Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ambassador, A Villa Center during CMS and state inspections, most recent first.
Improper Food Storage and Kitchen Sanitation: Surveyors observed prepared rice and gravy stored next to raw ground meat in the walk-in cooler, along with unlabeled and undated lunch meat. In the freezer, an unlabeled bag of turkey legs and an open bag of breaded tilapia were found. The kitchen also had grease, debris, and heavy soil on the fryer, warmer, clean pan shelves, and floors, and the KM stated the fryer had not been cleaned after use and the floors needed a deep clean.
A resident’s readmission paperwork containing diagnosis and other personal information was left face up on a medication cart in a hallway where staff, residents, and visitors could see it. An LPN acknowledged the PHI was visible, the UM said it should have been turned face down or given to another nurse or the UM, and the DON said readmit information should have been given to another nurse. The resident was cognitively intact with a BIMS of 15/15 and had diagnoses including pneumonia, osteomyelitis, paraplegia, CHF, and major depressive disorder, with readmission for sepsis.
Failure to Administer Influenza and Pneumococcal Vaccines: Three residents with significant medical conditions had signed consents for flu and pneumococcal immunizations, but the record showed no evidence the vaccines were administered, refused, or contraindicated. The IP stated they were new to the role and unfamiliar with the vaccine clinic protocol, and the DON reported no knowledge of the missing vaccinations.
Failure to administer COVID-19 vaccines after signed consent: Three residents had signed consents for the COVID-19 vaccine, but there was no record the immunizations were given and no evidence of refusal. The IP stated they were new to the role and unfamiliar with the vaccine clinic protocol, while the DON said they had no knowledge of the missing vaccinations and usually relied on the IP for that information. The affected residents had multiple significant diagnoses, including HF, DM2, schizophrenia, kidney disease, blindness, and encephalopathy.
Insufficient Resident Bedroom Square Footage: The facility failed to provide the required square footage in 32 resident rooms, including multiple-occupancy rooms that measured 141 or 150 square feet while housing two residents. Observation, interview, and record review confirmed the room measurements and occupancy, and no resident concerns or complaints about room size were voiced or noted.
A resident with cognitive impairment and significant care needs was found with a facial skin tear of unknown origin. Staff observed and documented the injury, but did not initiate an investigation or report the incident to the State Agency as required by facility policy. The administrator later acknowledged the failure to report and investigate the injury.
A resident with cognitive impairment and multiple medical conditions was found with a facial skin tear and accused staff of causing the injury. Despite facility policy requiring investigation of injuries of unknown origin, no investigation was conducted or reported to the state agency, and staff could not determine how the injury occurred.
Staff failed to don gowns as part of enhanced barrier precautions during high-contact wound care for two residents with significant wounds, despite clear signage, available PPE, and care plans requiring this practice. Interviews confirmed that the RN and LPNs involved did not follow established protocols for PPE use during these procedures.
The facility failed to post and plan alternate meals, resulting in numerous resident complaints about meal dissatisfaction. Observations revealed that menus lacked alternate meal options, and residents requested alternates from staff. The Dietary Manager was unaware of the alternate options, and a review of Food Committee minutes showed ongoing concerns about the issue. The facility's policy required posting of primary and alternate meals, but this was not followed.
The facility failed to maintain kitchen sanitation and safety, affecting 159 residents. Observations revealed an overflowing grease trap and unclean steam table wells, with employees navigating standing water during meal service. The Dietary Manager admitted the lack of cleaning, and the Corporate Maintenance Director noted a missed follow-up cleaning. Towels and rags were used to manage the water spill.
A resident experienced embarrassment and frustration due to the facility's failure to provide necessary foot care, despite a physician's order for a podiatrist visit. The resident, who required assistance for hygiene, had long, thick toenails and dry skin, which were not addressed by the nursing staff. The DON confirmed the oversight and acknowledged the resident's feelings.
A facility failed to ensure the accuracy of a PASARR form for a resident with mental illness and intellectual disability. The resident was admitted with conditions including Bipolar Disorder and was on antipsychotic medications, yet the form inaccurately stated no mental illness or treatment. The social worker admitted the form was not updated upon admission, leading to potential unmet care needs.
A resident with a history of neuropathy and functional quadriplegia experienced a delay in podiatry services, leading to long toenails and flaky skin buildup. Despite a podiatrist consult order, the resident was not seen, and the DON confirmed the oversight. The facility's foot care policy was not followed, resulting in unmet care needs.
A resident with vascular dementia expressed a desire to be discharged but lacked a legal guardian to assist with the process. Despite the psychiatrist's assessment of the resident's inability to make informed decisions, the social worker did not promptly secure a guardian, delaying discharge planning and causing resident frustration.
