Cycle 1
Health 2024-10-29 · Fire 2024-10-29
16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Bad Axe, MI
Courtney Manor
2-star overall rating with 2-star inspections with 16 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1167 E Hopson Street, Bad Axe, MI
(989) 269-9983
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ciena Healthcare/Laurel Health Care
Operator or chain grouping
Approved since
1986-07-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing
LPN hours / resident day
0.74
Licensed practical nurse staffing
Aide hours / resident day
1.82
Nurse aide staffing
Weekend hours
2.54
Weekend nurse staffing
RN turnover
53%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.5
1.3 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.0%
5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
4.1%
2.9 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.5%
5.5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.3% |
19.6%
1.7 pts worse
|
19.6%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
16.5%
3.8 pts better
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.2% |
13.9%
9.3 pts worse
|
16.3%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.1% |
11.7%
10.4 pts worse
|
14.9%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.7%
0.3 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.6% |
20.4%
8.2 pts worse
|
19.8%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
5.6%
1.3 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
82.8%
11.2 pts better
|
81.7%
12.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
11.5%
0.6 pts worse
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
79.5%
19.1 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.1% |
24.2%
5.9 pts worse
|
23.9%
6.2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-06 · Fire 2023-10-06
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-10-15 · Fire 2021-10-15
12 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-28
E · Potential for more than minimal harm
2023-10-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-10-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-11-06
F · Potential for more than minimal harm
2021-10-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-15
F · Potential for more than minimal harm
2021-10-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-11-15
E · Potential for more than minimal harm
2021-10-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-11-15
E · Potential for more than minimal harm
2021-10-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-15
E · Potential for more than minimal harm
2021-10-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-11-15
Inspection history
Recent health citations
G · Actual harm
2024-10-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-28
E · Potential for more than minimal harm
2024-10-29
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 2024-11-28
E · Potential for more than minimal harm
2024-10-29
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 2024-11-28
E · Potential for more than minimal harm
2024-10-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-28
E · Potential for more than minimal harm
2024-10-29
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 2024-11-28
E · Potential for more than minimal harm
2024-10-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-28
E · Potential for more than minimal harm
2024-10-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-29
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 2024-11-28
D · Potential for more than minimal harm
2024-10-29
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 2024-11-28
D · Potential for more than minimal harm
2024-10-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-29
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 2024-11-28
D · Potential for more than minimal harm
2024-10-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-29
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 2024-11-28
D · Potential for more than minimal harm
2024-10-29
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-11-28
E · Potential for more than minimal harm
2023-10-06
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 2023-11-06
E · Potential for more than minimal harm
2023-10-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-10-06
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 2023-11-06
E · Potential for more than minimal harm
2023-10-06
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 2023-11-06
E · Potential for more than minimal harm
2023-10-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-06
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 2023-11-06
D · Potential for more than minimal harm
2023-10-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-06
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-06
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 2023-11-06
D · Potential for more than minimal harm
2023-10-06
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 2023-11-06
F · Potential for more than minimal harm
2021-10-15
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 2021-11-15
F · Potential for more than minimal harm
2021-10-15
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2021-11-15
E · Potential for more than minimal harm
2021-10-15
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 2021-11-15
E · Potential for more than minimal harm
2021-10-15
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 2021-11-15
D · Potential for more than minimal harm
2021-10-15
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 2021-11-15
D · Potential for more than minimal harm
2021-10-15
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 2021-11-15
D · Potential for more than minimal harm
2021-10-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-11-15
D · Potential for more than minimal harm
2021-10-15
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 2021-11-15
D · Potential for more than minimal harm
2021-10-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-15
Penalties and ownership
What sits behind the stars
Ownership
Mohammad A Qazi Living Trust Dated 09/26/97
5% Or Greater Direct Ownership Interest · Organization
Qazi, Mohammad
5% Or Greater Indirect Ownership Interest · Individual
Chambers, Tina
Operational/Managerial Control · Individual
Ciena Healthcare Management Inc
Operational/Managerial Control · Organization
Khan, Anis
Operational/Managerial Control · Individual
Mohammad A Qazi Living Trust Dated 09/26/97
Operational/Managerial Control · Organization
Qazi, Mohammad
Operational/Managerial Control · Individual
Shisler, Scott
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Huron County Medical Care Facility
Bad Axe, MI
5-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Lakeview Extended Care and Rehabilitation
Harbor Beach, MI
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Medilodge of Cass City
Cass City, MI
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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