Douglas, MI

Douglas Cove Health and Rehabilitation

2-star overall rating with 2-star inspections with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

243 Wiley Road, Douglas, MI

(269) 857-2141

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Simcha Hyman & Naftali Zanziper

Operator or chain grouping

Approved since

1986-03-18

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

94 facilities

Chain averages 2 overall / 3 health / 2 staffing / 3 quality stars

Changed ownership

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

0.35

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

1.11

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

2.14

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

3.60

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.46

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

0.41

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.38

CMS adjusted RN staffing hours

Adjusted total hours

3.88

CMS adjusted total nurse staffing hours

Case-mix index

1.27

Higher values indicate more complex resident acuity

RN turnover

40%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

39%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,135

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

Performance score

59.54

Composite VBP score used to determine payment impact.

Payment multiplier

1.0147

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.67

Performance 18.81% · Measure score 5.67 · Achievement 5.67 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

4.61

Performance 6.46% · Measure score 4.61 · Achievement 4.61 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

Baseline 24.32% · Performance 16.22% · Measure score 10 · Achievement 10 · Improvement 9

Adjusted total nurse staffing

3.54

Baseline 4.36 hours · Performance 4.08 hours · Measure score 3.54 · Achievement 3.54 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.26%	10.72% 0.5 pts better	No Different than the National Rate · Eligible stays 42 · Observed rate 9.52% · Lower 95% interval 7.17%
Discharge to community	38.23%	50.57% 12.3 pts worse	No Different than the National Rate · Eligible stays 39 · Observed rate 25.64% · Lower 95% interval 27.83%
Medicare spending per beneficiary	0.78	1.02 0.2 pts better
Drug regimen review with follow-up	50%	95.27% 45.3 pts worse	Numerator 17 · Denominator 34
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 34
Discharge self-care score	44.44%	53.69% 9.2 pts worse	Numerator 12 · Denominator 27
Discharge mobility score	22.22%	50.94% 28.7 pts worse	Numerator 6 · Denominator 27
Pressure ulcers or injuries, new or worsened	2.94%	2.29% 0.6 pts worse	Numerator 1 · Denominator 34 · Adjusted rate 3.2%
Healthcare-associated infections requiring hospitalization	6.46%	7.12% 0.7 pts better	No Different than the National Rate · Eligible stays 29 · Observed rate 3.45% · Lower 95% interval 3.23%
Staff COVID-19 vaccination coverage	1.27%	8.2% 6.9 pts worse	Numerator 1 · Denominator 79
Staff flu vaccination coverage	8.85%	42% 33.1 pts worse	Numerator 10 · Denominator 113
Discharge function score	51.85%	56.45% 4.6 pts worse	Numerator 14 · Denominator 27
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	52.38%	25.2% 27.2 pts better	Numerator 11 · Denominator 21

