8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Detroit, MI
4-star overall rating with 3-star inspections with $19,321 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
19100 West Seven Mile Road, Detroit, MI
(313) 533-5002
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
168
Certified beds
Average residents
153
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ciena Healthcare/Laurel Health Care
Operator or chain grouping
Approved since
1986-07-01
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
RN hours / resident day
0.41
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.19
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
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.68
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Program rank
7,057
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9862
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.89
Baseline 22.73% · Performance 21.93% · Measure score 0.89 · Achievement 0 · Improvement 0.89
Healthcare-associated infections
4.34
Baseline 10.38% · Performance 7.78% · Measure score 4.34 · Achievement 0 · Improvement 4.34
Total nurse turnover
4.07
Baseline 43.61% · Performance 47.03% · Measure score 4.07 · Achievement 4.07 · Improvement 0
Adjusted total nurse staffing
3.05
Baseline 3.84 hours · Performance 3.95 hours · Measure score 3.05 · Achievement 3.05 · Improvement 0.06
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.01% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 96 · Observed rate 21.88% · Lower 95% interval 9.44% |
| Discharge to community | 44.96% |
50.57%
5.6 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 29.33% · Lower 95% interval 33.6% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.51% |
95.27%
1.8 pts worse
|
Numerator 72 · Denominator 77 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 77 |
| Discharge self-care score | 56.1% |
53.69%
2.4 pts better
|
Numerator 23 · Denominator 41 |
| Discharge mobility score | 51.22% |
50.94%
0.3 pts better
|
Numerator 21 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 77 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.78% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 11.54% · Lower 95% interval 4.76% |
| Staff COVID-19 vaccination coverage | 8.15% |
8.2%
About the same
|
Numerator 19 · Denominator 233 |
| Staff flu vaccination coverage | 15.56% |
42%
26.4 pts worse
|
Numerator 47 · Denominator 302 |
| Discharge function score | 48.78% |
56.45%
7.7 pts worse
|
Numerator 20 · Denominator 41 |
| Transfer of health information to provider | 96.77% |
95.95%
0.8 pts better
|
Numerator 30 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 14.58% |
25.2%
10.6 pts worse
|
Numerator 7 · Denominator 48 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 2.3 · Expected 3.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.5
1.1 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 3.8 · Expected 2.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
95.0%
4.8 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.7% |
95.0%
1.3 pts worse
|
95.5%
1.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.2% |
3.1%
2.9 pts better
|
3.3%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
4.1%
0.8 pts worse
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.1% · Q3 6.6% · Q4 3.2% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
5.5%
0.1 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 7.0% · Q3 4.9% · Q4 3.0% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
19.6%
5 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 15.5% · Q3 15.3% · Q4 13.4% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
16.5%
11.3 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 7.4% · Q3 4.2% · Q4 5.0% · 4Q avg 5.2% · 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 | 2.9% |
13.9%
11 pts better
|
16.3%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.0% · Q3 2.8% · Q4 3.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.2% |
11.7%
9.5 pts better
|
14.9%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.4% · Q3 1.9% · Q4 0.0% · 4Q avg 2.2% · 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 0.0% · Q3 0.6% · Q4 0.6% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.3% |
20.4%
14.1 pts better
|
19.8%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 10.0% · Q3 6.4% · Q4 5.5% · 4Q avg 6.3% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
5.6%
2.7 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 9.2% · Q3 8.3% · Q4 8.1% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
82.8%
10.6 pts better
|
81.7%
11.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 92.9% · Q3 96.8% · Q4 90.0% · 4Q avg 93.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
11.5%
3.6 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 9.6% · Expected 13.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.8% |
79.5%
11.3 pts better
|
79.7%
11.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
24.2%
3.4 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 27.4% · Expected 31.4% · Used in QM five-star |
Survey summary
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Rights (4 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-30
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-30
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-30
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-30
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 2025-06-30
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-02
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-21
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-01
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-02
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-05-02
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-02
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-31
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-07-10
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 2024-05-02
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-05-02
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-05-02
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-02
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-02
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-02
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-05-02
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-02
Fire Safety
Meet other general requirements.
Corrected 2023-03-21
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-21
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-21
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-21
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 2023-03-21
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 2023-03-21
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 2023-03-21
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-03-21
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-21
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-21
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-21
Inspection history
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-06-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-30
Health
Keep all essential equipment working safely.
Corrected 2025-06-30
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 2025-06-30
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-30
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-30
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-06-30
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-30
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-20
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-02
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-02
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-05-02
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-05-02
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-02
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 2024-05-02
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 2024-05-02
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-02
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-02
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-02
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-01-04
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-01-04
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-21
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
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
Health
Keep all essential equipment working safely.
Corrected 2023-03-21
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 2023-03-21
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
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-21
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-21
Penalties and ownership
Fine · fine $19,321
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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