Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Qualicare Nursing Home during CMS and state inspections, most recent first.
Inactive Water Management Plan and Unused Fixtures: The facility failed to have an active plan to reduce the risk of legionella and other OPPP. Surveyors observed unused kitchen faucets with no water flow, discolored water from domestic water fixtures above tub faucets in two tub rooms, and water spraying from a vacuum breaker and multiple nozzles in one tub room. The MS stated flushing occurred once a month for three minutes in intended fixtures, was unaware of the kitchen faucets, and confirmed the domestic water fixture above the tub was not flushed when the tub fixture was flushed.
Premises Not Maintained in Clean and Repaired Condition: Multiple areas were observed with leaks, loose fixtures, exposed rough edges, missing wall tiles, dust accumulation, and soiled toilet surfaces. The kitchen 3-compartment sink was dripping onto the floor, the biohazard room sink foot pedals leaked when engaged, and the maintenance supervisor was unaware of some of the issues. The CDM said the sink problem had been entered into the maintenance repair system, but could not say how long it had been documented.
Delayed PASSAR II Follow-Up: The facility failed to ensure timely follow-up of a PASSAR referral and Level II evaluation for one resident with metabolic encephalopathy, vascular dementia, delusional disorder, and major depressive disorder. The resident had a BIMS of 8/15, and the SW acknowledged the PASSAR II should have been initiated when the resident was admitted. The NHA stated PASSARs are expected for residents with mental health diagnoses and psych meds, and the Level 1 screening indicated a PASSAR II was needed.
A resident with severe cognitive impairment and multiple diagnoses was not assisted with eating in a dignified manner. Staff members were observed standing over the resident while feeding, citing a lack of chairs as the reason. This action was contrary to the facility's policy on resident dignity, which emphasizes respecting and enhancing each resident's dignity and individuality.
The facility failed to ensure that two residents had formulated an Advance Directive upon admission, which is necessary to grant or withhold life-sustaining treatment according to their wishes. One resident, who was alert and oriented, confirmed that the social worker discussed the advance directive only recently, despite multiple admissions. Another resident, who was cognitively intact, did not have a signed advance directive in their electronic medical record, despite care conferences taking place. This oversight could potentially result in the residents receiving unwanted medical treatment.
A facility failed to secure medications during administration when an RN left medications unattended on a cart while attending to another resident. The medications, intended for a resident who was sleeping, were not stored in a locked drawer as required by policy. The unit manager and DON confirmed the breach in protocol.
A facility failed to properly store medications during a medication pass, as an RN left medications unattended on a cart while attending to another resident. The medications, intended for a sleeping resident, were not secured in a locked drawer as required by the facility's policy. The unit manager, DON, and NHA confirmed the RN's failure to adhere to the medication administration policy.
A resident with intact cognition and a diagnosis of pneumothorax left the facility unnoticed for six and a half hours. The resident exited through a first-floor window, and staff failed to account for the resident during shift changes. The facility's elopement policy, which requires regular rounds, was not adequately followed, leading to the incident.
A resident experienced verbal abuse from a CNA during care, where the CNA used derogatory language. The incident was reported and substantiated by the facility's investigation. The resident, with moderately impaired cognitive function, reported feeling safe despite the incident. The abuse was confirmed by the resident's roommate and an LPN, who intervened and reported the incident to the Nursing Home Administrator.
The facility failed to provide scheduled showers for a resident who required extensive assistance with bathing. Despite being cognitively intact and having a care plan in place, the resident missed three out of seven scheduled shower days. The DON confirmed that the resident should have received the showers as scheduled.
The facility failed to timely initiate a wound consult order for a resident at risk for pressure ulcers, resulting in a potential delay in treatment. Despite recommendations from a physician and the facility's own protocols, the consult order was not placed in the EMR, leading to a delay in addressing the resident's pressure ulcer.
The facility failed to provide proper indwelling catheter care and document urine output for a resident with sepsis, urinary tract infection, and bacteremia. Multiple instances of missing documentation for catheter care and urine output were found across various shifts in September. The DON confirmed that undocumented care is assumed not to have been done.
