppler diagnostic and medication order to treat (Deep-Vein thrombosis) were initiated in a timely manner for one resident (R12) of one residents reviewed for Swelling/Edema. Findings include: On 2/26/24 at approximately 10:34 a.m., R12 was observed in their room, laying in their bed sleeping. R12 was observed to be difficult to arouse with verbal stimuli. On 2/28/24 at approximately 8:59 a.m., R12 was observed in their room, laying in their bed sleeping. R12 was still observed to be difficult to arouse with verbal stimuli. On 2/26/24 the medical record was reviewed and revealed the following: R12 was initially admitted to the facility on [DATE] and had diagnoses including Heart disease, Anemia and Urinary tract infection. A review of R12's MDS (minimum data set) with an ARD (assessment reference date) of 2/12/24 revealed R12 was dependent on staff for most of their…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate medical services to prevent the development of a pressure ulcer injury for one resident (R30) out of one reviewed for pressure ulcers resulting in the development of two stage two sacral (area on lower back where the spine and pelvis meet) pressure ulcers. Findings include: Clinical record review revealed R30 was admitted to this facility on 2/11/24 with diagnoses of left femoral fracture, hemiplegia (paralyzed on one side of the body), stroke, dementia, and malnutrition. A Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score totaled 5, indicating severe cognitive impairment. On 2/26/24 at 2:07 PM, A record review was conducted of R30's sacrum skin assessments and revealed the following: Skin Observation Tool V2: 2/11/24 skin discoloration to sacrum, no open areas. Skin Observation Tool V2: 2/12/24 sacrum with dark and soft discoloration. Possible DTI (Deep Tissue…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide social services that included competency assessment and obtaining services for legal representation for residents without a decision maker for two (R15 and R97) of five residents reviewed for advance directives. Findings include: On 2/26/24 at approximately 10:30 AM, R15 was observed lying in bed. When spoken to, R15 did not use words, became tearful, and reached out her hand and gestured as if blowing a kiss. R15 was unable to answer any questions about why she was tearful. On 2/27/24 at 9:00 AM, R15 was observed in bed with a tray of partially eaten food placed on the over bed table. R15 reached out her hand, became tearful, was not able to verbally respond to questions, and gestured to take the tray of food away. On 2/17/24 at approximately 9:15 AM, an interview was conducted with Certified Nursing Assistant (CNA) 'J'. When queried about how she communicated with R15, CNA 'J' reported she asked her questions and R15 would shake…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 properly store and dispose of outdated medications in one medication storage room and properly secure two treatment carts, of two storage rooms and five medication carts reviewed for labeling and storage. Findings include: On 2/27/24 at 1:05 PM, this surveyor entered the facility's station two medication room with nurse C. A small plastic storage container was found in the cupboard labeled with a physician's name. Inside the container were multiple outdated medications, including a multi-dose vial of lidocaine (a local anesthetic) which was opened and not dated, a multi-dose vial of Kenalog (an injectable steroid) with an open date of 5/22 and two unit dose vials of Kenalog labeled for a specific resident, dated 2022 (all medications were expired). When asked how these medications should have been handled nurse C deferred to her unit manager, unit manager D. Unit manager D stated that the medications were trash. Unit manager D reported that…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #MI00139289. Based on interview and record review, the facility failed to ensure a proper transfer for one resident, (R802) of three residents reviewed for accidents resulting in a 7.5 centimeter skin tear. Findings include: A complaint was received by the State Agency that alleged R802 sustained an injury during a transfer. On 9/20/23 at 11:38 AM, a review of R802's closed clinical record was conducted and revealed they admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses that included: protein calorie malnutrition, Alzheimer's Disease, heart failure, pressure ulcers, and peripheral vascular disease. R802's Minimum Data Set assessment dated [DATE] revealed R802 had severely impaired cognition, was non-ambulatory and required extensive two person assistance for transferring. A review of a progress note dated 5/16/23 entered into the record by Nurse 'A' was conducted and read, .Writer was informed by CNA (certified nurse aide) that 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-01-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 potentially hazardous food items were cooled to 41 degrees Fahrenheit or less within 6 hours, failed to ensure food items were stored covered, failed to date food items when opened, and failed to store wiping cloths in chemical sanitizer. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 1/24/23 from 8:50 AM-9:30 AM, during an initial tour of the kitchen with Dietary Manager (DM) I, the following items were observed: In the walk in cooler, there was a metal pan of chicken soup, covered tightly with plastic wrap, dated 1/23. The internal temperature of the soup was measured to be 45 degrees Fahrenheit. The DM I was queried as to whether staff utilized cooling logs, and confirmed that they did not. According to the 2017 FDA Food Code section 3-501.14 Cooling, 1. (A) Cooked POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); and (2) Within a total…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-26 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain an assessment and physician's order for self-administration of medications for one resident (R84) of one resident reviewed for self-administration of medications. Findings include: On 1/24/23 at approximately 11:15 AM, R84 was observed lying in bed. The resident had a bruise under their right eye and a cast on the right lower arm. The resident was alert and able to answer questions asked. A tube of Bacitracin ointment (a topical antibiotic) was observed on the bedside table. The resident reported that they were aware it was there and used it on occasion. On 1/25/23 at approximately 8:36 AM, R84 was observed sitting in their wheelchair. The Bacitracin was still on the bedside table. On 1/25/23 at approximately 1:02 PM, the Bacitracin was still observed in the resident's room. An interview was conducted with Nurse C after the observation. Nurse C was asked if R84 had an order for the Bacitracin and was assessed to self-administer it.