The facility did not meet the required minimum square footage per resident in 38 shared rooms, providing less than the mandated 80 square feet per resident. Despite this, residents did not express concerns about the room size affecting their health and safety.
Improper Food Storage and Kitchen Sanitation
Penalty
Summary
Food items were not properly stored in the kitchen during an initial tour with the Kitchen Manager. In the walk-in cooler, a prepared pan of rice and a prepared pan of gravy were stored on the bottom shelf directly next to raw ground meat. The Kitchen Manager stated prepared food should not be stored next to raw food. Also observed were an undated, unlabeled container holding approximately two dozen packages of lunch meat, which the Kitchen Manager identified as bologna and said should be labeled and dated. In the reach-in freezer, surveyors found an undated, unlabeled bag of frozen turkey legs and an open bag of breaded tilapia. The Kitchen Manager stated the items were freezer burned and should be labeled, dated, and thrown out due to freezer burn. Surveyors also observed the deep fryer surface soiled with grease and debris, the exterior of the double-door warmer soiled with grease and food debris, the clean pot and pan shelf area soiled with debris, and heavily soiled flooring under and between the deep fryer and flat grill as well as under the dish machine line. The Kitchen Manager stated the fryer had not been cleaned after the last use and that the line floor and dish room floor needed a deep clean and had not been done lately. The Nursing Home Administrator stated the kitchen should be clean and sanitary and food should be stored properly.
PHI Left Visible on Medication Cart
Penalty
Summary
The facility failed to properly secure protected health information for one resident, R28, when the resident’s personal admission information was observed face up on a medication cart in the 1 north hallway. The information was visible to staff, residents, and visitors walking through the hallway, and it included R28’s diagnosis and other personal information related to the resident’s readmission to the facility. During interview, an LPN acknowledged that the admitting information was left face up on the medication cart and stated it should not have been left where anyone passing by could see it because it contained the resident’s diagnosis and other documentation. The UM said the information may have been left by the admissions department and stated it should have been turned face down or given to another nurse or the UM. The DON stated that readmit information should have been given to another nurse for best practice instead of being placed on the medication cart. Record review showed R28 was initially admitted with pneumonia, osteomyelitis of the vertebra, sacral and sacrococcygeal region, paraplegia, congestive heart failure, and major depressive disorder, and was readmitted with sepsis. The MDS dated 12/4/2025 showed a BIMS score of 15 out of 15, indicating R28 was cognitively intact.
Failure to Administer Ordered Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide Influenza and Pneumococcal immunizations for three residents, R7, R9, and R128, even though signed consents were present in the record. On 01/08/2026, the Infection Preventionist reviewed vaccine consents and administration forms and found that, for three of five residents reviewed, there was no record that the immunizations had been administered. There was also no documentation that the residents refused the vaccines or that the vaccines were contraindicated. Record review showed signed consents dated 10/13/25 for R7 and R9 to receive Influenza and Pneumococcal vaccinations, and a signed consent dated 10/21/25 for R128 to receive the same vaccinations. As of 1/08/2026, there was still no evidence that the vaccines had been given to these residents. R7 had diagnoses including Heart Failure, Type 2 Diabetes, Schizophrenia, Hypertension, Peripheral Vascular Disease, Dysphagia, and Mood Disorder. R9 had diagnoses including End of Stage Heart Failure, Osteomyelitis of the Vertebrae, Hemialgia, Psychotic Disorder, Dysphasia, Hyperlipidemia, Kidney Disease, and Blindness. R128 had diagnoses including Encephalopathy, Diabetes, Heart Failure, Hypertension, Pressure Ulcer, and Kidney Failure. The IP stated they were new in the position, unfamiliar with the vaccine clinic protocol, and had not realized the amount of time required to administer immunizations to facility residents. The DON reported having no knowledge of late or missing vaccinations and stated the IP would usually report this.
Failure to Administer COVID-19 Vaccines After Signed Consent
Penalty
Summary
The facility failed to provide COVID-19 vaccinations for three residents who had signed consents for the vaccine. Record review showed that R7 and R9 each had a signed consent dated 10/13/25 for the COVID-19 vaccination, but there was no record that either immunization had been administered, and there was no evidence that either resident refused the vaccine. R128 also had a signed consent dated 10/21/25 for the COVID-19 vaccination, but there was no record that the immunization had been given. During interview, the Infection Preventionist stated they were new to the position, unfamiliar with the vaccine clinic protocol, and had not realized how much time was required to administer immunizations to residents. The DON reported having no knowledge of late or missing vaccinations and stated that the IP would usually report this information. Record review also identified that R7 had diagnoses including heart failure, type 2 diabetes, schizophrenia, hypertension, peripheral vascular disease, dysphagia, and mood disorder; R9 had diagnoses including end stage heart failure, osteomyelitis of the vertebrae, hemialgia, psychotic disorder, dysphasia, hyperlipidemia, kidney disease, and blindness; and R128 had diagnoses including encephalopathy, diabetes, heart failure, hypertension, pressure ulcer, and kidney failure.
