Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 4 | 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 | — | 16 | 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 August 2026) and official state health department websites.