Jackson, MI

Regency at Jackson

1-star overall rating with 2-star inspections with $15,593 in total fines with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

434 W North Street, Jackson, MI

(517) 787-3250

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Ciena Healthcare/Laurel Health Care

Operator or chain grouping

Approved since

1967-01-01

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

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

0.42

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.81

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

1.84

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

3.08

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.24

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

2.77

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.30

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.45

CMS adjusted RN staffing hours

Adjusted total hours

3.27

CMS adjusted total nurse staffing hours

Case-mix index

1.29

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

11,314

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

17.27

Composite VBP score used to determine payment impact.

Payment multiplier

0.9818

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 18.75% · Performance 21.55% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

2.18

Baseline 5.72% · Performance 7.18% · Measure score 2.18 · Achievement 2.18 · Improvement 0

Total nurse turnover

1.80

Baseline 73.13% · Performance 62.02% · Measure score 1.80 · Achievement 0 · Improvement 1.80

Adjusted total nurse staffing

2.93

Baseline 3.31 hours · Performance 3.91 hours · Measure score 2.93 · Achievement 2.93 · Improvement 1.95

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.72%	10.72% 1 pts better	No Different than the National Rate · Eligible stays 85 · Observed rate 9.41% · Lower 95% interval 6.91%
Discharge to community	50.52%	50.57% About the same	No Different than the National Rate · Eligible stays 88 · Observed rate 37.5% · Lower 95% interval 40.35%
Medicare spending per beneficiary	1.17	1.02 0.1 pts worse
Drug regimen review with follow-up	98.25%	95.27% 3 pts better	Numerator 56 · Denominator 57
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 57
Discharge self-care score	51.16%	53.69% 2.5 pts worse	Numerator 22 · Denominator 43
Discharge mobility score	41.86%	50.94% 9.1 pts worse	Numerator 18 · Denominator 43
Pressure ulcers or injuries, new or worsened	7.02%	2.29% 4.7 pts worse	Numerator 4 · Denominator 57 · Adjusted rate 6.67%
Healthcare-associated infections requiring hospitalization	7.18%	7.12% 0.1 pts worse	No Different than the National Rate · Eligible stays 62 · Observed rate 8.06% · Lower 95% interval 3.84%
Staff COVID-19 vaccination coverage	7.95%	8.2% 0.2 pts worse	Numerator 7 · Denominator 88
Staff flu vaccination coverage	18.89%	42% 23.1 pts worse	Numerator 17 · Denominator 90
Discharge function score	51.16%	56.45% 5.3 pts worse	Numerator 22 · Denominator 43
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 25 · Denominator 25
Resident COVID-19 vaccinations up to date	30%	25.2% 4.8 pts better	Numerator 9 · Denominator 30

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	96.8%	95.0% 1.8 pts better	93.4% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 94.0% · Q3 97.9% · Q4 100.0% · 4Q avg 96.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.0%	95.0% 3 pts better	95.5% 2.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0%
Percentage of long-stay residents experiencing one or more falls with major injury	2.6%	3.1% 0.5 pts better	3.3% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.0% · Q3 4.2% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	4.6%	4.1% 0.5 pts worse	11.4% 6.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.4% · Q3 9.1% · Q4 0.0% · 4Q avg 4.6%
Percentage of long-stay residents who lose too much weight	6.1%	5.5% 0.6 pts worse	5.4% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 4.7% · Q3 7.0% · Q4 4.8% · 4Q avg 6.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	8.7%	19.6% 10.9 pts better	19.6% 10.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 6.7% · Q3 13.3% · Q4 4.7% · 4Q avg 8.7%
Percentage of long-stay residents who received an antipsychotic medication	23.8%	16.5% 7.3 pts worse	16.7% 7.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 16.7% · Q3 25.0% · Q4 26.5% · 4Q avg 23.8% · 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	5.5%	13.9% 8.4 pts better	16.3% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q3 9.4% · 4Q avg 5.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	10.4%	11.7% 1.3 pts better	14.9% 4.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 11.9% · Q3 11.6% · Q4 5.0% · 4Q avg 10.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.6%	0.9% 0.7 pts worse	1.0% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · 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 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.1% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	18.6%	20.4% 1.8 pts better	19.8% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 27.2% · Q3 23.6% · Q4 7.0% · 4Q avg 18.6%
Percentage of long-stay residents with pressure ulcers	4.3%	5.6% 1.3 pts better	5.1% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.2% · Q3 2.2% · Q4 3.7% · 4Q avg 4.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	88.6%	82.8% 5.8 pts better	81.7% 6.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 88.9% · Q3 84.4% · Q4 89.2% · 4Q avg 88.6%
Percentage of short-stay residents who had an outpatient emergency department visit	23.2%	11.5% 11.7 pts worse	12.0% 11.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 23.3% · Expected 11.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.6%	1.3% 0.3 pts worse	1.6% About the same	Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	79.6%	79.5% 0.1 pts better	79.7% 0.1 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 79.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.6%	24.2% 0.4 pts worse	23.9% 0.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 25.6% · Expected 24.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-16 · Fire 2025-04-16

