Cycle 1
Health 2025-03-19 · Fire 2025-03-19
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Ann Arbor, MI
Glacier Hills
5-star overall rating with 4-star inspections with 2 recent health deficiencies
1200 Earhart Road, Ann Arbor, MI
(734) 769-0177
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
105
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Trinity Health
Operator or chain grouping
Approved since
1976-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 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
1.07
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.59
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.56
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.66
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.19
CMS adjusted RN staffing hours
Adjusted total hours
5.08
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
1,167
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.26
Composite VBP score used to determine payment impact.
Payment multiplier
1.0145
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.52% · Performance 22.96% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
10
Baseline 4.54% · Performance 4.94% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
7.72
Baseline 36.36% · Performance 32.14% · Measure score 7.72 · Achievement 7.72 · Improvement 3.17
Adjusted total nurse staffing
5.99
Baseline 4.79 hours · Performance 4.78 hours · Measure score 5.99 · Achievement 5.99 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.45% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 493 · Observed rate 7.51% · Lower 95% interval 7.33% |
| Discharge to community | 71.21% |
50.57%
20.6 pts better
|
Better than the National Rate · Eligible stays 532 · Observed rate 71.24% · Lower 95% interval 67.25% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 251 · Denominator 251 |
| Falls with major injury | 0.8% |
0.77%
About the same
|
Numerator 2 · Denominator 251 |
| Discharge self-care score | 53.37% |
53.69%
0.3 pts worse
|
Numerator 111 · Denominator 208 |
| Discharge mobility score | 62.98% |
50.94%
12 pts better
|
Numerator 131 · Denominator 208 |
| Pressure ulcers or injuries, new or worsened | 1.2% |
2.29%
1.1 pts better
|
Numerator 3 · Denominator 251 · Adjusted rate 2.25% |
| Healthcare-associated infections requiring hospitalization | 4.94% |
7.12%
2.2 pts better
|
No Different than the National Rate · Eligible stays 272 · Observed rate 2.21% · Lower 95% interval 3.15% |
| Staff COVID-19 vaccination coverage | 7.64% |
8.2%
0.6 pts worse
|
Numerator 21 · Denominator 275 |
| Staff flu vaccination coverage | 26.8% |
42%
15.2 pts worse
|
Numerator 67 · Denominator 250 |
| Discharge function score | 79.33% |
56.45%
22.9 pts better
|
Numerator 165 · Denominator 208 |
| Transfer of health information to provider | 98.8% |
95.95%
2.8 pts better
|
Numerator 165 · Denominator 167 |
| Transfer of health information to patient | 98.75% |
96.28%
2.5 pts better
|
Numerator 79 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 49.23% |
25.2%
24 pts better
|
Numerator 64 · Denominator 130 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 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 · 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 · 4Q avg 0.0% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
1.7%
2.8 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 0.0% |
20.4%
20.4 pts better
|
19.8%
19.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
5.6%
4.4 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
82.8%
16 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 98.6% · Q3 99.4% · Q4 99.2% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
11.5%
3.5 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 6.8% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.3%
1 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.2% |
79.5%
19.7 pts better
|
79.7%
19.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.3% |
24.2%
6.1 pts worse
|
23.9%
6.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.3% · Observed 22.0% · Expected 17.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-15 · Fire 2024-02-15
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-01-11 · Fire 2023-01-11
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-20
F · Potential for more than minimal harm
2024-02-15
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-03-20
F · Potential for more than minimal harm
2024-02-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-03-20
F · Potential for more than minimal harm
2024-02-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-20
F · Potential for more than minimal harm
2024-02-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-20
F · Potential for more than minimal harm
2023-01-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-16
F · Potential for more than minimal harm
2023-01-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-17
F · Potential for more than minimal harm
2023-01-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-31
F · Potential for more than minimal harm
2023-01-11
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-02-03
F · Potential for more than minimal harm
2023-01-11
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 2023-02-10
F · Potential for more than minimal harm
2023-01-11
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-02-01
F · Potential for more than minimal harm
2023-01-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-31
E · Potential for more than minimal harm
2023-01-11
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 2023-02-24
D · Potential for more than minimal harm
2023-01-11
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-02-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-19
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-10
F · Potential for more than minimal harm
2024-02-15
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 2024-03-20
E · Potential for more than minimal harm
2024-02-15
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 2024-03-20
D · Potential for more than minimal harm
2024-02-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-15
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 2024-03-20
D · Potential for more than minimal harm
2024-02-15
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-15
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 2024-03-20
D · Potential for more than minimal harm
2024-02-15
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 2024-03-20
B · Minimal harm
2024-02-15
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 2024-03-20
B · Minimal harm
2024-02-15
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 2024-03-20
F · Potential for more than minimal harm
2023-01-11
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 2023-02-09
F · Potential for more than minimal harm
2023-01-11
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 2023-02-09
D · Potential for more than minimal harm
2023-01-11
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 2023-02-09
D · Potential for more than minimal harm
2023-01-11
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 2023-02-09
D · Potential for more than minimal harm
2023-01-11
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 2023-02-09
D · Potential for more than minimal harm
2023-01-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-09
Penalties and ownership
What sits behind the stars
Ownership
Trinity Continuing Care Services
5% Or Greater Direct Ownership Interest · Organization
Trinity Health Corporation
5% Or Greater Indirect Ownership Interest · Organization
Abraham, Tarun
Corporate Director · Individual
Abraham, Tarun
Corporate Officer · Individual
Berry, Dale
Corporate Director · Individual
Berry, Dale
Corporate Officer · Individual
Bowens, Marcus
Corporate Director · Individual
Bowens, Marcus
Corporate Officer · Individual
Byron-Oilar, Amy
Corporate Director · Individual
Byron-Oilar, Amy
Corporate Officer · Individual
Defrain, David
Corporate Director · Individual
Latovick, Pamela
W-2 Managing Employee · Individual
Mckinnon, Benjamin
Operational/Managerial Control · Individual
Skaff, David
Corporate Director · Individual
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Optalis Health and Rehabilitation of Ann Arbor
Ann Arbor, MI
3-star overall rating with 2-star inspections with abuse icon flag with $80,619 in total fines with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Regency At Bluffs Park
Ann Arbor, MI
2-star overall rating with 2-star inspections with $26,852 in total fines with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Mission Point Nursing & Physical Rehabilitation Ce
Ypslianti, MI
3-star overall rating with 2-star inspections with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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