Cycle 1
Health 2025-05-01 · Fire 2025-05-01
10 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lake Orion, MI
Lake Orion Nursing Center
2-star overall rating with 2-star inspections with abuse icon flag with $15,593 in total fines with 10 recent health deficiencies
585 East Flint Street, Lake Orion, MI
(248) 693-0505
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
85
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-02-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.29
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
0.12
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
3.98
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,823
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9915
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.94
Baseline 20.46% · Performance 20.53% · Measure score 1.94 · Achievement 1.94 · Improvement 0
Healthcare-associated infections
5.38
Baseline 5.50% · Performance 6.23% · Measure score 5.38 · Achievement 5.38 · Improvement 0
Total nurse turnover
4.66
Baseline 78.95% · Performance 51.02% · Measure score 4.66 · Achievement 3.10 · Improvement 4.66
Adjusted total nurse staffing
3.40
Baseline 3.84 hours · Performance 4.04 hours · Measure score 3.40 · Achievement 3.40 · Improvement 0.54
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.65% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 146 · Observed rate 15.75% · Lower 95% interval 9.67% |
| Discharge to community | 47.89% |
50.57%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 132 · Observed rate 42.42% · Lower 95% interval 40.55% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 84 · Denominator 84 |
| Falls with major injury | 1.19% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 84 |
| Discharge self-care score | 51.61% |
53.69%
2.1 pts worse
|
Numerator 32 · Denominator 62 |
| Discharge mobility score | 54.84% |
50.94%
3.9 pts better
|
Numerator 34 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 84 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.23% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 4.49% · Lower 95% interval 3.74% |
| Staff COVID-19 vaccination coverage | 3.7% |
8.2%
4.5 pts worse
|
Numerator 4 · Denominator 108 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 61.29% |
56.45%
4.8 pts better
|
Numerator 38 · Denominator 62 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 37 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 37.74% |
25.2%
12.5 pts better
|
Numerator 20 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.7
0.7 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.7 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
95.0%
2.6 pts worse
|
93.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.7% · Q2 93.2% · Q3 93.2% · Q4 95.4% · 4Q avg 92.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.5% |
95.0%
5.5 pts worse
|
95.5%
6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.1%
0.1 pts worse
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 5.5% · Q3 2.7% · Q4 3.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
4.1%
1.8 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 1.5% · Q3 1.5% · Q4 1.6% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.5%
0.2 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 6.1% · Q3 9.1% · Q4 3.9% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
19.6%
3.5 pts worse
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 25.0% · Q3 22.7% · Q4 26.3% · 4Q avg 23.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
16.5%
10.3 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 7.8% · Q3 5.3% · Q4 6.5% · 4Q avg 6.2% · 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 | 22.0% |
13.9%
8.1 pts worse
|
16.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
11.7%
1.2 pts worse
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 14.3% · Q3 13.3% · Q4 15.7% · 4Q avg 12.9% · 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 | 1.5% |
1.7%
0.2 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 1.4% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
20.4%
0.8 pts worse
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 16.5% · Q3 27.4% · Q4 23.0% · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.6%
2.6 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.2% · Q3 3.5% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.4% |
82.8%
1.4 pts worse
|
81.7%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 80.6% · Q2 84.8% · Q3 81.3% · Q4 79.5% · 4Q avg 81.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
11.5%
5.5 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.6% · Expected 10.5% · 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 | 78.0% |
79.5%
1.5 pts worse
|
79.7%
1.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.8% |
24.2%
9.6 pts worse
|
23.9%
9.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.8% · Observed 32.7% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-26 · Fire 2024-03-26
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-04-06 · Fire 2023-04-06
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-03-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-26
F · Potential for more than minimal harm
2023-04-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-06
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-06
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-04-06
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-04-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-23
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-21
G · Actual harm
2025-09-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-09-10
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-11-10
G · Actual harm
2025-06-16
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 2025-07-15
D · Potential for more than minimal harm
2025-05-01
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 2025-05-28
D · Potential for more than minimal harm
2025-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-01
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-28
G · Actual harm
2025-03-25
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 2025-03-09
D · Potential for more than minimal harm
2025-01-29
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 2024-12-13
F · Potential for more than minimal harm
2024-03-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-26
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-26
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-26
D · Potential for more than minimal harm
2023-06-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-05-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-23
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-23
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 2023-06-15
G · Actual harm
2023-04-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-04-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-04-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-04-06
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 2023-05-03
D · Potential for more than minimal harm
2023-04-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-03
Penalties and ownership
What sits behind the stars
$0
2025-09-10
Payment Denial
Payment Denial · denial start 2025-10-02 · 39 days
39 day denial
$15,593
2023-04-06
Fine
Fine · fine $15,593
Fine
Ownership
Mclaren Health Care Corporation
5% Or Greater Indirect Ownership Interest · Organization
Mclaren Oakland
5% Or Greater Direct Ownership Interest · Organization
Ball, Kevin
Corporate Director · Individual
Grant, Chad
Corporate Director · Individual
Hain, Tony
Corporate Director · Individual
Incarnati, Philip
Corporate Director · Individual
Marcotte, Lynn
Operational/Managerial Control · Individual
Marcotte, Lynn
Corporate Director · Individual
Marcotte, Lynn
Corporate Officer · Individual
Mazurkiewicz, David
Corporate Director · Individual
Mbiya, Mary
Corporate Director · Individual
Mcdonald, Derrick
Corporate Director · Individual
Prince, Allen
Corporate Director · Individual
Salloum, Fadi
Operational/Managerial Control · Individual
Salloum, Fadi
Corporate Officer · Individual
Spicer, Jacqui
Corporate Director · Individual
Suter, Lorenzo
Corporate Director · Individual
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#3
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