Clinton Township, MI

Church of Christ Care Center

2-star overall rating with 2-star inspections with $23,595 in total fines with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

23575 15 Mile Rd, Clinton Township, MI

(586) 791-2470

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

129

Certified beds

Average residents

110

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2006-02-24

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

0.40

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.96

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

2.10

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

3.46

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.36

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

3.23

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.31

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.40

CMS adjusted RN staffing hours

Adjusted total hours

3.48

CMS adjusted total nurse staffing hours

Case-mix index

1.36

Higher values indicate more complex resident acuity

RN turnover

46%

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

10,828

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

Performance score

18.95

Composite VBP score used to determine payment impact.

Payment multiplier

0.9821

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 19.85% · Performance 24.96% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0

Baseline 7.73% · Performance 9.36% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

5.53

Baseline 46.79% · Performance 41.07% · Measure score 5.53 · Achievement 5.53 · Improvement 2.11

Adjusted total nurse staffing

2.05

Baseline 4.31 hours · Performance 3.66 hours · Measure score 2.05 · Achievement 2.05 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.67%
10.72%
1.1 pts better
No Different than the National Rate · Eligible stays 124 · Observed rate 7.26% · Lower 95% interval 5.96%
Discharge to community 52.73%
50.57%
2.2 pts better
No Different than the National Rate · Eligible stays 123 · Observed rate 44.72% · Lower 95% interval 43.41%
Medicare spending per beneficiary 0.86
1.02
0.2 pts better
Drug regimen review with follow-up 95.35%
95.27%
0.1 pts better
Numerator 82 · Denominator 86
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 86
Discharge self-care score 44.26%
53.69%
9.4 pts worse
Numerator 27 · Denominator 61
Discharge mobility score 42.62%
50.94%
8.3 pts worse
Numerator 26 · Denominator 61
Pressure ulcers or injuries, new or worsened 1.16%
2.29%
1.1 pts better
Numerator 1 · Denominator 86 · Adjusted rate 0.9%
Healthcare-associated infections requiring hospitalization 9.36%
7.12%
2.2 pts worse
No Different than the National Rate · Eligible stays 80 · Observed rate 12.5% · Lower 95% interval 5.58%
Staff COVID-19 vaccination coverage 4.08%
8.2%
4.1 pts worse
Numerator 6 · Denominator 147
Staff flu vaccination coverage Not Available
42%
Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score 52.46%
56.45%
4 pts worse
Numerator 32 · Denominator 61
Transfer of health information to provider 93.1%
95.95%
2.9 pts worse
Numerator 27 · Denominator 29
Transfer of health information to patient 100%
96.28%
3.7 pts better
Numerator 25 · Denominator 25
Resident COVID-19 vaccinations up to date 23.81%
25.2%
1.4 pts worse
Numerator 10 · Denominator 42

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.9
1.7
1.2 pts worse
1.9
1 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.7 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 1.9
1.5
0.4 pts worse
1.8
0.1 pts worse
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 80.9%
95.0%
14.1 pts worse
93.4%
12.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 83.9% · Q2 80.4% · Q3 84.6% · Q4 74.7% · 4Q avg 80.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 92.5%
95.0%
2.5 pts worse
95.5%
3 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.5%
Percentage of long-stay residents experiencing one or more falls with major injury 1.6%
3.1%
1.5 pts better
3.3%
1.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.0% · Q3 1.1% · Q4 2.1% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 4.9%
4.1%
0.8 pts worse
11.4%
6.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 10.8% · Q4 7.5% · 4Q avg 4.9%
Percentage of long-stay residents who lose too much weight 3.0%
5.5%
2.5 pts better
5.4%
2.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.3% · Q3 3.7% · Q4 3.7% · 4Q avg 3.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 18.3%
19.6%
1.3 pts better
19.6%
1.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 15.9% · Q3 16.7% · Q4 19.8% · 4Q avg 18.3%
Percentage of long-stay residents who received an antipsychotic medication 25.9%
16.5%
9.4 pts worse
16.7%
9.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 24.6% · Q3 29.7% · Q4 21.7% · 4Q avg 25.9% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.3%
0.1%
0.2 pts worse
0.1%
0.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3%
Percentage of long-stay residents whose ability to walk independently worsened 28.9%
13.9%
15 pts worse
16.3%
12.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 35.9% · Q3 35.5% · Q4 28.4% · 4Q avg 28.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 17.8%
11.7%
6.1 pts worse
14.9%
2.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 15.9% · Q3 25.6% · Q4 20.0% · 4Q avg 17.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 1.9%
0.9%
1 pts worse
1.0%
0.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.9% · Q3 0.0% · Q4 1.2% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 2.2%
1.7%
0.5 pts worse
1.7%
0.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.1% · Q3 2.3% · Q4 2.2% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 23.3%
20.4%
2.9 pts worse
19.8%
3.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 28.7% · Q2 23.6% · Q3 31.6% · Q4 9.0% · 4Q avg 23.3%
Percentage of long-stay residents with pressure ulcers 8.7%
5.6%
3.1 pts worse
5.1%
3.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 8.0% · Q3 10.2% · Q4 8.8% · 4Q avg 8.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 42.3%
82.8%
40.5 pts worse
81.7%
39.4 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 53.5% · Q2 57.3% · Q3 39.0% · Q4 22.5% · 4Q avg 42.3%
Percentage of short-stay residents who had an outpatient emergency department visit 15.3%
11.5%
3.8 pts worse
12.0%
3.3 pts worse
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 16.0% · Expected 11.6% · 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 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 56.2%
79.5%
23.3 pts worse
79.7%
23.5 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 41.7%
24.2%
17.5 pts worse
23.9%
17.8 pts worse
Short Stay · 20240701-20250630 · Adjusted 41.7% · Observed 44.0% · Expected 25.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-20 · Fire 2025-08-20

