Cycle 1
Health 2024-12-05 · Fire 2024-12-05
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Westland, MI
Four Chaplains Nursing Care Center
3-star overall rating with 3-star inspections with $45,126 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
28349 Joy Rd, Westland, MI
(734) 261-9500
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nexcare Health Systems
Operator or chain grouping
Approved since
1988-04-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 4 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
0.61
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
69%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,192
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.40
Baseline 22.98% · Performance 22.45% · Measure score 0.40 · Achievement 0 · Improvement 0.40
Healthcare-associated infections
0
Baseline 9.50% · Performance 9.37% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.26
Baseline 58.76% · Performance 46.25% · Measure score 4.26 · Achievement 4.26 · Improvement 3.19
Adjusted total nurse staffing
0.75
Baseline 3.76 hours · Performance 3.29 hours · Measure score 0.75 · Achievement 0.75 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.2% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 119 · Observed rate 15.13% · Lower 95% interval 8.18% |
| Discharge to community | 43.36% |
50.57%
7.2 pts worse
|
No Different than the National Rate · Eligible stays 121 · Observed rate 33.88% · Lower 95% interval 33.92% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 90.79% |
95.27%
4.5 pts worse
|
Numerator 69 · Denominator 76 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 76 |
| Discharge self-care score | 43.48% |
53.69%
10.2 pts worse
|
Numerator 20 · Denominator 46 |
| Discharge mobility score | 41.3% |
50.94%
9.6 pts worse
|
Numerator 19 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.33% |
2.29%
1 pts better
|
Numerator 1 · Denominator 75 · Adjusted rate 1.22% |
| Healthcare-associated infections requiring hospitalization | 9.37% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 16.39% · Lower 95% interval 5.67% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Staff flu vaccination coverage | 21.72% |
42%
20.3 pts worse
|
Numerator 58 · Denominator 267 |
| Discharge function score | 47.83% |
56.45%
8.6 pts worse
|
Numerator 22 · Denominator 46 |
| Transfer of health information to provider | 97.67% |
95.95%
1.7 pts better
|
Numerator 42 · Denominator 43 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 34.15% |
25.2%
8.9 pts better
|
Numerator 14 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.7
0.4 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.1 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.7% |
95.0%
9.3 pts worse
|
93.4%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.6% · Q2 83.1% · Q3 88.3% · Q4 97.5% · 4Q avg 85.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.4% |
95.0%
3.6 pts worse
|
95.5%
4.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.1%
0.2 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 3.9% · Q3 1.3% · Q4 2.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
4.1%
3.7 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
5.5%
4.1 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.9% · Q3 0.0% · Q4 1.3% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.1% |
19.6%
3.5 pts better
|
19.6%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 15.5% · Q3 13.9% · Q4 16.9% · 4Q avg 16.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
16.5%
5.4 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 12.3% · Q3 12.3% · Q4 10.2% · 4Q avg 11.1% · 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 | 10.7% |
13.9%
3.2 pts better
|
16.3%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 9.1% · Q3 15.9% · Q4 3.8% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.2% |
11.7%
1.5 pts better
|
14.9%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 16.4% · Q3 10.4% · Q4 2.9% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.9%
0.1 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 2.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.1% |
20.4%
14.3 pts better
|
19.8%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 9.7% · Q3 2.5% · Q4 3.8% · 4Q avg 6.1% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
5.6%
1.7 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 8.1% · Q3 8.3% · Q4 9.8% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.9% |
82.8%
26.9 pts worse
|
81.7%
25.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.6% · Q2 43.4% · Q3 36.1% · Q4 74.7% · 4Q avg 55.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
11.5%
6 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 5.9% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.3%
0.2 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.9% · Q3 2.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 41.6% |
79.5%
37.9 pts worse
|
79.7%
38.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 41.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.8% |
24.2%
2.6 pts worse
|
23.9%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.8% · Observed 31.4% · Expected 27.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-18 · Fire 2023-10-18
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-08-18 · Fire 2022-08-18
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-12-27
F · Potential for more than minimal harm
2024-12-05
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-12-27
F · Potential for more than minimal harm
2024-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-27
F · Potential for more than minimal harm
2024-12-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-27
F · Potential for more than minimal harm
2024-12-05
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-12-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-12-05
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-12-27
F · Potential for more than minimal harm
2023-10-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-08
F · Potential for more than minimal harm
2023-10-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-08
F · Potential for more than minimal harm
2023-10-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-08
E · Potential for more than minimal harm
2023-10-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-08
E · Potential for more than minimal harm
2023-10-18
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 2023-11-08
E · Potential for more than minimal harm
2023-10-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-08
F · Potential for more than minimal harm
2022-08-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-15
E · Potential for more than minimal harm
2022-08-18
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-09-15
E · Potential for more than minimal harm
2022-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-15
D · Potential for more than minimal harm
2022-08-18
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-09-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-05
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 2024-12-27
E · Potential for more than minimal harm
2024-12-05
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-05
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-05
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 2024-12-27
D · Potential for more than minimal harm
2024-12-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-12-05
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-09-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-06-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-08
J · Immediate jeopardy
2024-01-25
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 2024-01-26
D · Potential for more than minimal harm
2024-01-09
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 2024-01-22
E · Potential for more than minimal harm
2023-10-18
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 2023-11-08
D · Potential for more than minimal harm
2023-10-18
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-10-18
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-10-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-10-18
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 2023-11-08
D · Potential for more than minimal harm
2023-10-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-08
G · Actual harm
2023-05-03
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 2022-01-08
D · Potential for more than minimal harm
2023-05-03
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-05-16
J · Immediate jeopardy
2022-08-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-09-15
G · Actual harm
2022-08-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-15
F · Potential for more than minimal harm
2022-08-18
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 2022-09-15
D · Potential for more than minimal harm
2022-08-18
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-09-15
Penalties and ownership
What sits behind the stars
$45,126
2024-01-09
Fine
Fine · fine $45,126
Fine
Ownership
Branscum, James
5% Or Greater Direct Ownership Interest · Individual
Eisenberg, Leo
5% Or Greater Indirect Ownership Interest · Individual
Robin Eisenberg 2014 Family Trust
5% Or Greater Direct Ownership Interest · Organization
Wronski, Frank
5% Or Greater Direct Ownership Interest · Individual
Branscum, James
Corporate Director · Individual
Branscum, James
Corporate Officer · Individual
Eisenberg, Leo
Corporate Director · Individual
Eisenberg, Leo
Corporate Officer · Individual
Mallet, Deborah
W-2 Managing Employee · Individual
Nexcare Health Systems, LLC
Operational/Managerial Control · Organization
Perry, Michael
Operational/Managerial Control · Individual
Sangster, Todd
Corporate Officer · Individual
Wronski, Frank
Corporate Director · Individual
Wronski, Frank
Corporate Officer · Individual
Nearby options
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Fountain Bleu Health and Rehabilitation
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4-star overall rating with 4-star inspections with $8,985 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Optalis Health and Rehabilitation of Dearborn Heig
Dearborn Heights, MI
3-star overall rating with 2-star inspections with $42,136 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Regency at Livonia
Livonia, MI
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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