Midland, MI

Brittany Manor

2-star overall rating with 2-star inspections with abuse icon flag with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

3615 East Ashman Street, Midland, MI

(989) 631-0460

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

138

Certified beds

Average residents

91

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Ciena Healthcare/Laurel Health Care

Operator or chain grouping

Approved since

1976-05-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

84 facilities

Chain averages 3 overall / 3 health / 3 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

0.84

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.76

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

2.44

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

4.04

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.60

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

3.69

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.54

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.92

CMS adjusted RN staffing hours

Adjusted total hours

4.46

CMS adjusted total nurse staffing hours

Case-mix index

1.24

Higher values indicate more complex resident acuity

RN turnover

40%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

47%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,648

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

32.15

Composite VBP score used to determine payment impact.

Payment multiplier

0.9869

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.11

Baseline 19.61% · Performance 20.46% · Measure score 2.11 · Achievement 2.11 · Improvement 0

Healthcare-associated infections

0

Baseline 5.24% · Performance 8.19% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

7.62

Baseline 62.89% · Performance 32.53% · Measure score 7.62 · Achievement 7.62 · Improvement 7.48

Adjusted total nurse staffing

3.13

Baseline 3.52 hours · Performance 3.97 hours · Measure score 3.13 · Achievement 3.13 · Improvement 1.47

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.63%	10.72% 1.1 pts better	No Different than the National Rate · Eligible stays 168 · Observed rate 8.33% · Lower 95% interval 6.46%
Discharge to community	53.17%	50.57% 2.6 pts better	No Different than the National Rate · Eligible stays 162 · Observed rate 48.15% · Lower 95% interval 44.56%
Medicare spending per beneficiary	0.87	1.02 0.2 pts better
Drug regimen review with follow-up	99.13%	95.27% 3.9 pts better	Numerator 114 · Denominator 115
Falls with major injury	2.61%	0.77% 1.8 pts worse	Numerator 3 · Denominator 115
Discharge self-care score	59.55%	53.69% 5.9 pts better	Numerator 53 · Denominator 89
Discharge mobility score	71.91%	50.94% 21 pts better	Numerator 64 · Denominator 89
Pressure ulcers or injuries, new or worsened	2.61%	2.29% 0.3 pts worse	Numerator 3 · Denominator 115 · Adjusted rate 3.93%
Healthcare-associated infections requiring hospitalization	8.19%	7.12% 1.1 pts worse	No Different than the National Rate · Eligible stays 103 · Observed rate 9.71% · Lower 95% interval 5.39%
Staff COVID-19 vaccination coverage	8.33%	8.2% 0.1 pts better	Numerator 10 · Denominator 120
Staff flu vaccination coverage	37.93%	42% 4.1 pts worse	Numerator 66 · Denominator 174
Discharge function score	68.54%	56.45% 12.1 pts better	Numerator 61 · Denominator 89
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 37 · Denominator 37
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 51 · Denominator 51
Resident COVID-19 vaccinations up to date	15%	25.2% 10.2 pts worse	Numerator 9 · Denominator 60

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.6	1.7 0.9 pts worse	1.9 0.7 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 3.8 · Expected 2.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.7	1.5 1.2 pts worse	1.8 0.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.3 · Expected 2.0 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.6%	95.0% 2.6 pts better	93.4% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.4% · Q3 95.2% · Q4 97.0% · 4Q avg 97.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.7%	95.0% 0.3 pts worse	95.5% 0.8 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.7%
Percentage of long-stay residents experiencing one or more falls with major injury	3.9%	3.1% 0.8 pts worse	3.3% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.1% · Q3 3.2% · Q4 6.1% · 4Q avg 3.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.5%	4.1% 3.6 pts better	11.4% 10.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5%
Percentage of long-stay residents who lose too much weight	3.8%	5.5% 1.7 pts better	5.4% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 1.9% · Q3 0.0% · Q4 1.9% · 4Q avg 3.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	29.0%	19.6% 9.4 pts worse	19.6% 9.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 30.9% · Q3 25.0% · Q4 25.9% · 4Q avg 29.0%
Percentage of long-stay residents who received an antipsychotic medication	11.8%	16.5% 4.7 pts better	16.7% 4.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 17.9% · Q3 7.5% · Q4 7.1% · 4Q avg 11.8% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	20.4%	13.9% 6.5 pts worse	16.3% 4.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 37.8% · Q2 25.7% · Q3 14.4% · Q4 8.3% · 4Q avg 20.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	19.0%	11.7% 7.3 pts worse	14.9% 4.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 17.6% · Q3 18.2% · Q4 14.3% · 4Q avg 19.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.1%	0.9% 0.2 pts worse	1.0% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 1.1% · Q4 1.5% · 4Q avg 1.1% · 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 · Q1 0.0% · Q2 3.2% · Q3 3.4% · Q4 4.8% · 4Q avg 2.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	18.2%	20.4% 2.2 pts better	19.8% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 21.9% · Q3 22.9% · Q4 12.5% · 4Q avg 18.2%
Percentage of long-stay residents with pressure ulcers	10.3%	5.6% 4.7 pts worse	5.1% 5.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 13.1% · Q3 10.4% · Q4 6.4% · 4Q avg 10.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	93.7%	82.8% 10.9 pts better	81.7% 12 pts better	Short Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 94.1% · Q3 94.9% · Q4 88.2% · 4Q avg 93.7%
Percentage of short-stay residents who had an outpatient emergency department visit	12.1%	11.5% 0.6 pts worse	12.0% 0.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 12.7% · Expected 11.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.8%	1.3% 0.5 pts better	1.6% 0.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.7% · Q3 0.7% · Q4 0.7% · 4Q avg 0.8% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	81.6%	79.5% 2.1 pts better	79.7% 1.9 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 81.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.6%	24.2% 2.6 pts better	23.9% 2.3 pts better	Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 22.9% · Expected 25.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-27 · Fire 2025-03-27

6 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-04-04 · Fire 2024-04-04

12 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-06-08 · Fire 2023-06-08

2 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-27

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-04-26

F · Potential for more than minimal harm 2025-03-27

K111 · Construction Deficiencies

Fire Safety

Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

Corrected 2025-04-26

F · Potential for more than minimal harm 2025-03-27

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-04-26

F · Potential for more than minimal harm 2025-03-27

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-04-26

F · Potential for more than minimal harm 2025-03-27

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-04-26

E · Potential for more than minimal harm 2025-03-27

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-04-26

E · Potential for more than minimal harm 2025-03-27

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-04-26

E · Potential for more than minimal harm 2025-03-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-04-26

E · Potential for more than minimal harm 2025-03-27

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-04-26

F · Potential for more than minimal harm 2024-04-04

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-05-10

F · Potential for more than minimal harm 2024-04-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-10

E · Potential for more than minimal harm 2024-04-04

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 2024-05-10

F · Potential for more than minimal harm 2023-06-08

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-06-21

F · Potential for more than minimal harm 2023-06-08

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-06-21

E · Potential for more than minimal harm 2023-06-08

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2023-06-21

Inspection history

Recent health citations

G · Actual harm 2025-11-06

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-10-28

D · Potential for more than minimal harm 2025-10-08

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-09-15

E · Potential for more than minimal harm 2025-03-27

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-04-26

E · Potential for more than minimal harm 2025-03-27

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-27

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-04-26

D · Potential for more than minimal harm 2025-03-27

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-04-26

G · Actual harm 2025-01-23

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-02-18

G · Actual harm 2025-01-23

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-02-18

E · Potential for more than minimal harm 2024-04-04

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2024-05-03