Cycle 1
Health 2025-05-15 · Fire 2025-05-15
10 health deficiencies
Top issue: Resident Rights (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Lansing, MI
Aria Nursing and Rehabilitation
1-star overall rating with 1-star inspections with $75,834 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
707 Armstrong, Lansing, MI
(517) 393-5680
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ciena Healthcare/Laurel Health Care
Operator or chain grouping
Approved since
1995-07-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
84 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.99
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.79
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.44
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.82
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.16
CMS adjusted RN staffing hours
Adjusted total hours
5.20
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
7,124
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9861
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.28
Baseline 20.69% · Performance 20.37% · Measure score 2.28 · Achievement 2.28 · Improvement 0.37
Healthcare-associated infections
4.68
Baseline 9.56% · Performance 7.20% · Measure score 4.68 · Achievement 2.14 · Improvement 4.68
Total nurse turnover
0
Baseline 59.14% · Performance 66.67% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.30
Baseline 3.80 hours · Performance 4.59 hours · Measure score 5.30 · Achievement 5.30 · Improvement 3.48
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.04% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 9.43% · Lower 95% interval 6.68% |
| Discharge to community | 45.99% |
50.57%
4.6 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 37% · Lower 95% interval 33.91% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 85 · Denominator 85 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 85 |
| Discharge self-care score | 62.3% |
53.69%
8.6 pts better
|
Numerator 38 · Denominator 61 |
| Discharge mobility score | 52.46% |
50.94%
1.5 pts better
|
Numerator 32 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 3.53% |
2.29%
1.2 pts worse
|
Numerator 3 · Denominator 85 · Adjusted rate 3.13% |
| Healthcare-associated infections requiring hospitalization | 7.19% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 7.89% · Lower 95% interval 4.14% |
| Staff COVID-19 vaccination coverage | 4.86% |
8.2%
3.3 pts worse
|
Numerator 7 · Denominator 144 |
| Staff flu vaccination coverage | 6.3% |
42%
35.7 pts worse
|
Numerator 15 · Denominator 238 |
| Discharge function score | 59.02% |
56.45%
2.6 pts better
|
Numerator 36 · Denominator 61 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 34% |
25.2%
8.8 pts better
|
Numerator 17 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.7
1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
95.0%
2.8 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 95.8% · Q3 100.0% · Q4 100.0% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.1%
1.7 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.8% · Q3 5.6% · Q4 8.2% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.9% |
4.1%
7.8 pts worse
|
11.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 17.2% · Q3 10.3% · Q4 9.1% · 4Q avg 11.9% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
5.5%
0.7 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.2% · Q3 6.3% · Q4 5.9% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.8% |
19.6%
2.2 pts worse
|
19.6%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 22.7% · Q3 21.9% · Q4 20.8% · 4Q avg 21.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
16.5%
4.3 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 11.5% · Q3 12.5% · Q4 13.6% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.7% |
13.9%
5.8 pts worse
|
16.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 26.4% · Q3 16.5% · Q4 14.4% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.3% |
11.7%
0.4 pts better
|
14.9%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 12.9% · Q3 8.1% · Q4 11.5% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.9%
0.2 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.7%
0.6 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.6% |
20.4%
6.2 pts worse
|
19.8%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 39.2% · Q3 26.9% · Q4 14.0% · 4Q avg 26.6% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.6%
2.1 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.7% · Q3 4.1% · Q4 5.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.1% |
82.8%
10.7 pts worse
|
81.7%
9.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 82.1% · Q2 75.4% · Q3 65.5% · Q4 61.2% · 4Q avg 72.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.6% |
11.5%
9.1 pts worse
|
12.0%
8.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 21.9% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.6% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.6% |
79.5%
8.9 pts worse
|
79.7%
9.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.8% |
24.2%
7.4 pts better
|
23.9%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 18.8% · Expected 26.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-10 · Fire 2024-04-10
23 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-01-17 · Fire 2023-01-17
32 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-15
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-05-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-05-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-05-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-15
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2025-06-17
F · Potential for more than minimal harm
2024-04-10
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-05-03
F · Potential for more than minimal harm
2024-04-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-03
F · Potential for more than minimal harm
2024-04-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-04-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-04-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-13
F · Potential for more than minimal harm
2023-01-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-10
F · Potential for more than minimal harm
2023-01-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-10
F · Potential for more than minimal harm
2023-01-17
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-02-10
F · Potential for more than minimal harm
2023-01-17
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-02-24
F · Potential for more than minimal harm
2023-01-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-10
F · Potential for more than minimal harm
2023-01-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-01-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-24
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-21
F · Potential for more than minimal harm
2025-05-15
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-05-15
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-08-11
E · Potential for more than minimal harm
2025-05-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-11
E · Potential for more than minimal harm
2025-05-15
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-15
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-15
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-15
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-17
G · Actual harm
2024-07-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-30
E · Potential for more than minimal harm
2024-07-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-30
D · Potential for more than minimal harm
2024-06-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-05
G · Actual harm
2024-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-29
G · Actual harm
2024-04-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-04-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-04-10
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-04-10
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-04-29
E · Potential for more than minimal harm
2024-04-10
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2024-04-29
E · Potential for more than minimal harm
2024-04-10
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-29
E · Potential for more than minimal harm
2024-04-10
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-04-29
E · Potential for more than minimal harm
2024-04-10
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-04-29
E · Potential for more than minimal harm
2024-04-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-04-29
E · Potential for more than minimal harm
2024-04-10
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-29
B · Minimal harm
2024-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-29
G · Actual harm
2024-02-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-02-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-02-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-19
G · Actual harm
2023-11-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-06-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-06-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-06-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-06-26
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-06-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-01-17
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-01-17
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-01-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-17
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-02-10
C · Minimal harm
2023-01-17
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2023-02-10
Penalties and ownership
What sits behind the stars
$55,085
2024-04-10
Fine
Fine · fine $55,085
Fine
$0
2024-04-10
Payment Denial
Payment Denial · denial start 2024-05-07 · 6 days
6 day denial
$20,749
2024-02-02
Fine
Fine · fine $20,749
Fine
Ownership
Qazi, Mohammad
5% Or Greater Direct Ownership Interest · Individual
Ciena Healthcare Management Inc
Operational/Managerial Control · Organization
Khan, Anis
Operational/Managerial Control · Individual
Lorius, Lisa
Operational/Managerial Control · Individual
Qazi, Mohammad
Operational/Managerial Control · Individual
Qazi, Mohammad
Corporate Director · Individual
Qazi, Mohammad
Corporate Officer · Individual
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