Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 St. Joseph's, A Villa Center during CMS and state inspections, most recent first.
Two residents had late or missing MDS assessments. One resident’s Medicare 5-day MDS was marked incomplete and never batched, with no other MDS assessments submitted. Another resident with CKD had an incomplete discharge return anticipated/PPS assessment that was never batched, and multiple other MDS assessments were submitted late with coding warnings. The MDS Nurse stated both residents were Medicaid only and did not need the other assessments.
Failure to Apply Ordered Protective Appliances: A resident with PVD and polyneuropathy had an active order for a padded boot on the R foot and a leg rest pad to protect the RLE while up in a wheelchair. The resident, who had impaired cognition and needed staff assistance for mobility and transfers, was observed multiple times without either protective appliance, and the resident stated they still felt they needed them. The DOR said they would have to check into it, and the DON stated the order remained active because the resident still needed the interventions.
Accident Hazard at Bedside: A resident with dementia, impaired cognition, and a history of falls was observed in bed with a torn, curled bedside floor mat next to the bed. The resident's care plan included a landing mat at bedside, and the NHA stated fall mats are to be checked daily.
A resident with heart failure, pulmonary hypertension, and acute respiratory failure with hypoxia had active orders for both Trelegy Ellipta and Advair Diskus, even though Trelegy was to be stopped when Advair started. The MAR showed both inhalers were given over several days, and the UM confirmed both inhalers were present in the med cart while an RN stated both were administered. The facility policy on Medication Orders did not address unnecessary medications.
Inaccurate medical record documentation for a resident with metabolic encephalopathy and obstructive/reflux uropathy. The chart stated an indwelling catheter was in place, but the resident reported it had been removed and they were voiding with a urinal; the UM confirmed the resident pulled out the catheter and would not allow reinsertion, and the DON acknowledged the catheter was no longer in place.
Insufficient room space was identified in multiple resident rooms after observation and review of bed count information showed 16 rooms with 4 beds each that did not meet the required 80 sq ft per resident. The Administrator stated a remodeling plan was in process and that residents who voiced concern were offered a larger room if available.
A resident with multiple psychiatric diagnoses and a history of behavioral incidents, including emotional distress and repeated calls to emergency services, did not receive appropriate mental health assessment, medication management, or psychological therapy. Despite documented needs and facility policy requirements, there was no evidence of ongoing psychiatric follow-up, behavioral monitoring, or referrals for professional mental health services.
The facility failed to maintain sanitary conditions in the kitchen, affecting all residents consuming food. Observations included an empty paper towel dispenser, undated cheddar cheese, a cooler at 49°F, and unlabeled beverages in the freezer. The Dietary Manager attributed these issues to housekeeping, frequent refrigerator use, and employee actions.
A resident with Osteoarthritis, requiring assistance with ADLs, was observed with unmanaged chin and matted hair, expressing dissatisfaction with their appearance. Despite the facility's policy on personal hygiene, there was no documentation of refusal for care, indicating a failure to provide timely assistance.
The facility failed to provide the required 80 square feet per resident in 16 rooms, accommodating four residents in rooms measuring only 282 to 286 square feet. Efforts were being made to reduce room occupancy, with some residents transferring to other facilities. Additionally, the C-wing nursing unit had cleanliness issues, with dirty air vents and a stained light cover, which were acknowledged by the Maintenance Director and attributed to oversight in cleaning procedures.
Late and Missing MDS Assessments
Penalty
Summary
The facility failed to timely submit MDS assessments for two residents, R24 and R53, out of three residents reviewed for resident assessment. During the recertification survey, the resident assessment task was triggered because an MDS assessment was overdue by 120 days. R24 was admitted with a diagnosis of intervertebral disc disorder with radiculopathy in the [NAME] region. Review of R24’s record showed a Medicare 5-day MDS assessment marked incomplete, with the assessment never added to a batch, and no other MDS assessments were submitted for the resident. The tracking record showed A0410 coded 3, indicating the unit was Medicare and/or Medicaid certified bed. R53 was admitted and later readmitted with a diagnosis of chronic kidney disease. Review of R53’s record showed an incomplete MDS assessment dated 8/2/24 for discharge return anticipated/end of PPS Part A stay that was never added to a batch. The record also showed multiple MDS submissions for R53, including entry tracking, combined admission and 5-day PPS, PPS discharge, SCSA, discharge return anticipated, quarterly, and annual assessments, several of which were accepted late and included warnings such as late completion more than 14 days after the ARD. When asked about the late assessments, the MDS Nurse stated that both residents were Medicaid only and did not need the other assessments.
