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
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing
LPN hours / resident day
1.44
Licensed practical nurse staffing
Aide hours / resident day
2.22
Nurse aide staffing
Weekend hours
3.87
Weekend nurse staffing
RN turnover
14%
Annual RN turnover
Total nurse turnover
32%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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