Cycle 1
Health 2024-12-17 · Fire 2024-12-17
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Rochester Hills, MI
Bellbrook
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
873 W Avon Rd, Rochester Hills, MI
(248) 656-3239
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
36
Certified beds
Average residents
34
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Trinity Health
Operator or chain grouping
Approved since
1988-07-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 3 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
1.23
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.77
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.36
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.33
CMS adjusted RN staffing hours
Adjusted total hours
4.47
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,413
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9930
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.36
Baseline 17.75% · Performance 19.87% · Measure score 3.36 · Achievement 3.36 · Improvement 0
Healthcare-associated infections
3.78
Baseline 5.39% · Performance 6.71% · Measure score 3.78 · Achievement 3.78 · Improvement 0
Total nurse turnover
4.55
Baseline 40.48% · Performance 45.10% · Measure score 4.55 · Achievement 4.55 · Improvement 0
Adjusted total nurse staffing
4.35
Baseline 3.92 hours · Performance 4.31 hours · Measure score 4.35 · Achievement 4.35 · Improvement 1.60
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.46% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 381 · Observed rate 11.81% · Lower 95% interval 10.12% |
| Discharge to community | 70.23% |
50.57%
19.7 pts better
|
Better than the National Rate · Eligible stays 395 · Observed rate 66.58% · Lower 95% interval 65.51% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 189 · Denominator 189 |
| Falls with major injury | 0.53% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 189 |
| Discharge self-care score | 57.69% |
53.69%
4 pts better
|
Numerator 90 · Denominator 156 |
| Discharge mobility score | 55.13% |
50.94%
4.2 pts better
|
Numerator 86 · Denominator 156 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 189 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.71% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 216 · Observed rate 5.09% · Lower 95% interval 4.36% |
| Staff COVID-19 vaccination coverage | 4.74% |
8.2%
3.5 pts worse
|
Numerator 10 · Denominator 211 |
| Staff flu vaccination coverage | 24% |
42%
18 pts worse
|
Numerator 54 · Denominator 225 |
| Discharge function score | 63.46% |
56.45%
7 pts better
|
Numerator 99 · Denominator 156 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 121 · Denominator 121 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 64 · Denominator 64 |
| Resident COVID-19 vaccinations up to date | 32.53% |
25.2%
7.3 pts better
|
Numerator 27 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.0%
5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.1%
3.1 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.1%
4.1 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
5.5%
1.2 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.5% |
19.6%
15.9 pts worse
|
19.6%
15.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.9% |
16.5%
9.6 pts better
|
16.7%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.8% |
11.7%
3.1 pts worse
|
14.9%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.8% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
1.7%
1.2 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
20.4%
4.1 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
5.6%
3 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
82.8%
10 pts better
|
81.7%
11.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.0% · Q2 88.5% · Q3 95.7% · Q4 97.9% · 4Q avg 92.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
11.5%
6 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 4.9% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.3%
1 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.0% · Q4 0.6% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.3% |
79.5%
6.8 pts better
|
79.7%
6.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
24.2%
0.7 pts worse
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 21.3% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-10 · Fire 2024-01-10
1 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-12-14 · Fire 2022-12-14
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-17
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-01-09
F · Potential for more than minimal harm
2024-01-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-07
F · Potential for more than minimal harm
2024-01-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-07
E · Potential for more than minimal harm
2024-01-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-07
E · Potential for more than minimal harm
2024-01-10
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-02-07
F · Potential for more than minimal harm
2022-12-14
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-01-19
F · Potential for more than minimal harm
2022-12-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-01-19
F · Potential for more than minimal harm
2022-12-14
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-01-19
F · Potential for more than minimal harm
2022-12-14
K162 · Construction Deficiencies
Fire Safety
Have a combustible roofing system that meets safety standards.
Corrected 2023-01-19
F · Potential for more than minimal harm
2022-12-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-01-19
F · Potential for more than minimal harm
2022-12-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-19
F · Potential for more than minimal harm
2022-12-14
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-01-19
F · Potential for more than minimal harm
2022-12-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-19
F · Potential for more than minimal harm
2022-12-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-01-19
F · Potential for more than minimal harm
2022-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-19
F · Potential for more than minimal harm
2022-12-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-19
F · Potential for more than minimal harm
2022-12-14
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-01-19
F · Potential for more than minimal harm
2022-12-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-19
E · Potential for more than minimal harm
2022-12-14
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-01-19
E · Potential for more than minimal harm
2022-12-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-01-19
E · Potential for more than minimal harm
2022-12-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-19
E · Potential for more than minimal harm
2022-12-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-19
E · Potential for more than minimal harm
2022-12-14
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-19
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-17
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-17
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-17
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-01-10
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-07
F · Potential for more than minimal harm
2022-12-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-17
E · Potential for more than minimal harm
2022-12-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-01-17
D · Potential for more than minimal harm
2022-12-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-17
Penalties and ownership
What sits behind the stars
Ownership
Che Trinity Inc
5% Or Greater Indirect Ownership Interest · Organization
Trinity Continuing Care Services
5% Or Greater Direct Ownership Interest · Organization
Capasso, John
Corporate Director · Individual
Chandler, Alicia
Corporate Director · Individual
Chandler, Alicia
W-2 Managing Employee · Individual
Delaney, Elisabeth
W-2 Managing Employee · Individual
Handy, Joanne
Corporate Director · Individual
Henkel, Arthur
Corporate Director · Individual
Jones, Beverly
Corporate Director · Individual
Kastner, Steven
Corporate Director · Individual
Kastner, Steven
Corporate Officer · Individual
Kastner, Steven
W-2 Managing Employee · Individual
Latovick, Pamela
W-2 Managing Employee · Individual
Lunsmann, Kathleen
Corporate Director · Individual
Mcpherson, Mark
Corporate Director · Individual
Minnix, William
Corporate Director · Individual
Poole, Lejon
Corporate Director · Individual
Tag, Anna Marie
Corporate Director · Individual
Villarruel, Antonia
Corporate Director · Individual
Wells, Dewayne
Corporate Director · Individual
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#2
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#3
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