…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-26 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were administered according to professional standards of practice for one (R16). Findings include: R16 On 1/25/23 at 9:32 AM, R16 was observed sitting up in bed holding a medication cup that contained multiple tablets of medication. An over bed table positioned next to R16's bed was observed with a medication cup that contained red liquid. When addressed R16 reported, I'm just taking my medication. There was no nurse present in R16's room at that time. On 1/25/23 at 9:33 AM, Nurse 'C' was observed at the medication cart in the hallway. When queried about whether R16 was able to take medications on their own, Nurse 'C' reported they were able to. When asked to provide the assessment that showed R16 was safe to self administer medications, Nurse 'C' reported R16 was not assessed. When queried about the proper procedure for passing medications, Nurse 'C' reported they were supposed to stand there while the resident took…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 interview and record review, the facility failed to ensure adequate coordination of care and maintain timely documented communication with the resident's hospice provider for one (R20) of three residents reviewed for hospice services. Findings include: According to the facility's hospice contract dated, 5/1/2017: .Hospice and facility will communicate with each other and document communications ensuring the needs of the patient are met and addressed 24 hrs. (hours) a day. Hospice will document in facility medical record after each visit . According to the facility's policy titled, Hospice Referral - Services Agreement, dated 12/2016: .A communication process, including how the communication will be documented between the facility and hospice provider, to ensure the needs of the resident are addressed and met 24 hours per day . A review of the clinical record revealed that R20 was initially admitted into the facility on 9/18/22 with diagnoses that included: unspecified protein calorie malnutrition and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the safety of a resident from possible burns/fire from a heating pad for one (R329) out of seven residents reviewed for accidents. Findings include: On 1/24/23 at approximately 10:54 AM, R329 was observed lying in their bed. A Sunbeam heating pad with a green cover was observed underneath the resident. The resident, who was alert but confused during the interview reported that they liked having it in their bed to keep them warm. On 1/24/23 at approximately 2:25 PM the resident was observed lying in bed. Several staff were present in the room, and it was reported that they were having a meeting with the resident and family. The heating pad was observed to be plugged in and next to the resident. On 1/24/23 at approximately 2:58 PM, R329 was observed lying in bed. The heating pad was next to the resident, plugged into the wall and the control light was on indicating the pad was functioning. R329 was asked what they used the pad for, and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-26 · tag F0813 — isolated
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    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 follow their policy regarding monitoring temperature and proper functioning of refrigerators for one (R111) of one resident reviewed for having a personal refrigerator. This deficient practice may result in potentially hazardous food being held outside of the proper temperature and the increased risk of contamination and food-borne illness. Findings include: According to the facility's policy titled, Refrigerator Temperature Checks on Nursing Units and in Therapy Gym dated 4/6/17: .Temperatures in patient room refrigerators will be checked weekly and recorded using a log sheet. Acceptable temperature range for refrigerators containing food is 32-40 degrees Fahrenheit. On 1/24/23 at approximately 9:15 AM, R111's room was observed to have a personal refrigerator. The personal refrigerator was observed to have an egg salad sandwich (with a use by date of 1/25/23), multiple yogurts, and juices. The internal thermometer revealed a temperature of 49 degrees Fahrenheit (F). There was no temperature log in R111'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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-02-28 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview and record review the facility failed to ensure the daily nurse staff postings were updated daily and reflected the staffing at the facility potentially affecting all residents and visitors at the facility. Findings include: On 2/26/24 at approximately 8:30 AM, the daily nurse staffing posting was observed in the facility lobby. It was noted the posting was dated for 2/22/24. On 2/28/23 at 12:32 PM, the observation of the staffing posting for 2/26/24 was shared with the facility's Administrator and they said they would look into why it hadn't been updated. A review of a facility provided policy titled, Posted Staffing Data issued 11/28/05 was reviewed and read, It is the policy of the facility to abide by the .Benefits Improvement and Protection Act of 2000 .This act requires a Medicare/Medicaid participating skilled nursing facility to post staffing data that indicates the number licensed and unlicensed nursing staff on duty who are directly responsible for patient care on each daily shift .

