Cycle 1
Health 2025-08-06 · Fire 2025-08-06
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Chelsea, MI
Chelsea Retirement Community
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
805 W Middle Street, Chelsea, MI
(734) 475-8633
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
83
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.73
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.14
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.38
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.87
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.85
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
4.48
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,920
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.94
Composite VBP score used to determine payment impact.
Payment multiplier
1.0004
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.06
Baseline 25.51% · Performance 22.49% · Measure score 3.06 · Achievement 0 · Improvement 3.06
Healthcare-associated infections
7.19
Baseline 5.98% · Performance 5.69% · Measure score 7.19 · Achievement 7.19 · Improvement 2.51
Total nurse turnover
4.44
Baseline 46.51% · Performance 45.54% · Measure score 4.44 · Achievement 4.44 · Improvement 0
Adjusted total nurse staffing
4.09
Baseline 4.23 hours · Performance 4.24 hours · Measure score 4.09 · Achievement 4.09 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.73% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 428 · Observed rate 8.18% · Lower 95% interval 8.01% |
| Discharge to community | 66.31% |
50.57%
15.7 pts better
|
Better than the National Rate · Eligible stays 458 · Observed rate 63.76% · Lower 95% interval 62.38% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 253 · Denominator 253 |
| Falls with major injury | 0.79% |
0.77%
About the same
|
Numerator 2 · Denominator 253 |
| Discharge self-care score | 63.18% |
53.69%
9.5 pts better
|
Numerator 127 · Denominator 201 |
| Discharge mobility score | 71.14% |
50.94%
20.2 pts better
|
Numerator 143 · Denominator 201 |
| Pressure ulcers or injuries, new or worsened | 1.58% |
2.29%
0.7 pts better
|
Numerator 4 · Denominator 253 · Adjusted rate 1.91% |
| Healthcare-associated infections requiring hospitalization | 5.69% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 259 · Observed rate 3.47% · Lower 95% interval 3.73% |
| Staff COVID-19 vaccination coverage | 2.72% |
8.2%
5.5 pts worse
|
Numerator 7 · Denominator 257 |
| Staff flu vaccination coverage | 30.77% |
42%
11.2 pts worse
|
Numerator 116 · Denominator 377 |
| Discharge function score | 70.15% |
56.45%
13.7 pts better
|
Numerator 141 · Denominator 201 |
| Transfer of health information to provider | 96% |
95.95%
About the same
|
Numerator 48 · Denominator 50 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 174 · Denominator 174 |
| Resident COVID-19 vaccinations up to date | 64% |
25.2%
38.8 pts better
|
Numerator 80 · Denominator 125 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.7
0.7 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.5 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 4.4% |
3.1%
1.3 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.3% · Q3 4.5% · Q4 6.8% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
4.1%
3.5 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
5.5%
2.2 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.3% · Q3 2.9% · Q4 0.0% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.7% |
19.6%
9.9 pts better
|
19.6%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 10.0% · Q3 8.6% · Q4 10.5% · 4Q avg 9.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.5% |
16.5%
7 pts better
|
16.7%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 9.1% · Q3 10.3% · Q4 13.8% · 4Q avg 9.5% · 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 | 17.3% |
13.9%
3.4 pts worse
|
16.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.6% |
11.7%
3.1 pts better
|
14.9%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 13.2% · Q3 8.6% · Q4 5.4% · 4Q avg 8.6% · 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 · 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 with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.4% |
20.4%
11 pts worse
|
19.8%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 30.1% · Q3 31.5% · Q4 37.8% · 4Q avg 31.4% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.6%
2.1 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 7.3% · Q3 4.7% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
82.8%
16.7 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 100.0% · Q3 99.6% · Q4 98.9% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.1% |
11.5%
0.4 pts better
|
12.0%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 10.3% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.5% · Q3 0.0% · Q4 0.4% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.3% |
79.5%
18.8 pts better
|
79.7%
18.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.8% |
24.2%
2.4 pts better
|
23.9%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 20.6% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-08 · Fire 2024-08-08
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-05-25 · Fire 2023-05-25
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-09-11
E · Potential for more than minimal harm
2025-08-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-11
F · Potential for more than minimal harm
2024-08-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-08
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 2024-09-13
E · Potential for more than minimal harm
2024-08-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-13
E · Potential for more than minimal harm
2023-05-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-25
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-25
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-25
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 2023-06-30
E · Potential for more than minimal harm
2023-05-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-25
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-25
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-25
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2023-06-30
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-06
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 2025-09-11
D · Potential for more than minimal harm
2025-08-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-09-11
D · Potential for more than minimal harm
2024-08-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-13
F · Potential for more than minimal harm
2023-05-25
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 2023-06-20
D · Potential for more than minimal harm
2023-05-25
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-25
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-25
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-25
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-25
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-09
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-06-02
Penalties and ownership
What sits behind the stars
Ownership
Carlson, Kalen
W-2 Managing Employee · Individual
Dolan-Greene, Margaret
Corporate Director · Individual
Fetyko, Stephen
Corporate Officer · Individual
Fetyko, Stephen
W-2 Managing Employee · Individual
Fritz, Michael
Corporate Director · Individual
Huntington Bank
5% Or Greater Mortgage Interest · Organization
Ives, Harlem
Corporate Director · Individual
Lundy, Richard
Corporate Director · Individual
Maag, Nicole
W-2 Managing Employee · Individual
Michigan Strategic Fund
5% Or Greater Mortgage Interest · Organization
Musolf, Karen
Contracted Managing Employee · Individual
Nixon, John
Corporate Director · Individual
Shore, Michael
Corporate Director · Individual
Shores, Jennifer
W-2 Managing Employee · Individual
Umrcph, Inc.
Operational/Managerial Control · Organization
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#3
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