Cycle 1
Health 2025-03-05 · Fire 2025-03-05
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Shelby Township, MI
Shelby Health and Rehabilitation Center
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
46100 Schoenherr Road, Shelby Township, MI
(586) 566-1100
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
212
Certified beds
Average residents
178
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Optalis Health & Rehabilitation
Operator or chain grouping
Approved since
1991-07-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
37 facilities
Chain averages 3 overall / 2 health / 3 staffing / 5 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
0.56
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.30
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.92
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.86
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.72
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,582
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9967
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 20.72% · Performance 14.84% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
6.92
Baseline 6.51% · Performance 5.77% · Measure score 6.92 · Achievement 6.92 · Improvement 4.42
Total nurse turnover
0
Baseline 62.76% · Performance 61.79% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.55
Baseline 3.47 hours · Performance 3.23 hours · Measure score 0.55 · Achievement 0.55 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.85% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 827 · Observed rate 11% · Lower 95% interval 8.73% |
| Discharge to community | 54.36% |
50.57%
3.8 pts better
|
No Different than the National Rate · Eligible stays 809 · Observed rate 48.95% · Lower 95% interval 50.25% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 546 · Denominator 546 |
| Falls with major injury | 0.18% |
0.77%
0.6 pts better
|
Numerator 1 · Denominator 546 |
| Discharge self-care score | 66.82% |
53.69%
13.1 pts better
|
Numerator 288 · Denominator 431 |
| Discharge mobility score | 64.97% |
50.94%
14 pts better
|
Numerator 280 · Denominator 431 |
| Pressure ulcers or injuries, new or worsened | 2.38% |
2.29%
0.1 pts worse
|
Numerator 13 · Denominator 546 · Adjusted rate 2.14% |
| Healthcare-associated infections requiring hospitalization | 5.77% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 562 · Observed rate 4.98% · Lower 95% interval 4.09% |
| Staff COVID-19 vaccination coverage | 19.51% |
8.2%
11.3 pts better
|
Numerator 40 · Denominator 205 |
| Staff flu vaccination coverage | 21.18% |
42%
20.8 pts worse
|
Numerator 54 · Denominator 255 |
| Discharge function score | 62.88% |
56.45%
6.4 pts better
|
Numerator 271 · Denominator 431 |
| Transfer of health information to provider | 99.34% |
95.95%
3.4 pts better
|
Numerator 302 · Denominator 304 |
| Transfer of health information to patient | 98.43% |
96.28%
2.2 pts better
|
Numerator 188 · Denominator 191 |
| Resident COVID-19 vaccinations up to date | 25.1% |
25.2%
0.1 pts worse
|
Numerator 66 · Denominator 263 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.5
1.1 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
95.0%
0.4 pts better
|
93.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 87.2% · Q2 95.7% · Q3 98.9% · Q4 100.0% · 4Q avg 95.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.1% |
95.0%
3.9 pts worse
|
95.5%
4.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.3% |
3.1%
3.2 pts worse
|
3.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 7.6% · Q3 4.5% · Q4 6.6% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.0% |
4.1%
2.9 pts worse
|
11.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 14.0% · Q3 3.4% · Q4 2.4% · 4Q avg 7.0% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
5.5%
1.3 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 7.4% · Q3 3.9% · Q4 3.9% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.7% |
19.6%
6.9 pts better
|
19.6%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 13.3% · Q3 11.7% · Q4 13.0% · 4Q avg 12.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.8% |
16.5%
7.7 pts better
|
16.7%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 8.8% · Q3 9.1% · Q4 10.8% · 4Q avg 8.8% · 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 | 17.0% |
13.9%
3.1 pts worse
|
16.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 12.8% · Q3 14.8% · Q4 23.2% · 4Q avg 17.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.2% |
11.7%
3.5 pts better
|
14.9%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 10.5% · Q3 8.2% · Q4 6.8% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
1.7%
0.8 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 2.3% · Q4 4.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.7% |
20.4%
9.3 pts worse
|
19.8%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 31.6% · Q3 22.6% · Q4 30.5% · 4Q avg 29.7% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.6%
0.2 pts better
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 7.1% · Q3 3.8% · Q4 3.9% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.1% |
82.8%
7.3 pts better
|
81.7%
8.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 76.4% · Q2 92.5% · Q3 95.0% · Q4 96.5% · 4Q avg 90.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.0% |
11.5%
6.5 pts better
|
12.0%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.0% · Observed 4.4% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.3%
0.4 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.5% · Q3 2.1% · Q4 0.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.0% |
79.5%
7.5 pts better
|
79.7%
7.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
24.2%
3.6 pts better
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 19.9% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-23 · Fire 2024-01-23
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-10-13 · Fire 2022-10-13
23 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-05
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-04-08
F · Potential for more than minimal harm
2025-03-05
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-04-08
F · Potential for more than minimal harm
2025-03-05
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-04-08
F · Potential for more than minimal harm
2025-03-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-08
F · Potential for more than minimal harm
2025-03-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-04-08
F · Potential for more than minimal harm
2025-03-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-08
E · Potential for more than minimal harm
2025-03-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-03-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-08
E · Potential for more than minimal harm
2025-03-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-04-08
E · Potential for more than minimal harm
2025-03-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-08
E · Potential for more than minimal harm
2025-03-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-08
F · Potential for more than minimal harm
2024-01-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-27
F · Potential for more than minimal harm
2024-01-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-27