16 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2024-05-17 · Fire 2024-05-17

13 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2023-02-21 · Fire 2023-02-21

31 health deficiencies

Top issue: Quality of Life and Care (12 deficiencies)

2 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-04-16

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 2025-05-02

E · Potential for more than minimal harm 2025-04-16

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2025-05-02

E · Potential for more than minimal harm 2025-04-16

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-05-02

E · Potential for more than minimal harm 2024-05-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-17

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-05-31

F · Potential for more than minimal harm 2023-05-22

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2023-05-23

F · Potential for more than minimal harm 2023-02-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-03-21

Inspection history

Recent health citations

E · Potential for more than minimal harm 2026-01-13

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 2026-02-13

D · Potential for more than minimal harm 2026-01-13

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 2026-02-13

D · Potential for more than minimal harm 2026-01-13

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 2026-02-13

D · Potential for more than minimal harm 2026-01-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2026-02-13

E · Potential for more than minimal harm 2025-12-18

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 2026-01-13

D · Potential for more than minimal harm 2025-05-02

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-05-23

D · Potential for more than minimal harm 2025-05-02

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-05-23

D · Potential for more than minimal harm 2025-05-02

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 2025-05-23

F · Potential for more than minimal harm 2025-04-16

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 2025-05-02

F · Potential for more than minimal harm 2025-04-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-04-16

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 2025-05-02

D · Potential for more than minimal harm 2025-04-16

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-04-16

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 2025-05-02

D · Potential for more than minimal harm 2025-04-16

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-04-16

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 2025-05-02

D · Potential for more than minimal harm 2025-04-16

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-05-02

D · Potential for more than minimal harm 2025-01-29

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 2025-02-04

G · Actual harm 2024-05-17

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-05-31

G · Actual harm 2024-05-17

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 2024-04-03

F · Potential for more than minimal harm 2024-05-17

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 2024-05-31

E · Potential for more than minimal harm 2024-05-17

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 2024-05-31

D · Potential for more than minimal harm 2024-05-17

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 2024-05-31

D · Potential for more than minimal harm 2024-05-17

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 2024-05-31

D · Potential for more than minimal harm 2024-05-17

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-17

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 2024-05-31

D · Potential for more than minimal harm 2024-05-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-17

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-17

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-02-15

F622 · Resident Rights Deficiencies

Health

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected 2024-02-28

D · Potential for more than minimal harm 2024-02-15

F626 · Resident Rights Deficiencies

Health

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Corrected 2024-02-28

G · Actual harm 2023-11-21

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-12-03

G · Actual harm 2023-08-14

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 2023-07-20

D · Potential for more than minimal harm 2023-08-14

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 2023-09-06

D · Potential for more than minimal harm 2023-08-14

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-09-06

D · Potential for more than minimal harm 2023-06-26

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 2023-07-11

F · Potential for more than minimal harm 2023-02-21

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 2023-03-21

E · Potential for more than minimal harm 2023-02-21

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 2023-03-21

E · Potential for more than minimal harm 2023-02-21

F680 · Quality of Life and Care Deficiencies

Health

Ensure the activities program is directed by a qualified professional.

Corrected 2023-03-21

E · Potential for more than minimal harm 2023-02-21

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 2023-03-21

E · Potential for more than minimal harm 2023-02-21

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-03-21

E · Potential for more than minimal harm 2023-02-21

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 2023-03-21