Inactive Water Management Plan and Unused Fixtures
Penalty
Summary
The facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). During observation, a faucet on the back wall of the cookline in the kitchen was turned on and no water came out, and a faucet on the side of the three-compartment sink was also observed in the kitchen and identified by the CDM as not used by kitchen staff. In the first-floor tub room, a domestic water fixture above the tub faucet released slightly discolored water for a few seconds before running clear, and in the second-floor tub room, the domestic water fixture above the tub faucet released yellow discolored water for a few seconds before running clear. During interview, the Maintenance Supervisor stated flushing water fixtures was a control measure in low flow areas and said there were no low flow areas other than the tub rooms. He stated flushing occurred once a month for three minutes at each intended fixture. He was unaware of the kitchen faucets and did not know whether they were cut off six inches from the main line or turned off at the fixture, which could allow stagnant water in the line. On a follow-up tour, water was observed spraying out of the vacuum breaker and multiple nozzles when the first-floor tub room domestic water fixture was turned on, and the Maintenance Supervisor stated that the domestic water fixture above the tub is not flushed when the tub fixture is flushed. The facility's Water Management Plan, last reviewed 2/11/26, identified tub rooms as an area where Legionella could grow and spread and stated that because it is not in use at this time, it should be flushed at least once a month.
Premises Not Maintained in Clean and Repaired Condition
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises. During observations on 02/24/2026 and 02/25/2026, the kitchen three-compartment sink was seen draining sanitizer while the discharge pipe dripped onto the floor, and later a steady stream of water was observed dripping from the same sink onto the floor and traveling into the floor drain. The Certified Dietary Manager stated the problem had already been entered into the maintenance repair system but could not say how long it had been documented. The first-floor biohazard room was observed with foot pedals that activated the sink faucet leaking when engaged, and the maintenance supervisor later stated they were unaware of that leak. Additional observations showed multiple areas in disrepair or not maintained in a clean condition. The second-floor shower room had a missing fixture cover with rough edges exposed, and a hole in the wall with two missing tiles that exposed a water line and shutoff valve. The third-floor tub room toilet had dried yellow droplets on the rim and a brown stain along the back inside bowl. The third-floor shower room had a loose hand sink faucet and a soiled air duct with an accumulation of dust. In the first-floor tub room, water sprayed out of the vacuum breaker and nozzles when the domestic water fixture was turned on. The maintenance supervisor stated housekeeping was responsible for cleaning the toilet in the third-floor tub room and that the rooms were only used for resident care.
Delayed PASSAR II Follow-Up
Penalty
Summary
The facility failed to ensure timely follow-up of a PASSAR referral and Level II evaluation for one resident, R13, out of two residents reviewed for PASSAR requirements. R13 was admitted with diagnoses of metabolic encephalopathy, vascular dementia, delusional disorder, and major depressive disorder. A quarterly MDS dated 2/11/2026 showed a BIMS score of 8 out of 15, indicating moderate cognitive impairment. During interview, the Social Worker acknowledged that R13 should have been referred for a PASSAR II when admitted in August 2025. The Nursing Home Administrator stated that PASSARs are expected for residents with mental health diagnoses and those receiving psych meds, and that Social Services is expected to provide adequate follow-up and documentation to ensure they are current. The Level 1 pre-admission screening completed on 8/4/2025 indicated that a PASSAR II needed to be completed for R13, and the facility policy stated that Level 1 screenings and related communication are to be maintained in the resident's electronic medical record.
