Cycle 1
Health 2025-11-20 · Fire 2025-11-20
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Shelby Township, MI
Regency at Shelby Township
4-star overall rating with 4-star inspections with $15,593 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
7401 22 Mile Road, Shelby Township, MI
(586) 580-5500
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ciena Healthcare/Laurel Health Care
Operator or chain grouping
Approved since
2015-11-12
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
0.61
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.50
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.96
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.11
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,701
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9852
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.33
Baseline 25.77% · Performance 23.29% · Measure score 2.33 · Achievement 0 · Improvement 2.33
Healthcare-associated infections
4.27
Baseline 7.88% · Performance 6.56% · Measure score 4.27 · Achievement 4.27 · Improvement 4.07
Total nurse turnover
1.36
Baseline 64.03% · Performance 58.11% · Measure score 1.36 · Achievement 1.36 · Improvement 1.01
Adjusted total nurse staffing
3.64
Baseline 3.94 hours · Performance 4.11 hours · Measure score 3.64 · Achievement 3.64 · Improvement 0.43
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.94% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 439 · Observed rate 14.81% · Lower 95% interval 10.63% |
| Discharge to community | 54.8% |
50.57%
4.2 pts better
|
No Different than the National Rate · Eligible stays 455 · Observed rate 47.91% · Lower 95% interval 49.75% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.13% |
95.27%
3.9 pts better
|
Numerator 227 · Denominator 229 |
| Falls with major injury | 1.75% |
0.77%
1 pts worse
|
Numerator 4 · Denominator 229 |
| Discharge self-care score | 48.55% |
53.69%
5.1 pts worse
|
Numerator 84 · Denominator 173 |
| Discharge mobility score | 38.73% |
50.94%
12.2 pts worse
|
Numerator 67 · Denominator 173 |
| Pressure ulcers or injuries, new or worsened | 0.87% |
2.29%
1.4 pts better
|
Numerator 2 · Denominator 229 · Adjusted rate 0.76% |
| Healthcare-associated infections requiring hospitalization | 6.56% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 203 · Observed rate 6.4% · Lower 95% interval 4.37% |
| Staff COVID-19 vaccination coverage | 2.72% |
8.2%
5.5 pts worse
|
Numerator 4 · Denominator 147 |
| Staff flu vaccination coverage | 19.42% |
42%
22.6 pts worse
|
Numerator 40 · Denominator 206 |
| Discharge function score | 39.88% |
56.45%
16.6 pts worse
|
Numerator 69 · Denominator 173 |
| Transfer of health information to provider | 98.28% |
95.95%
2.3 pts better
|
Numerator 57 · Denominator 58 |
| Transfer of health information to patient | 99.28% |
96.28%
3 pts better
|
Numerator 137 · Denominator 138 |
| Resident COVID-19 vaccinations up to date | 18.94% |
25.2%
6.3 pts worse
|
Numerator 25 · Denominator 132 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.7
0.3 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.0 · 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 0.5 · 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 | 71.1% |
95.0%
23.9 pts worse
|
95.5%
24.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 71.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.1%
2.5 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.6% · Q3 6.1% · Q4 5.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.7% |
4.1%
1.6 pts worse
|
11.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 1.6% · Q3 6.7% · Q4 1.8% · 4Q avg 5.7% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.5%
1.8 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 6.1% · Q3 1.7% · Q4 0.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.1% |
19.6%
1.5 pts worse
|
19.6%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 24.2% · Q3 21.7% · Q4 18.9% · 4Q avg 21.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.4% |
16.5%
0.9 pts worse
|
16.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 13.5% · Q3 21.6% · Q4 21.7% · 4Q avg 17.4% · 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 | 32.4% |
13.9%
18.5 pts worse
|
16.3%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 36.7% · Q3 15.2% · Q4 44.7% · 4Q avg 32.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.8% |
11.7%
14.1 pts worse
|
14.9%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.3% · Q2 34.9% · Q3 13.6% · Q4 21.6% · 4Q avg 25.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
1.7%
1.3 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.6% · Q3 1.5% · Q4 1.7% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.6% |
20.4%
7.2 pts worse
|
19.8%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 32.0% · Q3 22.0% · Q4 28.3% · 4Q avg 27.6% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
5.6%
3.8 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 1.1% · Q4 3.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
82.8%
16.2 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 99.0% · Q3 98.9% · Q4 99.2% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.5% |
11.5%
7 pts better
|
12.0%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.5% · Observed 4.4% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.3%
0.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.5% · Q3 0.9% · Q4 1.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
79.5%
17.4 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
24.2%
0.9 pts better
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 25.1% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-12 · Fire 2024-09-12
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-07-26 · Fire 2023-07-26
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-12-02
F · Potential for more than minimal harm
2025-11-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-02
E · Potential for more than minimal harm
2025-11-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-02
F · Potential for more than minimal harm
2024-09-12
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-10-09
F · Potential for more than minimal harm
2023-07-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-16
E · Potential for more than minimal harm
2023-07-26
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-08-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-11-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-11-20
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 2025-12-02
F · Potential for more than minimal harm
2024-09-12
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-12
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 2024-10-09
D · Potential for more than minimal harm
2024-09-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-12
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 2024-10-09
D · Potential for more than minimal harm
2024-09-12
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 2024-10-09
D · Potential for more than minimal harm
2024-09-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-12
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 2024-10-09
D · Potential for more than minimal harm
2024-09-12
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 2024-10-09
D · Potential for more than minimal harm
2024-09-12
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-12
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-10-09
G · Actual harm
2023-07-26
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 2023-08-16
F · Potential for more than minimal harm
2023-07-26
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 2023-08-16
E · Potential for more than minimal harm
2023-07-26
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-08-16
E · Potential for more than minimal harm
2023-07-26
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 2023-08-16
D · Potential for more than minimal harm
2023-07-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-07-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-26
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 2023-08-16
D · Potential for more than minimal harm
2023-07-26
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 2023-08-16
D · Potential for more than minimal harm
2023-07-26
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-16
Penalties and ownership
What sits behind the stars
$15,593
2023-07-26
Fine
Fine · fine $15,593
Fine
Ownership
Ciena Healthcare Management Inc
Operational/Managerial Control · Organization
Khan, Anis
Operational/Managerial Control · Individual
Maze, Rebecca
Operational/Managerial Control · Individual
Qazi, Mohammad
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Regency Manor Nursing & Rehabilitation Center
Utica, MI
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Shelby Crossing Health Campus
Shelby Townhip, MI
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#3
Shelby Health and Rehabilitation Center
Shelby Township, MI
3-star overall rating with 2-star inspections with $41,847 in total fines with 15 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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