Cycle 1
Health 2025-03-05 · Fire 2025-03-05
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Temperance, MI
Hickory Ridge of Temperance
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
951 Hickory Creek Boulevard, Temperance, MI
(734) 206-8200
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
88
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
2009-02-23
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
0.66
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.27
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.95
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.98
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,955
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.71
Composite VBP score used to determine payment impact.
Payment multiplier
1.0001
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.10
Baseline 23.57% · Performance 23.18% · Measure score 0.10 · Achievement 0 · Improvement 0.10
Healthcare-associated infections
10
Baseline 4.30% · Performance 4.97% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
5.54
Baseline 52.11% · Performance 41.05% · Measure score 5.54 · Achievement 5.54 · Improvement 3.56
Adjusted total nurse staffing
3.04
Baseline 3.55 hours · Performance 3.94 hours · Measure score 3.04 · Achievement 3.04 · Improvement 1.25
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.13% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 265 · Observed rate 12.45% · Lower 95% interval 8.42% |
| Discharge to community | 55.02% |
50.57%
4.5 pts better
|
No Different than the National Rate · Eligible stays 252 · Observed rate 50.4% · Lower 95% interval 49.64% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.8% |
95.27%
3.5 pts better
|
Numerator 165 · Denominator 167 |
| Falls with major injury | 0.6% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 167 |
| Discharge self-care score | 51.64% |
53.69%
2 pts worse
|
Numerator 63 · Denominator 122 |
| Discharge mobility score | 36.07% |
50.94%
14.9 pts worse
|
Numerator 44 · Denominator 122 |
| Pressure ulcers or injuries, new or worsened | 1.2% |
2.29%
1.1 pts better
|
Numerator 2 · Denominator 167 · Adjusted rate 1.25% |
| Healthcare-associated infections requiring hospitalization | 4.97% |
7.12%
2.2 pts better
|
No Different than the National Rate · Eligible stays 155 · Observed rate 2.58% · Lower 95% interval 3.02% |
| Staff COVID-19 vaccination coverage | 8.89% |
8.2%
0.7 pts better
|
Numerator 12 · Denominator 135 |
| Staff flu vaccination coverage | 36.03% |
42%
6 pts worse
|
Numerator 49 · Denominator 136 |
| Discharge function score | 32.79% |
56.45%
23.7 pts worse
|
Numerator 40 · Denominator 122 |
| Transfer of health information to provider | 97.79% |
95.95%
1.8 pts better
|
Numerator 133 · Denominator 136 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 34.62% |
25.2%
9.4 pts better
|
Numerator 27 · Denominator 78 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.3 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 45.0% |
95.0%
50 pts worse
|
95.5%
50.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 45.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.1%
1.3 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.8% · Q3 0.0% · Q4 1.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 27.1% |
4.1%
23 pts worse
|
11.4%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 31.5% · Q3 19.6% · Q4 20.0% · 4Q avg 27.1% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
5.5%
1.9 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 8.2% · Q4 2.1% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.0% |
19.6%
13.4 pts worse
|
19.6%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.0% · Q2 33.3% · Q3 32.0% · Q4 30.6% · 4Q avg 33.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.0% |
16.5%
1.5 pts worse
|
16.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 15.9% · Q3 19.0% · Q4 16.3% · 4Q avg 18.0% · 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 | 20.6% |
13.9%
6.7 pts worse
|
16.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
11.7%
7.3 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 17.0% · Q3 17.0% · Q4 11.4% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.9%
0.5 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.2% · Q3 1.3% · Q4 1.2% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.7%
0.6 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.8% · Q3 1.9% · Q4 2.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.8% |
20.4%
6.4 pts worse
|
19.8%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 42.2% · Q3 17.7% · Q4 26.3% · 4Q avg 26.8% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
5.6%
1 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 6.6% · Q3 8.2% · Q4 6.5% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
82.8%
16.6 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 99.5% · Q3 100.0% · Q4 98.6% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.9% |
11.5%
8.6 pts better
|
12.0%
9.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.9% · Observed 3.2% · Expected 12.3% · 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 0.7% · Q2 0.0% · Q3 0.7% · Q4 0.7% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.0% |
79.5%
18.5 pts better
|
79.7%
18.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
24.2%
1.6 pts worse
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 27.2% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
2 health deficiencies
Top issue: Infection Control (1 deficiency)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2022-10-14 · Fire 2022-10-14
7 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-25
E · Potential for more than minimal harm
2025-03-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-25
F · Potential for more than minimal harm
2024-01-25
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-02-20
F · Potential for more than minimal harm
2024-01-25
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-02-20
F · Potential for more than minimal harm
2024-01-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-20
F · Potential for more than minimal harm
2024-01-25
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-02-20
F · Potential for more than minimal harm
2024-01-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-20
F · Potential for more than minimal harm
2024-01-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-20
F · Potential for more than minimal harm
2024-01-25
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-02-20
F · Potential for more than minimal harm
2024-01-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-01-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-01-25
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 2024-02-20
E · Potential for more than minimal harm
2024-01-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-01-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-25
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-02-20
F · Potential for more than minimal harm
2022-10-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-18
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-05
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-03-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-01
D · Potential for more than minimal harm
2024-01-25
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 2024-02-20
D · Potential for more than minimal harm
2024-01-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-20
E · Potential for more than minimal harm
2022-10-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-14
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 2022-11-18
D · Potential for more than minimal harm
2022-10-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-10-14
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 2022-11-18
D · Potential for more than minimal harm
2022-10-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-11-18
Penalties and ownership
What sits behind the stars
Ownership
Qazi, Mohammad
5% Or Greater Direct Ownership Interest · Individual
Baad, Matthew
Contracted Managing Employee · Individual
Ciena Healthcare Management Inc
Operational/Managerial Control · Organization
Qazi, Mohammad
Corporate Officer · Individual
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