Failure to Assist Resident with Eating in a Dignified Manner
Penalty
Summary
The facility failed to ensure a resident was assisted with eating in a dignified manner, as observed during meal times. On two separate occasions, staff members were seen standing over the resident while assisting with feeding, which is contrary to the facility's policy on resident dignity. The staff members, identified as CENA D and CENA C, did not use a chair while assisting the resident, citing a lack of available chairs as the reason for standing. Both staff members acknowledged that standing over someone while they eat would not be comfortable for them personally. The resident involved, identified as R12, was admitted with diagnoses including Parkinson's Disease, bipolar disorder, anxiety, and dementia, and was noted to have severe cognitive impairment and dependency for all activities of daily living. The resident's care plan indicated the need for assistance with meals, including one-on-one feeding as needed. The facility's policy on resident dignity emphasizes the importance of respecting and enhancing each resident's dignity and individuality, which was not adhered to in this instance.
Failure to Ensure Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that two residents, R45 and R55, had formulated an Advance Directive upon admission, which is necessary to grant or withhold life-sustaining treatment according to their wishes. R55, who was alert and oriented, confirmed that the social worker discussed the advance directive only recently, despite being admitted and readmitted multiple times. The clinical record for R55 showed no documentation of an advance directive or code status, and the facility's policy indicated that if an advance directive is not completed, the resident defaults to a Full Code status. The Social Service Director acknowledged that the advance directive should have been completed upon admission. Similarly, R45, who was cognitively intact, did not have a signed advance directive in their electronic medical record. The Social Worker confirmed the absence of an advance directive and noted that it should have been reviewed quarterly during care conferences. The Nursing Home Administrator also confirmed the lack of a signed advance directive, despite two care conferences having taken place. This oversight could potentially result in the resident receiving unwanted medical treatment.
Failure to Secure Medications During Administration
Penalty
Summary
The facility failed to ensure proper storage of medications during a medication pass, as observed with a registered nurse (RN) on the second floor. The RN left medications unattended in a cup on top of the medication cart while attending to another resident's vitals down the hallway. Upon returning, the RN prepared and administered medications to another resident, leaving the initial medications unsecured. The medications left unattended included Aspirin, Farxiga, Ferrous sulfate, Folic Acid, Sitagliptin, Multivitamin, Zoloft, and Metoprolol. The unit manager, an LPN, observed the unsecured medications and advised the RN that they should not have been left on top of the cart. The Director of Nursing later confirmed that the medications should have been placed in a locked drawer and reoffered to the resident once they were awake. The Nursing Home Administrator also stated that the RN was expected to follow the medication passing policy, which requires medications to be prepared immediately before administration.
Improper Storage of Medications During Administration
Penalty
Summary
The facility failed to ensure proper storage of medications during a medication pass on the second floor. A Registered Nurse (RN) was observed leaving medications unattended on top of a medication cart while attending to another resident. The medications, intended for a resident who was sleeping, included Aspirin, Farxiga, Ferrous sulfate, Folic Acid, Sitagliptin, Multivitamin, Zoloft, and Metoprolol. The RN admitted to leaving the medications unsecured and acknowledged that they should have been locked in a drawer. The unit manager, an LPN, confirmed that the medications should not have been left unsecured on the cart. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) both stated that the RN should have followed the facility's medication administration policy, which requires medications to be prepared immediately before administration. The incident highlights a failure to adhere to the policy, resulting in a deficiency related to the improper storage of medications.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident, resulting in the resident leaving the facility without staff knowledge for six and a half hours. The resident, who had intact cognition with a perfect score on the Brief Interview for Mental Status, was admitted with a diagnosis of pneumothorax. On the day of the incident, a physical therapist reported the resident missing when attempting to provide therapy services. A code was called, and a search was conducted throughout the facility, but the resident could not be located. It was later discovered that the resident had left the facility at 3:30 AM through a first-floor window, as confirmed by video footage. