Cycle 1
Health 2025-02-20 · Fire 2025-02-20
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Monroe, MI
IHM Senior Living Community
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
610 West Elm Avenue, Monroe, MI
(734) 241-3660
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
52
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Saint Therese Senior Communities
Operator or chain grouping
Approved since
2009-10-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 5 overall / 4 health / 5 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
0.86
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.44
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.51
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.29
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.40
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
0.86
CMS adjusted RN staffing hours
Adjusted total hours
4.54
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
501
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.69
Composite VBP score used to determine payment impact.
Payment multiplier
1.0217
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.17
Baseline 16.95% · Performance 18.57% · Measure score 6.17 · Achievement 6.17 · Improvement 0
Healthcare-associated infections
6.54
Baseline 5.50% · Performance 5.88% · Measure score 6.54 · Achievement 6.54 · Improvement 0
Total nurse turnover
10
Baseline 33.33% · Performance 21.57% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
4.76
Baseline 4.12 hours · Performance 4.43 hours · Measure score 4.76 · Achievement 4.76 · Improvement 1.38
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.7% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 108 · Observed rate 16.67% · Lower 95% interval 8.58% |
| Discharge to community | 58.93% |
50.57%
8.4 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 56.48% · Lower 95% interval 49.55% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 57 · Denominator 57 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 57 |
| Discharge self-care score | 65.38% |
53.69%
11.7 pts better
|
Numerator 34 · Denominator 52 |
| Discharge mobility score | 65.38% |
50.94%
14.4 pts better
|
Numerator 34 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 57 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.88% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 2.7% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 6.09% |
8.2%
2.1 pts worse
|
Numerator 7 · Denominator 115 |
| Staff flu vaccination coverage | 69.08% |
42%
27.1 pts better
|
Numerator 105 · Denominator 152 |
| Discharge function score | 73.08% |
56.45%
16.6 pts better
|
Numerator 38 · Denominator 52 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28.57% |
25.2%
3.4 pts better
|
Numerator 8 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.7
0.8 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · 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 | 2.7% |
3.1%
0.4 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.9% · Q3 2.6% · Q4 3.0% · 4Q avg 2.7% · 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 5.9% · Q2 0.0% · Q3 0.0% · Q4 6.7% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.5%
2.1 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.7% · Q3 3.6% · Q4 4.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
19.6%
1.4 pts better
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 17.1% · Q3 13.8% · Q4 22.2% · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.2% |
16.5%
9.3 pts better
|
16.7%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.1% · Q3 8.7% · Q4 9.1% · 4Q avg 7.2% · 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 | 22.3% |
13.9%
8.4 pts worse
|
16.3%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
11.7%
1.6 pts worse
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 8.8% · Q3 20.7% · Q4 22.2% · 4Q avg 13.3% · 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 | 1.4% |
1.7%
0.3 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.7% |
20.4%
8.3 pts worse
|
19.8%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.2% · Q2 26.5% · Q3 34.4% · Q4 21.1% · 4Q avg 28.7% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
5.6%
3.2 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.1% · Q3 4.5% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
82.8%
17.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
11.5%
3.8 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 7.5% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.3%
0.3 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 2.4% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.5%
20.5 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.3% |
24.2%
7.9 pts better
|
23.9%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 15.1% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
3 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-05-10 · Fire 2023-05-10
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-02-20
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-03-20
F · Potential for more than minimal harm
2025-02-20
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-03-20
F · Potential for more than minimal harm
2024-03-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-24
F · Potential for more than minimal harm
2024-03-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-24
F · Potential for more than minimal harm
2024-03-28
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-03-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-03-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-24
F · Potential for more than minimal harm
2023-05-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-16
F · Potential for more than minimal harm
2023-05-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-16
F · Potential for more than minimal harm
2023-05-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-10
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-06-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-03-28
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 2024-05-03
D · Potential for more than minimal harm
2024-03-28
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 2024-05-03
D · Potential for more than minimal harm
2024-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-03
Penalties and ownership
What sits behind the stars
Ownership
Saint Therese
5% Or Greater Indirect Ownership Interest · Organization
Saint Therese Communities
5% Or Greater Direct Ownership Interest · Organization
Abbott, Craig
Corporate Director · Individual
Abbott, Craig
Corporate Officer · Individual
Gillespie, Joseph
Corporate Director · Individual
Herb, Mary
Corporate Director · Individual
Hoffmann, David
Corporate Director · Individual
Hoffmann, David
Corporate Officer · Individual
Horstmann, Steven
Corporate Director · Individual
Kennedy, Nicole
Operational/Managerial Control · Individual
Krenn, David
Corporate Director · Individual
Mccluskey, Patricia
Corporate Director · Individual
Mccrossan, Jane
Corporate Director · Individual
Meads, Steven
Corporate Director · Individual
Parmar, Mona
Corporate Director · Individual
Saint Therese
Operational/Managerial Control · Organization
Saint Therese Communities
Operational/Managerial Control · Organization
Saint Therese Management Services, LLC
Operational/Managerial Control · Organization
Sawyer, Keegan
Operational/Managerial Control · Individual
Shelangoski, Cal
Corporate Officer · Individual
Snider, Mark
Operational/Managerial Control · Individual
Taffe, Patrick
Corporate Director · Individual
Wornson, Kathryn
Corporate Director · Individual
Wornson, Kathryn
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Medilodge of Monroe
Monroe, MI
4-star overall rating with 4-star inspections with 1 recent health deficiencies
#2
Wellspring Lutheran Nursing and Rehab Services
Monroe, MI
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Seacrest Rehabilitation and Nursing Center
Monroe, MI
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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