Cycle 1
Health 2025-02-05 · Fire 2025-02-05
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Adrian, MI
Lenawee Medical Care Facility
5-star overall rating with 4-star inspections with $15,593 in total fines with 3 recent health deficiencies
200 Sand Creek Highway, Adrian, MI
(517) 263-6794
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
113
Certified beds
Average residents
111
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1973-08-01
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
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.60
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
5.14
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.52
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
5.45
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,268
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.57
Composite VBP score used to determine payment impact.
Payment multiplier
1.0047
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.03
Baseline 19.42% · Performance 19.56% · Measure score 4.03 · Achievement 4.03 · Improvement 0
Healthcare-associated infections
5.22
Baseline 6.24% · Performance 6.27% · Measure score 5.22 · Achievement 5.22 · Improvement 0
Total nurse turnover
2.65
Baseline 36.92% · Performance 52.87% · Measure score 2.65 · Achievement 2.65 · Improvement 0
Adjusted total nurse staffing
8.32
Baseline 5.26 hours · Performance 5.45 hours · Measure score 8.32 · Achievement 8.32 · Improvement 3.10
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.9% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 177 · Observed rate 9.6% · Lower 95% interval 7.4% |
| Discharge to community | 62.8% |
50.57%
12.2 pts better
|
Better than the National Rate · Eligible stays 161 · Observed rate 63.98% · Lower 95% interval 56.49% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 51 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | 43.48% |
53.69%
10.2 pts worse
|
Numerator 20 · Denominator 46 |
| Discharge mobility score | 56.52% |
50.94%
5.6 pts better
|
Numerator 26 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.96% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 51 · Adjusted rate 1.77% |
| Healthcare-associated infections requiring hospitalization | 6.27% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 3.45% · Lower 95% interval 3.48% |
| Staff COVID-19 vaccination coverage | 3.59% |
8.2%
4.6 pts worse
|
Numerator 8 · Denominator 223 |
| Staff flu vaccination coverage | 90.4% |
42%
48.4 pts better
|
Numerator 226 · Denominator 250 |
| Discharge function score | 56.52% |
56.45%
0.1 pts better
|
Numerator 26 · Denominator 46 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.7
0.6 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
95.0%
4.8 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.3% |
95.0%
1.3 pts better
|
95.5%
0.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.1%
2.3 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.0% · Q3 4.0% · Q4 5.8% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.6% |
4.1%
0.5 pts worse
|
11.4%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.8% · Q3 6.1% · Q4 3.8% · 4Q avg 4.6% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
5.5%
2.6 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.5% · Q3 3.5% · Q4 4.3% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.4% |
19.6%
5.2 pts better
|
19.6%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 13.3% · Q3 11.4% · Q4 17.4% · 4Q avg 14.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
16.5%
10.4 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 5.4% · Q3 7.4% · Q4 3.8% · 4Q avg 6.1% · 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 | 17.7% |
13.9%
3.8 pts worse
|
16.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 15.7% · Q3 28.8% · Q4 12.3% · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
11.7%
1.4 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 7.7% · Q3 13.8% · Q4 12.0% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.7%
1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.3% |
20.4%
10.9 pts worse
|
19.8%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 31.0% · Q3 28.2% · Q4 33.5% · 4Q avg 31.3% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
5.6%
4.3 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 2.6% · Q4 0.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
82.8%
15.4 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 100.0% · Q3 96.0% · Q4 100.0% · 4Q avg 98.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.6% |
11.5%
4.1 pts worse
|
12.0%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 14.0% · Expected 10.0% · 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 · 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 | 93.8% |
79.5%
14.3 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.5% |
24.2%
12.7 pts better
|
23.9%
12.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 9.3% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-14 · Fire 2022-09-14
5 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-09-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-10-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-22
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-12-11
G · Actual harm
2025-06-25
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 2025-05-29
D · Potential for more than minimal harm
2025-06-25
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-13
D · Potential for more than minimal harm
2024-08-01
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-08-01
G · Actual harm
2023-11-16
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-11-16
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 2023-12-04
D · Potential for more than minimal harm
2023-11-16
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 2023-12-04
D · Potential for more than minimal harm
2023-11-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-11-16
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 2023-12-04
B · Minimal harm
2023-11-16
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-12-04
G · Actual harm
2023-10-19
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 2023-10-20
E · Potential for more than minimal harm
2022-09-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-14
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 2022-10-21
D · Potential for more than minimal harm
2022-09-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-14
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 2022-10-21
Penalties and ownership
What sits behind the stars
$15,593
2023-11-16
Fine
Fine · fine $15,593
Fine
Ownership
Lenawee County
5% Or Greater Direct Ownership Interest · Organization
Blevins, Christina
Operational/Managerial Control · Individual
Lenawee County
Operational/Managerial Control · Organization
Scarborough, Joyce
Operational/Managerial Control · Individual
Nearby options
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3-star overall rating with 3-star inspections with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Lynwood Manor Healthcare Center
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3-star overall rating with 3-star inspections with $23,761 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Adrian Bay Rehabilitation and Nursing Center
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2-star overall rating with 2-star inspections with $245,476 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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