Insufficient Resident Bedroom Square Footage
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple-occupancy bedrooms and at least 100 square feet in single-resident bedrooms, affecting 32 resident rooms identified as 113, 115, 117, 119, 120, 121, 122, 123, 124, 125, 126, 127, 129, 130, 131, 132, 133, 135, 138, 213, 215, 217, 219, 221, 223, 224, 225, 226, 227, 228, 229, and 230. Observation of the rooms and review of facility documentation showed that the listed rooms measured 141 square feet or 150 square feet while housing two residents in each room, with the documentation reflecting bed counts ranging from 1 to 6 in the room entries. During observation and interview of the residents in these rooms, no concerns or complaints were voiced or noted regarding room size.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident to the State Agency, as required by policy and regulation. The resident, who was cognitively impaired and required substantial assistance with activities of daily living, was observed with a dark, faded area on her left cheek. Staff interviews and record reviews revealed that the origin of the injury was unknown, and the resident had accused staff of hitting her. The unit manager observed the injury, reported it to the wound care team, and documented the area as a skin tear, but no investigation was initiated to determine the cause of the injury. Despite the facility's policy requiring immediate reporting and investigation of injuries of unknown origin, the incident was not reported to the State Agency, and no investigation was conducted. The administrator confirmed that the information was not forwarded to them until after the surveyor's inquiry, and acknowledged that the incident should have been reported and investigated. The facility's failure to follow its own policy resulted in the injury going unreported and uninvestigated.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident, resulting in a deficiency related to abuse prevention and reporting. The resident, who was cognitively impaired with a BIMS score of 6/15 and multiple significant medical diagnoses including vascular dementia and chronic kidney disease, was observed with a dark, faded area on her left cheek. The care plan noted a skin tear on the resident's face and documented that the resident had accused staff of hitting her. Despite this, there was no evidence that an investigation was initiated to determine the cause of the injury or to rule out abuse, as required by facility policy. Interviews with the Unit Manager and wound care nurse confirmed that the injury was observed and treated, but no one could explain how the injury occurred. The Acting DON and the administrator both acknowledged that no investigation had been conducted, and the administrator confirmed that the incident should have been investigated and reported to the state agency. The facility's policy mandates prompt and thorough investigation of injuries of unknown origin, but this was not followed in this case.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during wound care for two residents who required such measures due to their medical conditions. Both residents had significant wounds, including stage 3 and stage 4 pressure ulcers, and one had a diagnosis of Fournier gangrene. During wound care observations, signage and PPE supplies were present at the residents' doors, indicating the need for EBP. However, three staff members, including an RN and two LPNs, entered the rooms and performed high-contact wound care without donning gowns as required by the facility's policy and the residents' care plans. Interviews with the involved staff confirmed that gowns were not worn during the procedures, despite their awareness that EBP should be followed for wound care. The residents' care plans specifically documented the need for staff to don gowns and gloves before providing high-contact care activities, and the facility's policy outlined the use of PPE for residents with wounds or indwelling medical devices. The Acting Director of Nursing also confirmed that staff are expected to adhere to these protocols.
Failure to Post and Plan Alternate Meals
Penalty
Summary
The facility failed to post and plan alternate meals and All Time Available food choices, leading to numerous complaints from residents about meal dissatisfaction. During an observation in the kitchen, the posted menu only included a single meal choice without any alternates. This issue was further observed during lunch meal observations on two units, where no alternate meal selections were posted, and residents requested alternates from the nursing staff. These residents were identified as cognitively intact, indicating they were aware of the lack of meal options. Further investigation revealed that the Dietary Manager was unaware of the alternate meal options and could not provide an explanation for the absence of posted alternates. A review of the Food Committee minutes from the Resident Council indicated ongoing concerns about the lack of alternate menus being posted and followed. The facility's policy stated that menus should include primary and alternate meals and be posted in various areas, but this was not adhered to. No additional information was provided to explain why the alternate food choices were not planned and posted.
