Cycle 1
Health 2025-02-12 · Fire 2025-02-12
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Westland, MI
Four Seasons Nursing Center of Westland
3-star overall rating with 2-star inspections with abuse icon flag with $15,593 in total fines with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
8365 Newburgh Road, Westland, MI
(734) 416-2000
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
155
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Optalis Health & Rehabilitation
Operator or chain grouping
Approved since
1997-05-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
37 facilities
Chain averages 3 overall / 2 health / 3 staffing / 5 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
1.00
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.01
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
1.61
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,556
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0029
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.55
Baseline 22.71% · Performance 19.28% · Measure score 5.55 · Achievement 4.65 · Improvement 5.55
Healthcare-associated infections
5.75
Baseline 10.70% · Performance 7.14% · Measure score 5.75 · Achievement 2.33 · Improvement 5.75
Total nurse turnover
6.75
Baseline 37.17% · Performance 36.09% · Measure score 6.75 · Achievement 6.75 · Improvement 0.38
Adjusted total nurse staffing
1.58
Baseline 3.39 hours · Performance 3.53 hours · Measure score 1.58 · Achievement 1.58 · Improvement 0.08
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.49% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 147 · Observed rate 12.93% · Lower 95% interval 7.36% |
| Discharge to community | 45.68% |
50.57%
4.9 pts worse
|
No Different than the National Rate · Eligible stays 140 · Observed rate 32.86% · Lower 95% interval 35.84% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 89 · Denominator 89 |
| Falls with major injury | 1.12% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 89 |
| Discharge self-care score | 81.67% |
53.69%
28 pts better
|
Numerator 49 · Denominator 60 |
| Discharge mobility score | 45% |
50.94%
5.9 pts worse
|
Numerator 27 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 89 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.14% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 84 · Observed rate 10.71% · Lower 95% interval 4.34% |
| Staff COVID-19 vaccination coverage | 3.95% |
8.2%
4.2 pts worse
|
Numerator 9 · Denominator 228 |
| Staff flu vaccination coverage | 36.61% |
42%
5.4 pts worse
|
Numerator 82 · Denominator 224 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 40 · Denominator 60 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 96.15% |
96.28%
0.1 pts worse
|
Numerator 25 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 21.95% |
25.2%
3.2 pts worse
|
Numerator 9 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.3 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.5
1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.6 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
95.0%
4.5 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.3% · Q3 99.3% · Q4 99.4% · 4Q avg 99.5% |
| 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 | 2.8% |
3.1%
0.3 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.7% · Q3 2.0% · Q4 3.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
4.1%
3.2 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 1.4% · Q4 1.5% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
5.5%
2.3 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 5.2% · Q3 5.8% · Q4 10.0% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
19.6%
0.1 pts better
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 19.4% · Q3 20.0% · Q4 21.8% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
16.5%
1.7 pts better
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 13.8% · Q3 13.3% · Q4 14.8% · 4Q avg 14.8% · 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 | 11.4% |
13.9%
2.5 pts better
|
16.3%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 13.9% · Q3 6.4% · Q4 8.8% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
11.7%
6.1 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.8% · Q3 6.3% · Q4 3.1% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.5% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.7%
0.5 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.4% · Q3 0.7% · Q4 0.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.6% |
20.4%
6.8 pts better
|
19.8%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 13.1% · Q3 10.0% · Q4 17.2% · 4Q avg 13.6% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
5.6%
1.6 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.9% · Q3 4.8% · Q4 4.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
82.8%
13.2 pts better
|
81.7%
14.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 93.3% · Q3 96.7% · Q4 95.3% · 4Q avg 96.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
11.5%
2.1 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 10.4% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
79.5%
15.6 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.6% |
24.2%
5.6 pts better
|
23.9%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 25.4% · Expected 32.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-06 · Fire 2023-12-06
17 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2022-09-22 · Fire 2022-09-22
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-07
F · Potential for more than minimal harm
2025-02-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-07
F · Potential for more than minimal harm
2025-02-12
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-02-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-02-12
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2025-03-07
F · Potential for more than minimal harm
2023-12-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-12-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-12-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-12-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-12-06
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-12-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-12-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-06
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 2024-01-12
E · Potential for more than minimal harm
2023-12-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-06
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 2024-01-12
E · Potential for more than minimal harm
2023-12-06
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-01-22
E · Potential for more than minimal harm
2023-12-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-06
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 2024-01-12
E · Potential for more than minimal harm
2023-12-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-12-06
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-01-12
F · Potential for more than minimal harm
2022-09-22
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-10-17
F · Potential for more than minimal harm
2022-09-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-17
F · Potential for more than minimal harm
2022-09-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-22
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 2022-10-17
E · Potential for more than minimal harm
2022-09-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-22
E · Potential for more than minimal harm
2022-09-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-30
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 2025-07-16
D · Potential for more than minimal harm
2025-07-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-19
D · Potential for more than minimal harm
2025-07-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-19
D · Potential for more than minimal harm
2025-06-11
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 2025-06-30
D · Potential for more than minimal harm
2025-06-11
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 2025-06-30
D · Potential for more than minimal harm
2025-05-29
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 2025-06-18
D · Potential for more than minimal harm
2025-05-29
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-06-18
F · Potential for more than minimal harm
2025-02-12
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-12
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 2025-03-07
D · Potential for more than minimal harm
2025-02-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-12
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 2025-03-07
D · Potential for more than minimal harm
2025-02-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-12
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-03-07
G · Actual harm
2025-01-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-11-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-23
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 2024-11-06
D · Potential for more than minimal harm
2024-10-23
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 2024-11-06
D · Potential for more than minimal harm
2024-10-23
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-05-29
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 2024-06-11
E · Potential for more than minimal harm
2024-03-13
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-13
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-03-29
F · Potential for more than minimal harm
2023-12-06
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 2023-12-29
F · Potential for more than minimal harm
2023-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-06
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 2023-12-29
D · Potential for more than minimal harm
2023-12-06
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 2023-12-29
D · Potential for more than minimal harm
2023-12-06
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 2023-12-29
D · Potential for more than minimal harm
2023-12-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-06
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-06
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 2023-12-29
D · Potential for more than minimal harm
2023-12-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-12-29
G · Actual harm
2023-10-09
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 2023-10-19
D · Potential for more than minimal harm
2023-08-15
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-08-03
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 2023-08-23
D · Potential for more than minimal harm
2023-08-03
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 2023-08-23
D · Potential for more than minimal harm
2023-08-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-23
G · Actual harm
2022-09-22
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 2022-10-17
F · Potential for more than minimal harm
2022-09-22
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 2022-10-17
E · Potential for more than minimal harm
2022-09-22
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 2022-10-17
E · Potential for more than minimal harm
2022-09-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-22
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 2022-10-17
D · Potential for more than minimal harm
2022-09-22
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 2022-10-17
D · Potential for more than minimal harm
2022-09-22
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 2022-10-17
D · Potential for more than minimal harm
2022-09-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-22
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 2022-10-17
D · Potential for more than minimal harm
2022-09-22
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 2022-10-17
C · Minimal harm
2022-09-22
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-10-17
Penalties and ownership
What sits behind the stars
$15,593
2023-10-09
Fine
Fine · fine $15,593
Fine
Ownership
Dunn, Charles
5% Or Greater Direct Ownership Interest · Individual
Conner, Marianne
Corporate Officer · Individual
Dunn, Charles
Corporate Officer · Individual
Verhulst, Chris
W-2 Managing Employee · Individual
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