Cycle 1
Health 2025-05-22 · Fire 2025-05-22
28 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Waterford, MI
Regency at Waterford
1-star overall rating with 1-star inspections with 27 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1901 N Telegraph Rd, Waterford, MI
(248) 836-1000
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
122
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ciena Healthcare/Laurel Health Care
Operator or chain grouping
Approved since
1976-01-01
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
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
0.71
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.23
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.80
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
4.33
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,282
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.38
Baseline 20.95% · Performance 20.79% · Measure score 1.38 · Achievement 1.38 · Improvement 0
Healthcare-associated infections
0
Baseline 5.10% · Performance 9.78% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.5
Baseline 68.39% · Performance 46.62% · Measure score 4.5 · Achievement 4.17 · Improvement 4.5
Adjusted total nurse staffing
3.79
Baseline 4.21 hours · Performance 4.16 hours · Measure score 3.79 · Achievement 3.79 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.34% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 132 · Observed rate 15.15% · Lower 95% interval 8.78% |
| Discharge to community | 45.53% |
50.57%
5 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 34.09% · Lower 95% interval 32.5% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.07% |
95.27%
3.8 pts better
|
Numerator 106 · Denominator 107 |
| Falls with major injury | 0.93% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 107 |
| Discharge self-care score | 38.33% |
53.69%
15.4 pts worse
|
Numerator 23 · Denominator 60 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 20 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 6.54% |
2.29%
4.2 pts worse
|
Numerator 7 · Denominator 107 · Adjusted rate 4.76% |
| Healthcare-associated infections requiring hospitalization | 9.78% |
7.12%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 17.81% · Lower 95% interval 6.42% |
| Staff COVID-19 vaccination coverage | 5.88% |
8.2%
2.3 pts worse
|
Numerator 12 · Denominator 204 |
| Staff flu vaccination coverage | 20.48% |
42%
21.5 pts worse
|
Numerator 51 · Denominator 249 |
| Discharge function score | 46.67% |
56.45%
9.8 pts worse
|
Numerator 28 · Denominator 60 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 38 · Denominator 38 |
| Transfer of health information to patient | 90.91% |
96.28%
5.4 pts worse
|
Numerator 30 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 30.16% |
25.2%
5 pts better
|
Numerator 19 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.7
1.2 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 4.2 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.5 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
95.0%
2.4 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 95.5% · Q3 98.1% · Q4 98.0% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.2% |
95.0%
0.8 pts worse
|
95.5%
1.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.1%
0.7 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.8% · Q3 2.9% · Q4 2.9% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
4.1%
2.7 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 1.1% · Q3 0.0% · Q4 1.1% · 4Q avg 1.4% |
| 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 1.0% · Q2 2.0% · Q3 6.6% · Q4 5.4% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.8% |
19.6%
0.2 pts worse
|
19.6%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 18.4% · Q3 20.0% · Q4 20.8% · 4Q avg 19.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.1% |
16.5%
1.4 pts better
|
16.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 15.4% · Q3 12.1% · Q4 11.1% · 4Q avg 15.1% · 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 | 28.2% |
13.9%
14.3 pts worse
|
16.3%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.4% · Q2 38.8% · Q3 19.6% · Q4 7.2% · 4Q avg 28.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
11.7%
1.4 pts worse
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 16.3% · Q3 5.6% · Q4 12.4% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
0.9%
1.3 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.1% · Q3 2.6% · Q4 0.7% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.6% |
1.7%
3.9 pts worse
|
1.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.5% · Q3 8.0% · Q4 1.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.1% |
20.4%
0.3 pts better
|
19.8%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 22.3% · Q3 21.1% · Q4 13.0% · 4Q avg 20.1% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
5.6%
1.4 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 8.2% · Q3 8.4% · Q4 5.2% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.1% |
82.8%
4.7 pts worse
|
81.7%
3.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.3% · Q2 73.8% · Q3 79.9% · Q4 82.0% · 4Q avg 78.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
11.5%
1.1 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 15.0% · Expected 13.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.3%
0.7 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.2% · Q3 1.1% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.7% |
79.5%
8.8 pts worse
|
79.7%
9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.8% |
24.2%
6.6 pts worse
|
23.9%
6.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.8% · Observed 42.0% · Expected 32.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-12 · Fire 2024-06-12
22 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-07-27 · Fire 2023-07-27
20 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-26
E · Potential for more than minimal harm
2025-05-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-26
E · Potential for more than minimal harm
2023-07-27
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-08-22
Inspection history
Recent health citations
G · Actual harm
2026-01-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-04
D · Potential for more than minimal harm
2025-09-10
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-10-06
F · Potential for more than minimal harm
2025-05-22
