Cycle 1
Health 2025-08-27 · Fire 2025-08-27
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Clinton Township, MI
Lakepointe Senior Care and Rehabilitation Center
5-star overall rating with 5-star inspections with $34,034 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
37700 Harper Avenue, Clinton Township, MI
(586) 468-0827
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
134
Certified beds
Average residents
128
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nexcare Health Systems
Operator or chain grouping
Approved since
1993-12-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 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
0.45
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.07
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
3.61
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.92
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,197
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.15
Baseline 22.02% · Performance 20.20% · Measure score 3.15 · Achievement 2.67 · Improvement 3.15
Healthcare-associated infections
0
Baseline 6.56% · Performance 8.99% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.22
Baseline 68.33% · Performance 43.44% · Measure score 5.22 · Achievement 4.95 · Improvement 5.22
Adjusted total nurse staffing
1.43
Baseline 2.85 hours · Performance 3.41 hours · Measure score 1.43 · Achievement 1.18 · Improvement 1.43
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.33% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 10.42% · Lower 95% interval 6.92% |
| Discharge to community | 38.6% |
50.57%
12 pts worse
|
Worse than the National Rate · Eligible stays 72 · Observed rate 29.17% · Lower 95% interval 29.49% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.08% |
95.27%
2.8 pts better
|
Numerator 51 · Denominator 52 |
| Falls with major injury | 1.92% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 52 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 11 · Denominator 33 |
| Discharge mobility score | 27.27% |
50.94%
23.7 pts worse
|
Numerator 9 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 52 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.99% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 15.22% · Lower 95% interval 5.17% |
| Staff COVID-19 vaccination coverage | 5.13% |
8.2%
3.1 pts worse
|
Numerator 10 · Denominator 195 |
| Staff flu vaccination coverage | 28.11% |
42%
13.9 pts worse
|
Numerator 61 · Denominator 217 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 11 · Denominator 33 |
| Transfer of health information to provider | 95.65% |
95.95%
0.3 pts worse
|
Numerator 22 · Denominator 23 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 40% |
25.2%
14.8 pts better
|
Numerator 12 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.2 · 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 0.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
95.0%
4.3 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 100.0% · Q3 100.0% · Q4 99.1% · 4Q avg 99.3% |
| 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 | 2.2% |
3.1%
0.9 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.9% · Q3 2.5% · Q4 3.4% · 4Q avg 2.2% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
5.5%
4.1 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 0.0% · Q4 3.8% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.4% |
19.6%
11.8 pts worse
|
19.6%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 33.9% · Q3 29.8% · Q4 32.4% · 4Q avg 31.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.9% |
16.5%
6.4 pts worse
|
16.7%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 22.9% · Q3 23.2% · Q4 22.4% · 4Q avg 22.9% · 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 | 15.3% |
13.9%
1.4 pts worse
|
16.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 26.5% · Q3 17.0% · Q4 4.3% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.0% |
11.7%
0.3 pts worse
|
14.9%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 21.6% · Q3 8.6% · Q4 7.0% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.3% |
20.4%
15.1 pts better
|
19.8%
14.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 11.2% · Q3 6.0% · Q4 2.7% · 4Q avg 5.3% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
5.6%
0.5 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 8.5% · Q3 5.0% · Q4 6.0% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.0% |
82.8%
0.2 pts better
|
81.7%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.7% · Q2 80.8% · Q3 77.4% · Q4 84.0% · 4Q avg 83.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
11.5%
3.3 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 9.3% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
1.3%
1.6 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.6% · Q3 3.0% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.2% |
79.5%
1.3 pts worse
|
79.7%
1.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
24.2%
3.7 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 30.2% · Expected 25.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-09 · Fire 2024-08-09
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2023-06-28 · Fire 2023-06-28
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-09-15
E · Potential for more than minimal harm
2025-08-27
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-09-15
E · Potential for more than minimal harm
2025-08-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-15
E · Potential for more than minimal harm
2025-08-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-09-15
F · Potential for more than minimal harm
2024-08-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-21
F · Potential for more than minimal harm
2024-08-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-21
F · Potential for more than minimal harm
2024-08-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-21
F · Potential for more than minimal harm
2024-08-09
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-08-21
E · Potential for more than minimal harm
2024-08-09
K224 · Egress Deficiencies
Fire Safety
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.
Corrected 2024-08-21
E · Potential for more than minimal harm
2024-08-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-21
E · Potential for more than minimal harm
2024-08-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-21
E · Potential for more than minimal harm
2023-06-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-06-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-06-28
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-27
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 2025-09-15
D · Potential for more than minimal harm
2025-08-27
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 2025-09-15
E · Potential for more than minimal harm
2024-08-09
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-08-09
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 2024-08-21
D · Potential for more than minimal harm
2024-08-09
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 2024-08-21
D · Potential for more than minimal harm
2024-08-09
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 2024-08-21
D · Potential for more than minimal harm
2024-08-09
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-08-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-08-09
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 2024-08-21
G · Actual harm
2023-06-28
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 2023-07-24
E · Potential for more than minimal harm
2023-06-28
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-06-28
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 2023-07-24
D · Potential for more than minimal harm
2023-06-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-28
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-07-24
C · Minimal harm
2023-06-28
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-07-24
Penalties and ownership
What sits behind the stars
$34,034
2023-06-28
Fine
Fine · fine $34,034
Fine
Ownership
Nexcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Branscum, James
5% Or Greater Indirect Ownership Interest · Individual
Eisenberg, Leo
5% Or Greater Indirect Ownership Interest · Individual
Laurain, Brian
W-2 Managing Employee · Individual
Nexcare Health Systems, LLC
Operational/Managerial Control · Organization
Perry, Michael
Operational/Managerial Control · Individual
Robin Eisenberg 2014 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Sangster, Todd
Corporate Officer · Individual
Wronski, Frank
5% Or Greater Indirect Ownership Interest · Individual
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