Cycle 1
Health 2025-03-19 · Fire 2025-03-19
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Dearborn, MI
CH Rehab & Nurs Cnt - Commons Dearborn
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
16391 Rotunda Dr, Dearborn, MI
(313) 253-9700
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
196
Certified beds
Average residents
95
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Corewell Health
Operator or chain grouping
Approved since
1991-04-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 4 overall / 4 health / 5 staffing / 5 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
0.53
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.22
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.12
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
2.87
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.43
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.05
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,682
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9920
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.76
Baseline 24.49% · Performance 21.31% · Measure score 3.76 · Achievement 0 · Improvement 3.76
Healthcare-associated infections
5.86
Baseline 8.34% · Performance 6.21% · Measure score 5.86 · Achievement 5.43 · Improvement 5.86
Total nurse turnover
3.35
Baseline 43.21% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0
Adjusted total nurse staffing
2.62
Baseline 3.83 hours · Performance 3.82 hours · Measure score 2.62 · Achievement 2.62 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.6% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 257 · Observed rate 8.17% · Lower 95% interval 6.77% |
| Discharge to community | 63.15% |
50.57%
12.6 pts better
|
Better than the National Rate · Eligible stays 260 · Observed rate 57.69% · Lower 95% interval 56.83% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 83.43% |
95.27%
11.8 pts worse
|
Numerator 146 · Denominator 175 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 175 |
| Discharge self-care score | 46.34% |
53.69%
7.3 pts worse
|
Numerator 57 · Denominator 123 |
| Discharge mobility score | 65.04% |
50.94%
14.1 pts better
|
Numerator 80 · Denominator 123 |
| Pressure ulcers or injuries, new or worsened | 1.14% |
2.29%
1.2 pts better
|
Numerator 2 · Denominator 175 · Adjusted rate 1.21% |
| Healthcare-associated infections requiring hospitalization | 6.21% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 165 · Observed rate 4.24% · Lower 95% interval 4.09% |
| Staff COVID-19 vaccination coverage | 3.33% |
8.2%
4.9 pts worse
|
Numerator 5 · Denominator 150 |
| Staff flu vaccination coverage | 78.95% |
42%
37 pts better
|
Numerator 150 · Denominator 190 |
| Discharge function score | 58.54% |
56.45%
2.1 pts better
|
Numerator 72 · Denominator 123 |
| Transfer of health information to provider | 97.86% |
95.95%
1.9 pts better
|
Numerator 137 · Denominator 140 |
| Transfer of health information to patient | 96.67% |
96.28%
0.4 pts better
|
Numerator 29 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 18.89% |
25.2%
6.3 pts worse
|
Numerator 17 · Denominator 90 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
95.0%
3.9 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.7% · Q4 98.1% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
5.5%
1.9 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 8.8% · Q3 11.8% · Q4 2.2% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.0% |
19.6%
15.6 pts better
|
19.6%
15.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 2.9% · Q3 2.9% · Q4 4.4% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
16.5%
1.5 pts better
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 17.9% · Q3 19.2% · Q4 7.9% · 4Q avg 15.0% · 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 | 2.4% |
13.9%
11.5 pts better
|
16.3%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.6% |
11.7%
2.1 pts better
|
14.9%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 6.1% · Q3 3.0% · Q4 11.4% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.4% |
20.4%
9 pts better
|
19.8%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 12.6% · Q3 4.9% · Q4 10.4% · 4Q avg 11.4% |
| Percentage of long-stay residents with pressure ulcers | 14.9% |
5.6%
9.3 pts worse
|
5.1%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 16.1% · Q3 14.4% · Q4 14.8% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.3% |
82.8%
11.5 pts better
|
81.7%
12.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 95.0% · Q3 94.8% · Q4 91.3% · 4Q avg 94.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
11.5%
4.2 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 6.9% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.3%
0.2 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.4% · Q3 0.5% · Q4 2.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.8% |
79.5%
13.3 pts better
|
79.7%
13.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.1% |
24.2%
0.9 pts worse
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 26.0% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2024-02-29
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-12-15 · Fire 2022-12-15
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-04-04
F · Potential for more than minimal harm
2024-02-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-06
F · Potential for more than minimal harm
2024-02-29
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-02-29
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-02-29
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-02-29
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-02-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-02-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-05
F · Potential for more than minimal harm
2022-12-15
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-02-17
F · Potential for more than minimal harm
2022-12-15
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-02-17
F · Potential for more than minimal harm
2022-12-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-02-17
F · Potential for more than minimal harm
2022-12-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-13
F · Potential for more than minimal harm
2022-12-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-17
F · Potential for more than minimal harm
2022-12-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-02-17
F · Potential for more than minimal harm
2022-12-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-17
E · Potential for more than minimal harm
2022-12-15
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-02-17
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-19
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 2025-04-11
D · Potential for more than minimal harm
2025-03-19
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 2025-04-11
D · Potential for more than minimal harm
2025-03-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-11
G · Actual harm
2024-02-29
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 2024-03-26
F · Potential for more than minimal harm
2024-02-29
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 2024-03-26
F · Potential for more than minimal harm
2024-02-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-26
E · Potential for more than minimal harm
2024-02-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-26
E · Potential for more than minimal harm
2024-02-29
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-03-26
D · Potential for more than minimal harm
2024-02-29
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 2024-03-26
D · Potential for more than minimal harm
2024-02-29
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 2024-03-26
Penalties and ownership
What sits behind the stars
$0
2024-02-29
Payment Denial
Payment Denial · denial start 2024-03-27 · 33 days
33 day denial
Ownership
Oakwood Healthcare Inc
5% Or Greater Direct Ownership Interest · Organization
Beaumont Health
5% Or Greater Indirect Ownership Interest · Organization
Corewell Health
5% Or Greater Indirect Ownership Interest · Organization
Corewell Health
Operational/Managerial Control · Organization
Cox, Matthew
Operational/Managerial Control · Individual
Cox, Matthew
Corporate Officer · Individual
Flores, Christopher
Corporate Director · Individual
Freese Decker, Christina
Corporate Officer · Individual
Mahmood, Ali
Operational/Managerial Control · Individual
Marlow, Tamila
Operational/Managerial Control · Individual
Oakwood Healthcare Inc
Operational/Managerial Control · Organization
Pakkala, Karen
Operational/Managerial Control · Individual
Pakkala, Karen
Corporate Director · Individual
Pakkala, Karen
Corporate Officer · Individual
Rumsey, Dean
Operational/Managerial Control · Individual
Sadler, Kelli
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Allegria Village
Dearborn, MI
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Fairlane Senior Care and Rehab Center
Detroit, MI
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Optalis Health and Rehabilitation of Allen Park
Allen Park, MI
3-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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