Facility Fails to Maintain Kitchen Sanitation and Safety
Penalty
Summary
The facility failed to maintain the physical plant and kitchen equipment, specifically the grease trap and steam table wells, which affected 159 of the 170 residents consuming food from the kitchen. During observations, the grease trap drain was seen overflowing with water from the three-compartment sink, and employees were observed standing and sliding through standing water while attempting to complete lunch service. Additionally, the steam table wells were found with old food particles, ash, and burnt residue, indicating they had not been cleaned for an extended period. The Dietary Manager acknowledged the lack of cleaning and was unable to provide a master cleaning schedule upon request. The Corporate Maintenance Director confirmed that the grease trap had been cleaned recently but noted that the scheduled follow-up cleaning did not occur. Towels and old rags were used as a temporary barrier for the spilling water from the grease drain, further highlighting the facility's failure to maintain a safe and sanitary environment in the kitchen.
Failure to Provide Dignified Foot Care
Penalty
Summary
The facility failed to ensure the dignity of a resident, identified as R110, by not providing necessary foot care, which resulted in the resident experiencing embarrassment and frustration. R110, who was cognitively intact and required assistance for hygiene due to functional quadriplegia, reported that a physician had ordered a podiatrist visit at least two months prior to address long, thick toenails and dry skin, but this had not occurred. During an observation, R110's feet were noted to have long, thick, discolored toenails with an unpleasant odor, dry scaly skin, and a broken toenail exposing thick dried skin. The Director of Nursing (DON) confirmed that R110 had not been seen by a podiatrist and could not explain why the nursing staff failed to provide basic foot hygiene. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, which was not upheld in this case. The lack of foot care for R110 was acknowledged by the DON, who agreed that the resident had valid reasons for feeling frustrated and embarrassed.
Inaccurate PASARR Form for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the Preadmission Screening and Annual Resident Review (PASARR) form for a resident with mental illness and intellectual disability. The resident, identified as R57, was admitted with diagnoses including Adjustment Disorder, Bipolar Disorder, Anxiety, and Depression, and was prescribed antipsychotic medications. Despite these conditions, the PASARR form dated 8/21/24 inaccurately indicated that the resident had no mental illness and was not being treated with antidepressants or antipsychotic medications. This discrepancy was discovered during a review of the resident's electronic health record (EHR). The social worker acknowledged the oversight, admitting that the PASARR form had not been updated upon the resident's admission. The facility's guidelines require a preadmission assessment for individuals with mental disorders or intellectual disabilities, and the PASARR process involves completing a Level I screen and implementing Level II recommendations. The failure to update the PASARR form resulted in the potential for unmet care needs related to the resident's intellectual and developmental disabilities.
Failure to Provide Timely Podiatry Services
Penalty
Summary
The facility failed to provide timely podiatry services and treatment for a resident, resulting in the growth of long toenails, flaky skin buildup, and a delay in necessary treatment. The resident, who was cognitively intact and had a history of neuropathy, pressure ulcers, major depressive disorder, and functional quadriplegia, complained of needing a podiatrist appointment for over two months. Observations revealed long, thick, discolored toenails and dry, scaly skin on the resident's feet, with some toes showing signs of discoloration and detachment. The resident's electronic health record indicated a podiatrist consult order dated several months prior, but no evidence of a consult or progress notes was found. The Director of Nursing confirmed the oversight and could not explain why the resident was not seen by the podiatrist during the monthly visit. The facility's foot care policy stated that residents should receive foot care in accordance with professional standards and assistance with specialist appointments, which was not adhered to in this case.
Failure to Obtain Legal Guardian Delays Resident Discharge
Penalty
Summary
The facility failed to provide medically related social services for a resident, resulting in a delay in obtaining a legal guardian necessary for discharge planning. The resident, who was admitted with vascular dementia and demonstrated moderate cognitive impairment, expressed a desire to be discharged but lacked a legal guardian to facilitate the process. Despite the psychiatrist's assessment indicating the resident's inability to make informed decisions, the social worker did not take timely action to secure a guardian. The social worker acknowledged the oversight in not consistently monitoring the situation and initiating the legal process to obtain a guardian. The nursing home administrator confirmed that the social worker did not attempt to secure a legal guardian promptly, which hindered the decision-making process for the resident's discharge or placement. This inaction led to the resident's frustration and a delay in addressing their discharge needs.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, affecting 38 rooms. Observations and record reviews revealed that these rooms did not meet the regulatory requirement of at least 80 square feet per resident in shared rooms. The rooms in question were observed to have dimensions that provided less than the required space per resident, with each room accommodating two residents despite having insufficient square footage. Interviews with residents occupying these rooms indicated that they did not express concerns regarding the room size in relation to their health and safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverview Health & Rehab Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Hamilton Nursing Home | 1 mi | ★★★★★ | 10 | 0 |
| Qualicare Nursing Home | 1.2 mi | ★★★★★ | 8 | 0 |
| Regency At Chene | 1.9 mi | ★★★★★ | 1 | 0 |
| Mission Point Nursing & Physical Rehab Center Of D | 2.2 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.