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 2025-06-26
F · Potential for more than minimal harm
2025-05-22
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-06-26
F · Potential for more than minimal harm
2025-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-26
F · Potential for more than minimal harm
2025-05-22
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-06-26
E · Potential for more than minimal harm
2025-05-22
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 2025-06-26
E · Potential for more than minimal harm
2025-05-22
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-06-26
E · Potential for more than minimal harm
2025-05-22
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-26
E · Potential for more than minimal harm
2025-05-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-26
E · Potential for more than minimal harm
2025-05-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-26
E · Potential for more than minimal harm
2025-05-22
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 2025-06-26
E · Potential for more than minimal harm
2025-05-22
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 2025-06-26
E · Potential for more than minimal harm
2025-05-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-26
E · Potential for more than minimal harm
2025-05-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-26
E · Potential for more than minimal harm
2025-05-22
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 2025-06-26
E · Potential for more than minimal harm
2025-05-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-26
E · Potential for more than minimal harm
2025-05-22
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-22
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-22
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 2025-06-26
D · Potential for more than minimal harm
2025-05-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-22
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 2025-06-26
D · Potential for more than minimal harm
2025-05-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-22
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-04-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-08
D · Potential for more than minimal harm
2025-04-10
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 2025-05-08
D · Potential for more than minimal harm
2025-04-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-08
E · Potential for more than minimal harm
2024-10-07
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-07
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 2024-11-07
D · Potential for more than minimal harm
2024-10-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-10-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-06-12
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 2024-07-11
E · Potential for more than minimal harm
2024-06-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-11
E · Potential for more than minimal harm
2024-06-12
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 2024-07-11
E · Potential for more than minimal harm
2024-06-12
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-07-11
E · Potential for more than minimal harm
2024-06-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-07-11
E · Potential for more than minimal harm
2024-06-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-06-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-06-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-06-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-06-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-06-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-06-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-06-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-06-12
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 2024-07-11
D · Potential for more than minimal harm
2024-06-12
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-03-20
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-20
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-11
G · Actual harm
2023-07-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-07-27
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 2023-08-22
E · Potential for more than minimal harm
2023-07-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-07-27
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 2023-08-22
D · Potential for more than minimal harm
2023-07-27
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-27
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 2023-08-22
D · Potential for more than minimal harm
2023-07-27
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 2023-08-22
D · Potential for more than minimal harm
2023-07-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-06-07
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 2023-06-20
L · Immediate jeopardy
2023-03-15
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-04-09
G · Actual harm
2023-03-15
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 2022-10-10
F · Potential for more than minimal harm
2023-03-15
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 2023-04-09
E · Potential for more than minimal harm
2023-03-15
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2023-04-09
D · Potential for more than minimal harm
2023-03-15
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-04-09
D · Potential for more than minimal harm
2023-03-15
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 2023-04-09
D · Potential for more than minimal harm
2023-03-15
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 2023-04-09
D · Potential for more than minimal harm
2023-03-15
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-04-09
C · Minimal harm
2023-03-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-04-09
Penalties and ownership
What sits behind the stars
Ownership
Mohammad A Qazi Living Trust Dated 09/26/97
5% Or Greater Direct Ownership Interest · Organization
Qazi, Mohammad
5% Or Greater Indirect Ownership Interest · Individual
Avery, Scott
Operational/Managerial Control · Individual
Ciena Healthcare Management Inc
Operational/Managerial Control · Organization
Khan, Anis
Operational/Managerial Control · Individual
Patel, Purvaj
Operational/Managerial Control · Individual
Qazi, Mohammad
Operational/Managerial Control · Individual
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