Cycle 1
Health 2025-09-10 · Fire 2025-09-10
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Livonia, MI
Fountain Bleu Health and Rehabilitation
4-star overall rating with 4-star inspections with $8,985 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
28910 Plymouth Road, Livonia, MI
(734) 425-4814
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
93
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Optalis Health & Rehabilitation
Operator or chain grouping
Approved since
1998-12-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
37 facilities
Chain averages 3 overall / 2 health / 3 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
0.43
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.47
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.82
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.91
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,323
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.57% · Performance 22.98% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.36% · Performance 8.60% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.1
Baseline 60.44% · Performance 59.18% · Measure score 1.1 · Achievement 1.1 · Improvement 0
Adjusted total nurse staffing
1.53
Baseline 3.72 hours · Performance 3.51 hours · Measure score 1.53 · Achievement 1.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.43% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 166 · Observed rate 13.25% · Lower 95% interval 8.09% |
| Discharge to community | 53.93% |
50.57%
3.4 pts better
|
No Different than the National Rate · Eligible stays 161 · Observed rate 45.96% · Lower 95% interval 45.85% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 151 · Denominator 151 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 151 |
| Discharge self-care score | 59.18% |
53.69%
5.5 pts better
|
Numerator 58 · Denominator 98 |
| Discharge mobility score | 48.98% |
50.94%
2 pts worse
|
Numerator 48 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 3.97% |
2.29%
1.7 pts worse
|
Numerator 6 · Denominator 151 · Adjusted rate 3.5% |
| Healthcare-associated infections requiring hospitalization | 8.6% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 10.38% · Lower 95% interval 5.46% |
| Staff COVID-19 vaccination coverage | 30.88% |
8.2%
22.7 pts better
|
Numerator 42 · Denominator 136 |
| Staff flu vaccination coverage | 8.02% |
42%
34 pts worse
|
Numerator 15 · Denominator 187 |
| Discharge function score | 53.06% |
56.45%
3.4 pts worse
|
Numerator 52 · Denominator 98 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 66 · Denominator 66 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 59 · Denominator 59 |
| Resident COVID-19 vaccinations up to date | 25.33% |
25.2%
0.1 pts better
|
Numerator 19 · Denominator 75 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.7
1 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 4.0 · Expected 2.8 · 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 1.2 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
95.0%
4.6 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
95.0%
3.8 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.1%
2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.7% |
4.1%
0.6 pts worse
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.5% · Q3 3.6% · Q4 1.8% · 4Q avg 4.7% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.5%
1.6 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 5.2% · Q3 5.4% · Q4 3.6% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.7% |
19.6%
1.9 pts better
|
19.6%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 16.7% · Q3 15.8% · Q4 21.4% · 4Q avg 17.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.1% |
16.5%
0.6 pts worse
|
16.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 19.2% · Q3 15.2% · Q4 11.4% · 4Q avg 17.1% · 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 | 12.5% |
13.9%
1.4 pts better
|
16.3%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.3% |
11.7%
4.4 pts better
|
14.9%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 0.0% · Q3 8.9% · Q4 5.5% · 4Q avg 7.3% · 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 | 2.2% |
1.7%
0.5 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.3% · Q3 1.6% · Q4 1.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.0% |
20.4%
0.4 pts better
|
19.8%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 22.2% · Q3 11.7% · Q4 21.4% · 4Q avg 20.0% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
5.6%
0.6 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 4.4% · Q3 5.5% · Q4 3.2% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
82.8%
17 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
11.5%
2.1 pts worse
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 13.4% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.6% · Q4 0.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.1% |
79.5%
18.6 pts better
|
79.7%
18.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.8% |
24.2%
10.6 pts worse
|
23.9%
10.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.8% · Observed 34.6% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
9 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Cycle 3
Health 2023-07-12 · Fire 2023-07-12
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-29
E · Potential for more than minimal harm
2025-09-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-29
E · Potential for more than minimal harm
2025-09-10
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-09-29
E · Potential for more than minimal harm
2025-09-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-29
F · Potential for more than minimal harm
2024-08-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-08-15
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-08-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-08-15
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-08-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-08-15
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-08-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-08-15
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-09-04
E · Potential for more than minimal harm
2023-07-12
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 2023-08-01
E · Potential for more than minimal harm
2023-07-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-07-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-07-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-07-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-01
Inspection history
Recent health citations
G · Actual harm
2025-12-03
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.
Not marked corrected
D · Potential for more than minimal harm
2025-09-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-09-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-29
D · Potential for more than minimal harm
2025-04-15
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 2025-05-02
G · Actual harm
2024-08-15
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 2024-09-04
D · Potential for more than minimal harm
2024-08-15
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 2024-09-04
D · Potential for more than minimal harm
2024-08-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-08-15
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-06-18
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 2024-07-10
D · Potential for more than minimal harm
2024-06-18
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-07-10
G · Actual harm
2023-07-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-07-12
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 2023-08-01
E · Potential for more than minimal harm
2023-07-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-07-12
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-07-12
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 2023-08-01
D · Potential for more than minimal harm
2023-07-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-08-01
Penalties and ownership
What sits behind the stars
$8,985
2024-08-15
Fine
Fine · fine $8,985
Fine
Ownership
Dunn, Charles
5% Or Greater Direct Ownership Interest · Individual
Patel, Pinal
5% Or Greater Direct Ownership Interest · Individual
Shah, Nayana
5% Or Greater Direct Ownership Interest · Individual
Cervi-Jonski, Laura
W-2 Managing Employee · Individual
Dunn, Charles
Corporate Officer · Individual
Optum Management Solutions. Inc
Operational/Managerial Control · Organization
Patel, Rajan
Operational/Managerial Control · Individual
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