F · Potential for more than minimal harm
2024-01-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-07
F · Potential for more than minimal harm
2024-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-27
F · Potential for more than minimal harm
2024-01-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-01-23
K222 · Egress Deficiencies
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 2024-02-27
E · Potential for more than minimal harm
2024-01-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-27
E · Potential for more than minimal harm
2022-10-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-08
D · Potential for more than minimal harm
2022-10-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-08
D · Potential for more than minimal harm
2022-10-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-07-10
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 2025-07-18
G · Actual harm
2025-04-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-04-02
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-01
F · Potential for more than minimal harm
2025-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-01
E · Potential for more than minimal harm
2025-03-05
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 2025-04-01
E · Potential for more than minimal harm
2025-03-05
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-03-05
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 2025-04-01
D · Potential for more than minimal harm
2025-03-05
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-03-05
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 2025-04-01
D · Potential for more than minimal harm
2025-03-05
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 2025-04-01
D · Potential for more than minimal harm
2025-03-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-03-05
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 2025-04-01
D · Potential for more than minimal harm
2025-03-05
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 2025-04-01
D · Potential for more than minimal harm
2025-03-05
F803 · Nutrition and Dietary Deficiencies
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 2025-04-01
G · Actual harm
2024-11-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-02-21
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 2024-03-19
D · Potential for more than minimal harm
2024-02-21
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 2024-03-19
E · Potential for more than minimal harm
2024-01-23
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 2024-02-27
D · Potential for more than minimal harm
2024-01-23
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 2024-02-27
D · Potential for more than minimal harm
2024-01-23
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-01-23
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 2024-02-27
D · Potential for more than minimal harm
2024-01-23
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 2024-02-27
D · Potential for more than minimal harm
2024-01-23
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 2024-02-27
D · Potential for more than minimal harm
2024-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-01-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-01-23
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-01-23
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-27
G · Actual harm
2023-09-27
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 2023-10-10
G · Actual harm
2023-09-18
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 2023-10-05
D · Potential for more than minimal harm
2023-08-17
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 2023-09-13
G · Actual harm
2022-10-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-08
G · Actual harm
2022-10-13
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 2022-11-08
F · Potential for more than minimal harm
2022-10-13
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 2022-11-08
F · Potential for more than minimal harm
2022-10-13
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-11-08
E · Potential for more than minimal harm
2022-10-13
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 2022-11-08
E · Potential for more than minimal harm
2022-10-13
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 2022-11-08
E · Potential for more than minimal harm
2022-10-13
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2022-11-08
D · Potential for more than minimal harm
2022-10-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-11-08
D · Potential for more than minimal harm
2022-10-13
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 2022-11-08
D · Potential for more than minimal harm
2022-10-13
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 2022-11-08
D · Potential for more than minimal harm
2022-10-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-08
D · Potential for more than minimal harm
2022-10-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-08
D · Potential for more than minimal harm
2022-10-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-08
D · Potential for more than minimal harm
2022-10-13
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 2022-11-08
D · Potential for more than minimal harm
2022-10-13
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2022-11-08
D · Potential for more than minimal harm
2022-10-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-11-08
D · Potential for more than minimal harm
2022-10-13
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 2022-11-08
Penalties and ownership
What sits behind the stars
$41,847
2025-03-05
Fine
Fine · fine $41,847
Fine
$0
2025-03-05
Payment Denial
Payment Denial · denial start 2025-04-25 · 6 days
6 day denial
Ownership
Om Holdco, LLC
5% Or Greater Direct Ownership Interest · Organization
Charles A. Dunn Agreement Of Trust 3.14.2001
5% Or Greater Indirect Ownership Interest · Organization
Charles Franklin LLC
5% Or Greater Indirect Ownership Interest · Organization
Checkley, Eric
Operational/Managerial Control · Individual
East West Bank
5% Or Greater Security Interest · Organization
Hemant Shah 2018 Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Merchants Bank Of Indiana
5% Or Greater Mortgage Interest · Organization
Optalis LP Investors 1, LLC
5% Or Greater Indirect Ownership Interest · Organization
Optum Management Solutions. Inc
Operational/Managerial Control · Organization
Paar 108 LLC
5% Or Greater Indirect Ownership Interest · Organization
Parker, Seth
Operational/Managerial Control · Individual
Patel, Rajan
Operational/Managerial Control · Individual
Pinal R. Patel 2017 Irrevocable Trust F/B/O Aarna R. Patel
5% Or Greater Indirect Ownership Interest · Organization
Pinal R. Patel 2017 Irrevocable Trust F/B/O Ansh R. Patel
5% Or Greater Indirect Ownership Interest · Organization
Pinal R. Patel 2020 Irrevocable Family Trust Uad 10-6-2020
5% Or Greater Indirect Ownership Interest · Organization
Rajan G Patel 2020 Irr Fam Tr Uad 12-3-2020
5% Or Greater Indirect Ownership Interest · Organization
Rouse, Tammy
Operational/Managerial Control · Individual
Sharon, Robert
Operational/Managerial Control · Individual
Snw LLC
5% Or Greater Indirect Ownership Interest · Organization
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