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.5	1.7 0.8 pts worse	1.9 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 1.9 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	1.5 0.3 pts better	1.8 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.4%	95.0% 0.4 pts better	93.4% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 94.6% · Q3 100.0% · Q4 100.0% · 4Q avg 95.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	93.2%	95.0% 1.8 pts worse	95.5% 2.3 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 93.2%
Percentage of long-stay residents experiencing one or more falls with major injury	3.3%	3.1% 0.2 pts worse	3.3% About the same	Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 2.7% · Q3 2.6% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.9%	4.1% 1.2 pts better	11.4% 8.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 6.1% · Q3 2.9% · Q4 0.0% · 4Q avg 2.9%
Percentage of long-stay residents who lose too much weight	9.7%	5.5% 4.2 pts worse	5.4% 4.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 17.9% · Q3 3.4% · Q4 6.7% · 4Q avg 9.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	31.3%	19.6% 11.7 pts worse	19.6% 11.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 37.9% · Q3 26.7% · Q4 23.3% · 4Q avg 31.3%
Percentage of long-stay residents who received an antipsychotic medication	21.7%	16.5% 5.2 pts worse	16.7% 5 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 28.6% · Q3 18.2% · Q4 21.7% · 4Q avg 21.7% · 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	16.5%	13.9% 2.6 pts worse	16.3% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 16.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	17.1%	11.7% 5.4 pts worse	14.9% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 39.1% · Q2 7.7% · Q3 7.1% · Q4 17.9% · 4Q avg 17.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.0%	0.9% 1.1 pts worse	1.0% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.3%	1.7% 0.4 pts better	1.7% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.9%	20.4% 4.5 pts worse	19.8% 5.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 30.6% · Q3 18.9% · Q4 12.5% · 4Q avg 24.9%
Percentage of long-stay residents with pressure ulcers	9.1%	5.6% 3.5 pts worse	5.1% 4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 12.8% · Q3 6.9% · Q4 7.3% · 4Q avg 9.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	94.1%	82.8% 11.3 pts better	81.7% 12.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 79.7% · Q2 98.4% · Q3 100.0% · Q4 100.0% · 4Q avg 94.1%
Percentage of short-stay residents who had an outpatient emergency department visit	9.2%	11.5% 2.3 pts better	12.0% 2.8 pts better	Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 8.8% · Expected 10.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	89.2%	79.5% 9.7 pts better	79.7% 9.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 89.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.9%	24.2% 3.3 pts better	23.9% 3 pts better	Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 17.6% · Expected 20.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-17 · Fire 2025-07-17

13 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

8 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 2 Health 2024-07-18 · Fire 2024-07-18

11 health deficiencies

Top issue: Infection Control (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-06-07 · Fire 2023-06-07

3 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-07-17

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2025-08-25

F · Potential for more than minimal harm 2025-07-17

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-08-25

F · Potential for more than minimal harm 2025-07-17

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2025-08-25

E · Potential for more than minimal harm 2025-07-17

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 2025-08-25

E · Potential for more than minimal harm 2025-07-17

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-08-25

E · Potential for more than minimal harm 2025-07-17

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 2025-08-25

E · Potential for more than minimal harm 2025-07-17

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-08-25

D · Potential for more than minimal harm 2025-07-17

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-08-25

F · Potential for more than minimal harm 2024-07-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-08-21

E · Potential for more than minimal harm 2024-07-18

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2024-08-21

E · Potential for more than minimal harm 2024-07-18

K372 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-08-21

E · Potential for more than minimal harm 2024-07-18

K374 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-08-21

F · Potential for more than minimal harm 2023-06-07

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 2023-07-14

F · Potential for more than minimal harm 2023-06-07

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-07-14

E · Potential for more than minimal harm 2023-06-07

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 2023-07-14

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-05

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-09-29

D · Potential for more than minimal harm 2025-09-05

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-09-29

D · Potential for more than minimal harm 2025-09-05

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-09-29

F · Potential for more than minimal harm 2025-07-17

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 2025-08-25

F · Potential for more than minimal harm 2025-07-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-25

E · Potential for more than minimal harm 2025-07-17

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 2025-08-25

E · Potential for more than minimal harm 2025-07-17

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 2025-08-25

D · Potential for more than minimal harm 2025-07-17

F553 · Resident Rights Deficiencies

Health

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Corrected 2025-08-25

D · Potential for more than minimal harm 2025-07-17

F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Corrected 2025-08-25

D · Potential for more than minimal harm 2025-07-17

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2025-08-25

D · Potential for more than minimal harm 2025-05-21

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2025-06-16

F · Potential for more than minimal harm 2025-03-12

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2025-04-15

D · Potential for more than minimal harm 2025-03-12

F728 · Nursing and Physician Services Deficiencies

Health

Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

Corrected 2025-04-09

F · Potential for more than minimal harm 2024-07-18

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-08-21

F · Potential for more than minimal harm 2024-07-18

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 2024-08-21

F · Potential for more than minimal harm 2024-07-18