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

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 →

RatingThis homeChain avg
Overall 3 of 52.8+0.2 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 4 of 53.2+0.8 vs chain
Quality measures 3 of 54.0-1.0 vs chain
The other 80 homes this chain runs (chain average 2.8★, per CMS)
1 of 5Aria Nursing and RehabilitationLansing, MI 1 of 5Autumnwood of McBainMcBain, MI 1 of 5Christian Park Health Care CenterEscanaba, MI 1 of 5Courtney ManorBad Axe, MI 1 of 5Ely ManorAllegan, MI 1 of 5Kith HavenFlint, MI 1 of 5Laurels Of Norworth TheWorthington, OH 1 of 5Laurels Of West Carrollton TheWest Carrollton, OH 1 of 5Laurels Of West Columbus, TheColumbus, OH 1 of 5Notting Hill of West BloomfieldWest Bloomfield, MI 1 of 5Regency at FremontFremont, MI 1 of 5Regency at JacksonJackson, MI 1 of 5Regency at TroyTroy, MI 1 of 5Regency at WaterfordWaterford, MI 1 of 5Regency at Whitmore LakeWhitmore Lake, MI 1 of 5Royalton Manor, LLCSt Joseph, MI 1 of 5The Laurels Of HeathHeath, OH 1 of 5The Laurels Of Walden ParkColumbus, OH 1 of 5The Laurels of GalesburgGalesburg, MI 1 of 5The Laurels of HudsonvilleHudsonville, MI 1 of 5The Manor of NoviNovi, MI 2 of 5Laurels Of Athens, TheAthens, OH 2 of 5Laurels Of Mt Vernon TheMount Vernon, OH 2 of 5Laurels Of Steubenville TheSteubenville, OH 2 of 5Regency At Bluffs ParkAnn Arbor, MI 2 of 5Regency at CheneDetroit, MI 2 of 5The Laurels Of GahannaColumbus, OH 2 of 5The Laurels Of KetteringKettering, OH 2 of 5The Laurels Of University ParkRichmond, VA 2 of 5The Laurels Of Willow CreekMidlothian, VA 2 of 5The Laurels of BedfordBattle Creek, MI 2 of 5The Laurels of ChathamPittsboro, NC 2 of 5The Laurels of ColdwaterColdwater, MI 2 of 5The Laurels of Forest GlennGarner, NC 2 of 5The Manor of Farmington HillsFarmington Hills, MI 2 of 5Willowbrook ManorFlint, MI 3 of 5Autumnwood of DeckervilleDeckerville, MI 3 of 5Boulevard Temple Care Center, LLCDetroit, MI 3 of 5Brittany ManorMidland, MI 3 of 5Hamilton Respiratory and Nursing CenterHamilton, OH

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 / managerTypeRoleShareSince
CIENA MICHIGAN OPERATIONS GROUP II, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 11/01/2025
MOHAMMAD A QAZI LIVING TRUST DATED 09/26/97OrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2025
QAZI, MOHAMMADIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 11/01/2025
CIENA HEALTHCARE MANAGEMENT INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
JACKSON, SCOTTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/13/2025
KHAN, ANISIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
CIENA MICHIGAN REAL ESTATE II, LLCOrganizationADP OF THE SNFsince 11/01/2025
MOHAMMAD QAZI 2022 CHILDREN'S TRUST UAD 5-4-2022OrganizationADP OF THE SNFsince 11/01/2025
WEST MAPLE SENIOR LEASING, LLCOrganizationADP OF THE SNFsince 11/01/2025

CMS files one row per role, so the 13 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

$18.5M
Net patient revenuemost recent cost report
-6.2%
Operating marginrevenue minus expenses
$660K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 20%Other / private 21%

This home reported $660K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$400per resident / day
operating cost
$12,175per month
≈ monthly operating cost
$377per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Michigan
$11,254/mo
Nursing home (semi-private)
$11,969/mo
Nursing home (private)
$5,818/mo
Assisted living

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 235488. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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