Failure to Apply Ordered Protective Appliances
Penalty
Summary
The facility failed to apply protective appliances according to the physician’s order for one resident with Peripheral Vascular Disease and Polyneuropathy. The active order dated 1/16/2026 directed that the resident be out of bed daily in a wheelchair to tolerance with a padded boot on the right foot and a leg rest pad to protect the right lower extremity. The resident’s most recent MDS showed a BIMS score of 12/15, indicating impaired cognition, and the resident also required staff assistance for bed mobility and transfers. On 3/25/2026, the resident was observed up in a wheelchair at 9:52 AM, in the therapy room at 11:44 AM, and in a chair eating lunch at 12:58 PM, and no padded boot or leg rest pad was observed during any of these observations. The resident stated they had used to wear a boot on the right foot but had not worn it in quite some time, and also stated they still felt they needed the boot and leg rest pad. The DOR stated the resident had improved and they would have to check into the boot and leg rest pad, while the DON stated therapy had evaluated the resident and the order remained active because the resident still needed the interventions in place.
Accident Hazard at Bedside
Penalty
Summary
The facility failed to ensure one resident's environment was free from accident hazards when R58 was observed lying in bed with the right side of the bed against the wall and the left side open to the room, while a floor mat next to the bed appeared torn in the middle and curled up at the ends. R58's record showed a diagnosis of dementia with severity, without behavioral disturbance, psychotic disturbance, and mood disturbance, and the MDS noted moderately impaired cognition and the need for some assistance with activities of daily living. The resident's progress note documented a prior incident in which the resident was found on the floor in front of her wheelchair and stated, 'I don't know,' when asked where she had been trying to go. The care plan identified a history of actual falls related to behaviors, impulsiveness, poor balance, dementia, poor communication/comprehension, psychoactive drug use, unsteady gait, and encephalopathy, and included a landing mat at bedside when in bed. The Nursing Home Administrator stated that fall mats are to be checked daily.
Unnecessary Duplicate Inhaler Therapy
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary medications. The resident was admitted with diagnoses of heart failure, pulmonary hypertension, and acute respiratory failure with hypoxia, and the most recent MDS showed a BIMS score of 15/15. Medication orders showed active orders for both Trelegy Ellipta, to be discontinued when Fluticasone/Salmeterol arrived, and Advair Diskus for asthma. The March 2026 MAR showed both inhalers were administered from March 19 through March 25. During interview, the Unit Manager stated Trelegy had been ordered as a therapeutic interchange until Advair could be started and confirmed the order indicated Trelegy should be stopped when Advair was started. The Unit Manager also observed both inhalers in the medication cart, and an RN stated both inhalers were administered to the resident that morning. The facility policy titled Medication Orders did not address unnecessary medications.
Inaccurate Medical Record Documentation for Indwelling Catheter
Penalty
Summary
The facility failed to maintain accurate information in the medical record for one resident. R57 was admitted with diagnoses of metabolic encephalopathy and obstructive and reflux uropathy, and the most recent MDS showed a BIMS score of 6/15 with impaired cognition and need for staff assistance with bed mobility and transfers. During observation, R57 was sitting up in a wheelchair and stated they were doing much better after completing therapy and hoped to discharge home soon. The medical record contained a provider note stating that an indwelling catheter was in place and that the patient should be monitored closely for urinary retention, but R57 reported that the catheter was no longer in place and that they had been voiding with a urinal for about 2 weeks. The Unit Manager reported that R57 had pulled out the catheter and would not allow reinsertion, and that the physician had been notified. The DON stated providers should be reviewing their notes for accuracy and confirmed that R57 no longer had the indwelling catheter in place.
Insufficient Room Space in Multiple-Occupancy Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple resident rooms, affecting 16 of 49 multiple-occupancy rooms identified as #112, 113, 114, 115, 116, 118, 119, 120, 122, 123, 124, 210, 213, 214, 215, and 216. On observation and review of the facility bed count information, these rooms were documented at 282 square feet with 4 beds each in rooms 112 through 213, and 286 square feet with 4 beds each in rooms 214 through 216, which did not meet the minimum space requirement. When questioned about the insufficient square footage, the Administrator stated that a remodeling plan was in process and that, in the interim, residents who expressed concern were offered a larger room if available.