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that the midnight nurse did not properly report the resident's presence at shift change, assuming the resident was in the bathroom. The facility's elopement policy requires rounds to be made at the beginning of the shift, at mealtimes, and at the end of the shift, which were not adequately followed. The DON acknowledged that adequate supervision was not provided, and the NHA emphasized the importance of frequent rounds to ensure residents are accounted for.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to prevent verbal abuse towards a resident, identified as R801, by a Certified Nursing Assistant (CNA A). The incident occurred during the delivery of care when CNA A called R801 a 'mean hateful bitch.' This incident was reported to the State Agency as a Facility Reported Incident (FRI) and was later substantiated by the facility's investigation. The resident, R801, who has multiple diagnoses including adjustment disorder and is legally blind, was found to have moderately impaired cognitive function. Despite the incident, R801 reported feeling safe at the facility. The incident was corroborated by R801's roommate, who heard the verbal abuse but did not see the perpetrator due to a closed curtain. Additionally, a Licensed Practical Nurse (LPN C) confirmed hearing the verbal abuse and intervened by removing CNA A from the situation. The LPN reported the incident to the Nursing Home Administrator immediately. The facility's investigation confirmed the verbal abuse, leading to the termination of CNA A's employment. The report indicates that there was no change or decline in R801's medical or emotional status following the incident.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers for a resident (R101) who required extensive one-person assistance with bathing. R101, who was admitted with diagnoses including osteoarthritis, muscle weakness, and difficulty walking, had a BIMS score of 15/15, indicating cognitive intactness. According to the MDS dated 6/13/23, R101 required supervision with showers. The ADL care plan initiated on 6/8/23 specified that R101 needed extensive assistance with bathing. However, a review of the shower/bathing documentation from 6/8/23 through 7/7/23 revealed that R101 missed three out of seven scheduled shower days. The DON confirmed that R101 should have received the scheduled showers and expected all residents to receive showers at least twice a week.
Failure to Timely Initiate Wound Consult Order
Penalty
Summary
The facility failed to initiate a wound consult order in a timely manner for a resident (R101) who was at risk for pressure ulcers. R101, who had a BIMS score of 15/15 indicating cognitive intactness, was admitted with medical diagnoses including Type 2 Diabetes Mellitus, local infection of the skin and subcutaneous tissue, and difficulty walking. The resident required moderate assistance with bed mobility and maximal assistance with transfers. Despite being at risk for pressure ulcers and having a pressure-reducing device for their bed, the facility did not place a wound care consult order in the EMR for the duration of R101's stay. The resident's pressure ulcer care plan, initiated on 7/3/23, included a directive to consult a wound clinic as ordered, but no such order was found in the EMR. A physician's progress note dated 6/30/23 recommended a wound care consult, but the consult documentation was not completed until 7/6/23, indicating a delay in treatment initiation. The Director of Nursing (DON) confirmed that the facility's expectations for handling new wounds include assessing the wound, notifying the physician and dietitian, and implementing preventative measures. The DON stated that a wound care consult order should be placed when a new wound is identified. However, in this case, the facility did not follow these protocols, resulting in a potential delay in the treatment of R101's pressure ulcer. The deficiency was identified during a review of R101's EMR and interviews with facility staff.
Failure to Document Catheter Care and Urine Output
Penalty
Summary
The facility failed to provide proper indwelling catheter care and document urine output for a resident (R100) who was admitted with medical diagnoses including sepsis, urinary tract infection, and bacteremia. The resident had a BIMS score indicating moderate cognitive impairment and was dependent on toilet hygiene. The care plan for R100 included specific orders for catheter care and urine output recording per shift, starting from 9/6/23. However, a review of the Treatment Administration Record (TAR) revealed multiple instances where catheter care and urine output were not documented across various shifts on different dates in September 2023. During an interview on 3/15/23, the Director of Nursing (DON) confirmed that it was the expectation for nursing staff to document catheter care and urine output as ordered. The DON stated that if the care is not documented, it is assumed that it was not done. This lack of documentation indicates a failure to adhere to the prescribed care plan for R100, potentially compromising the resident's health and safety.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Hamilton Nursing Home | 0.2 mi | ★★★★★ | 10 | 0 |
| Riverview Health & Rehab Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Ambassador, A Villa Center | 1.2 mi | ★★★★★ | 8 | 0 |
| Regency At Chene | 1.4 mi | ★★★★★ | 1 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 1.5 mi | ★★★★★ | 26 | 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.