9 health deficiencies

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

7 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-08-01 · Fire 2024-08-01

9 health deficiencies

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

7 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Cycle 3 Health 2023-06-14 · Fire 2023-06-14

9 health deficiencies

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

14 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-08-20

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2025-09-23

F · Potential for more than minimal harm 2025-08-20

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-09-23

F · Potential for more than minimal harm 2025-08-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-09-23

F · Potential for more than minimal harm 2025-08-20

K374 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-09-29

F · Potential for more than minimal harm 2025-08-20

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-09-23

F · Potential for more than minimal harm 2025-08-20

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-09-23

E · Potential for more than minimal harm 2025-08-20

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-09-23

F · Potential for more than minimal harm 2024-08-01

K291 · Egress Deficiencies

Fire Safety

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

Corrected

F · Potential for more than minimal harm 2024-08-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected

E · Potential for more than minimal harm 2024-08-01

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected

E · Potential for more than minimal harm 2024-08-01

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected

E · Potential for more than minimal harm 2024-08-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected

E · Potential for more than minimal harm 2024-08-01

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected

E · Potential for more than minimal harm 2024-08-01

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected

F · Potential for more than minimal harm 2023-06-14

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-07-15

F · Potential for more than minimal harm 2023-06-14

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2023-07-15

F · Potential for more than minimal harm 2023-06-14

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2023-07-15

F · Potential for more than minimal harm 2023-06-14

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2023-07-15

F · Potential for more than minimal harm 2023-06-14

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2023-07-15

F · Potential for more than minimal harm 2023-06-14

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-07-15

E · Potential for more than minimal harm 2023-06-14

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2023-07-15

E · Potential for more than minimal harm 2023-06-14

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-07-15

E · Potential for more than minimal harm 2023-06-14

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-07-15

E · Potential for more than minimal harm 2023-06-14

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-07-15

E · Potential for more than minimal harm 2023-06-14

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2023-07-15

E · Potential for more than minimal harm 2023-06-14

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-07-15

D · Potential for more than minimal harm 2023-06-14

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-07-15

D · Potential for more than minimal harm 2023-06-14

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2023-07-15

Inspection history

Recent health citations

G · Actual harm 2025-08-20

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 2025-09-23

F · Potential for more than minimal harm 2025-08-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-23

F · Potential for more than minimal harm 2025-08-20

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2025-09-23

E · Potential for more than minimal harm 2025-08-20

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 2025-09-23

D · Potential for more than minimal harm 2025-08-20

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-09-23

D · Potential for more than minimal harm 2025-08-20

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2025-09-23

D · Potential for more than minimal harm 2025-08-20

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-09-23

D · Potential for more than minimal harm 2025-08-20

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-09-23

D · Potential for more than minimal harm 2025-08-20

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-09-23

D · Potential for more than minimal harm 2024-09-18

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 2024-09-11

G · Actual harm 2024-08-01

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-08-23

E · Potential for more than minimal harm 2024-08-01

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-08-23

D · Potential for more than minimal harm 2024-08-01

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 2024-08-23

D · Potential for more than minimal harm 2024-08-01

F675 · Quality of Life and Care Deficiencies

Health

Honor each resident's preferences, choices, values and beliefs.

Corrected 2024-08-23

D · Potential for more than minimal harm 2024-08-01

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-08-23

D · Potential for more than minimal harm 2024-08-01

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-08-23

G · Actual harm 2024-05-02

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 2024-05-25

D · Potential for more than minimal harm 2024-05-02

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 2024-05-25

D · Potential for more than minimal harm 2024-02-07

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 2024-02-21

E · Potential for more than minimal harm 2023-06-14

F804 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2023-07-15

D · Potential for more than minimal harm 2023-06-14

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-07-15

D · Potential for more than minimal harm 2023-06-14

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-07-15

D · Potential for more than minimal harm 2023-06-14

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-07-15

D · Potential for more than minimal harm 2023-06-14

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2023-07-15

D · Potential for more than minimal harm 2023-06-14

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2023-07-15

D · Potential for more than minimal harm 2023-06-14

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2023-07-15

D · Potential for more than minimal harm 2023-06-14

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 2023-07-15

Penalties and ownership

What sits behind the stars

$23,595 2024-08-01

Fine

Fine · fine $23,595

Fine

Ownership

Almasri, Basem

Operational/Managerial Control · Individual

0% 2 facilities 2009-08-07
Hardyfoster, Lenora

Corporate Director · Individual

0% 1 facilities 2020-02-13
Jenema, Patti

Operational/Managerial Control · Individual

0% 1 facilities 2021-10-01
Olafsson, Janet

Operational/Managerial Control · Individual

0% 1 facilities 2022-09-19
Stewart, David

Corporate Director · Individual

0% 1 facilities 2019-10-22
Stoinski, Jenel

Operational/Managerial Control · Individual

0% 2 facilities 2025-01-02

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