Failure to Provide Adequate Mental Health Assessment and Services
Penalty
Summary
A resident with diagnoses including Bipolar Disorder, Mood Disorder, Adjustment Disorder with mixed anxiety and depressed mood, and Cerebral Palsy was observed to be emotionally distressed, crying, and expressing concerns about not receiving adequate mental health care or psychological services. The resident reported a decline in mobility and stated they were not receiving any psychological support in the facility. Review of the resident's medical record confirmed the absence of prescribed antidepressants, mood stabilizers, or antipsychotic medications, despite the documented psychiatric diagnoses. The last psychological service provided was over six months prior, and there was no evidence of ongoing therapy or psychiatric follow-up. Progress notes and interviews revealed multiple behavioral incidents, including the resident calling 911 for non-emergent situations, verbal aggression, and refusal of medications and care. Despite these behaviors, there was no documentation of behavioral monitoring or interventions in the CNA records, and no referrals for psychiatric or psychological services were made after the last visit. The DON and Social Services Director confirmed the lack of psychotropic medications and therapy, and the Nurse Practitioner stated that no referral had been received for further psychiatric evaluation or treatment. Facility policy required ongoing assessment and care planning for residents with behavioral health needs, including documentation and referral for professional services as indicated. However, the facility failed to provide adequate assessment, treatment, and services to support the resident's mental and psychosocial well-being, as evidenced by the lack of medication management, therapy, and behavioral interventions for a resident with significant psychiatric diagnoses and documented behavioral concerns.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect all 142 residents consuming food from the kitchen. During an initial tour, it was observed that the paper towel dispenser by the handwashing sink at the kitchen entrance was empty, violating the 2017 FDA Food Code requirement for hand drying provisions. Additionally, a pack of cheddar cheese in the walk-in cooler was found without a date, and the smaller cooler was operating at a temperature of 49 degrees Fahrenheit, which is above the recommended temperature for food safety. Furthermore, three individual beverages were found in the freezer without any labeling, which were indicated to be employee beverages. The Dietary Manager (DM) was interviewed and indicated that housekeeping was responsible for replacing the paper towels. The DM suggested that the label on the cheddar cheese might have fallen off and attributed the high refrigerator temperature to frequent opening and closing by staff. The DM also confirmed that the unlabeled beverages should not have been placed in the freezer. These observations and interviews highlight the facility's failure to adhere to professional standards for food storage, preparation, and sanitation as outlined in the FDA Food Code.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance with Activities of Daily Living (ADLs) for a resident, identified as R140, who was observed with thick chin hair and matted hair on multiple occasions. R140, who was admitted with a diagnosis of Osteoarthritis and required assistance with ADLs, expressed dissatisfaction with their appearance, stating that their facial hair was 'out of control' and that they had not refused to have it cut. Despite this, there was no documentation in R140's medical record indicating any refusal to have their chin hair trimmed. The Unit Manager confirmed that shaving should be addressed during personal hygiene care, and the facility's policy on ADLs emphasized the importance of maintaining personal hygiene, including shaving facial hair unless otherwise requested by the resident. However, the assigned Certified Nursing Assistant (CNA) for R140's care did not address the issue, and there was no record of any refusal by R140 to receive this care. This oversight indicates a failure to adhere to the facility's policy and ensure the resident's personal hygiene needs were met.
Deficiencies in Resident Room Space and Cleanliness
Penalty
Summary
The facility was found to have two deficient practices during a survey. The first deficiency involved the failure to provide the required 80 square feet of living space per resident in 16 out of 49 multiple resident rooms. Observations and interviews revealed that rooms #112, 113, 114, 115, 116, 118, 119, 120, 122, 123, 124, 210, 213, 214, 215, and 216 did not meet this requirement, as they were accommodating four residents in rooms measuring only 282 to 286 square feet. The Maintenance Director acknowledged that some rooms had been converted to accommodate fewer residents, and the Nursing Home Administrator stated that efforts were being made to eliminate four-person rooms, with some residents being assisted in transferring to other facilities due to space concerns. The second deficiency was related to the cleanliness and homelike environment of the C-wing nursing unit. During an observation, the air vents in the C-wing medication storage room were found to be covered in layers of dirt and dust, and a dried reddish stain was noted on a light cover in the C-wing hallway. The Maintenance Director admitted that the cleaning of these areas might have been overlooked. The Nursing Home Administrator confirmed that environmental services were responsible for cleaning these areas according to the facility's cleaning policy, which includes dusting high surfaces such as vents and light fixtures.
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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 Hamtramck
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Point Nursing & Physical Rehabilitation Ce | 1.7 mi | ★★★★★ | 26 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 1.9 mi | ★★★★★ | 4 | 0 |
| The Villa At The Park | 2.7 mi | ★★★★★ | 9 | 0 |
| The Orchards At Samaritan | 2.8 mi | ★★★★★ | 5 | 0 |
| Qualicare Nursing Home | 3.1 mi | ★★★★★ | 8 | 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.