Cycle 1
Health 2025-06-25 · Fire 2025-06-25
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Detroit, MI
West Oaks Senior Care & Rehab Center
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
22355 W Eight Mile Rd, Detroit, MI
(313) 255-6450
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nexcare Health Systems
Operator or chain grouping
Approved since
1978-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 4 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
0.40
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.87
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,285
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.17
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.03
Baseline 6.54% · Performance 6.93% · Measure score 3.03 · Achievement 3.03 · Improvement 0
Total nurse turnover
1.69
Baseline 59.30% · Performance 56.76% · Measure score 1.69 · Achievement 1.69 · Improvement 0.24
Adjusted total nurse staffing
2.53
Baseline 4.10 hours · Performance 3.80 hours · Measure score 2.53 · Achievement 2.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.14% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 5.56% · Lower 95% interval 6.44% |
| Discharge to community | 50.34% |
50.57%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 38.71% · Lower 95% interval 33.7% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 39 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 9 · Denominator 21 |
| Discharge mobility score | 47.62% |
50.94%
3.3 pts worse
|
Numerator 10 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 39 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 12% · Lower 95% interval 3.52% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 145 · Denominator 145 |
| Staff flu vaccination coverage | 22.42% |
42%
19.6 pts worse
|
Numerator 37 · Denominator 165 |
| Discharge function score | 52.38% |
56.45%
4.1 pts worse
|
Numerator 11 · Denominator 21 |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 32% |
25.2%
6.8 pts better
|
Numerator 8 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.4 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| 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 95.5% · Q2 95.2% · Q3 96.5% · Q4 100.0% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.1%
1.6 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.2% · Q3 1.2% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
4.1%
0.7 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.7% · Q3 4.2% · Q4 5.1% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
5.5%
2.6 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 7.9% · Q3 7.6% · Q4 11.7% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
19.6%
4 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 16.9% · Q3 15.0% · Q4 12.8% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.9% |
16.5%
2.6 pts better
|
16.7%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 13.3% · Q3 15.0% · Q4 14.1% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.7% |
0.1%
1.6 pts worse
|
0.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.2% · Q3 1.2% · Q4 2.3% · 4Q avg 1.7% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.9% |
13.9%
7 pts better
|
16.3%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 10.2% · Q3 0.0% · Q4 3.7% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.6% |
11.7%
7.1 pts better
|
14.9%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.9% · Q3 2.8% · Q4 2.9% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
1.7%
0.2 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.9% · Q3 1.2% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 1.9% |
20.4%
18.5 pts better
|
19.8%
17.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
5.6%
0.8 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 5.3% · Q3 5.4% · Q4 6.4% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.8% |
82.8%
15 pts worse
|
81.7%
13.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 54.5% · Q2 62.5% · Q3 72.8% · Q4 81.2% · 4Q avg 67.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
11.5%
1.4 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 14.3% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 68.1% |
79.5%
11.4 pts worse
|
79.7%
11.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 68.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
24.2%
1.1 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 28.6% · Expected 26.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2023-07-27 · Fire 2023-07-27
9 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-15
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-10-16
F · Potential for more than minimal harm
2025-06-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-07-14
F · Potential for more than minimal harm
2025-06-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-07-14
F · Potential for more than minimal harm
2025-06-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-14
F · Potential for more than minimal harm
2025-06-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-14
F · Potential for more than minimal harm
2024-06-27
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-06-27
K321 · Smoke Deficiencies
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 2024-07-12
F · Potential for more than minimal harm
2024-06-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-06-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-06-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-30
F · Potential for more than minimal harm
2024-06-27
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-06-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-06-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-06-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-06-27
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 2024-07-12
F · Potential for more than minimal harm
2023-07-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-16
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 2025-12-17
D · Potential for more than minimal harm
2025-06-25
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 2025-07-14
D · Potential for more than minimal harm
2025-06-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-04-08
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 2025-04-06
D · Potential for more than minimal harm
2024-12-05
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 2024-12-23
D · Potential for more than minimal harm
2024-05-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-29
E · Potential for more than minimal harm
2023-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-12-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-09-18
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 2023-09-25
F · Potential for more than minimal harm
2023-07-27
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-07-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-08-15
D · 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 2023-08-15
D · Potential for more than minimal harm
2023-07-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-27
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-27
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-08-15
Penalties and ownership
What sits behind the stars
Ownership
Nexcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Branscum, James
5% Or Greater Indirect Ownership Interest · Individual
Eisenberg, Leo
5% Or Greater Indirect Ownership Interest · Individual
Gardner, Rosemary
W-2 Managing Employee · Individual
Nexcare Health Systems, LLC
Operational/Managerial Control · Organization
Perry, Michael
Operational/Managerial Control · Individual
Robin Eisenberg 2014 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Sangster, Todd
Corporate Officer · Individual
Wronski, Frank
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Regency Heights-Detroit
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
#2
The Villa at Great Lakes Crossing
Detroit, MI
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Beaconshire Nursing Centre
Detroit, MI
1-star overall rating with 2-star inspections with $33,243 in total fines with 10 recent health deficiencies with 26 fire-safety deficiencies in the latest cycle
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