Cycle 1
Health 2025-08-28 · Fire 2025-08-28
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Waterford, MI
Lourdes Rehabilitation and Healthcare Center
5-star overall rating with 5-star inspections with $15,593 in total fines with 1 recent health deficiencies
2300 Watkins Lake Rd, Waterford, MI
(248) 674-2241
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
80
Certified beds
Average residents
70
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-01-06
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
0.71
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.91
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.55
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
0.76
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,927
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9912
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.92% · Performance 22.93% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.56
Baseline 5.40% · Performance 6.77% · Measure score 3.56 · Achievement 3.56 · Improvement 0
Total nurse turnover
8.91
Baseline 28.38% · Performance 27.27% · Measure score 8.91 · Achievement 8.91 · Improvement 2.63
Adjusted total nurse staffing
2.76
Baseline 4.27 hours · Performance 3.86 hours · Measure score 2.76 · Achievement 2.76 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.13% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 247 · Observed rate 11.74% · Lower 95% interval 9.22% |
| Discharge to community | 62.56% |
50.57%
12 pts better
|
Better than the National Rate · Eligible stays 256 · Observed rate 59.77% · Lower 95% interval 56.71% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.9% |
95.27%
3.6 pts better
|
Numerator 180 · Denominator 182 |
| Falls with major injury | 1.1% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 182 |
| Discharge self-care score | 61.29% |
53.69%
7.6 pts better
|
Numerator 95 · Denominator 155 |
| Discharge mobility score | 74.19% |
50.94%
23.2 pts better
|
Numerator 115 · Denominator 155 |
| Pressure ulcers or injuries, new or worsened | 3.85% |
2.29%
1.6 pts worse
|
Numerator 7 · Denominator 182 · Adjusted rate 4.44% |
| Healthcare-associated infections requiring hospitalization | 6.77% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 161 · Observed rate 4.97% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 2.88% |
8.2%
5.3 pts worse
|
Numerator 3 · Denominator 104 |
| Staff flu vaccination coverage | 45.3% |
42%
3.3 pts better
|
Numerator 53 · Denominator 117 |
| Discharge function score | 69.68% |
56.45%
13.2 pts better
|
Numerator 108 · Denominator 155 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 49 · Denominator 49 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 116 · Denominator 116 |
| Resident COVID-19 vaccinations up to date | 36.36% |
25.2%
11.2 pts better
|
Numerator 36 · Denominator 99 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.1 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.5
1.3 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
95.0%
4.4 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| 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 | 1.7% |
3.1%
1.4 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · 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 | 3.4% |
5.5%
2.1 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.4% · Q3 2.8% · Q4 3.1% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.8% |
19.6%
6.8 pts better
|
19.6%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 13.5% · Q3 11.1% · Q4 15.6% · 4Q avg 12.8% |
| 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 8.3% · Q2 6.2% · Q3 5.9% · Q4 3.6% · 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 | 27.5% |
13.9%
13.6 pts worse
|
16.3%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.4% |
11.7%
0.3 pts better
|
14.9%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 9.7% · Q3 13.3% · Q4 7.7% · 4Q avg 11.4% · 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 | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.5% |
20.4%
17.1 pts worse
|
19.8%
17.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 40.3% · Q3 36.1% · Q4 49.5% · 4Q avg 37.5% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
5.6%
2.7 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.4% · Q3 5.1% · Q4 1.5% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
82.8%
11.9 pts better
|
81.7%
13 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.3% · Q2 92.8% · Q3 97.7% · Q4 97.0% · 4Q avg 94.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
11.5%
1.1 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 9.3% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.5% |
79.5%
10 pts better
|
79.7%
9.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.4% |
24.2%
3.8 pts better
|
23.9%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.4% · Observed 16.8% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-23 · Fire 2024-07-23
4 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-08-24 · Fire 2023-08-24
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-07-23
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-08-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-19
F · Potential for more than minimal harm
2024-07-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-23
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 2024-08-06
D · Potential for more than minimal harm
2024-07-23
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-08-06
G · Actual harm
2023-08-24
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 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
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 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-13
Penalties and ownership
What sits behind the stars
$15,593
2023-08-24
Fine
Fine · fine $15,593
Fine
Ownership
Acho, Richard
Operational/Managerial Control · Individual
Acho, Richard
Corporate Officer · Individual
Asdell, Erin
Corporate Director · Individual
Aziz, Nada
Contracted Managing Employee · Individual
Bachman, Janice
Corporate Director · Individual
Boal, James
Corporate Director · Individual
Gifford, Linda
Corporate Director · Individual
Holden, Margaret
Corporate Director · Individual
Lefevre, Michael
Corporate Director · Individual
Manuszak, Joseph
Corporate Director · Individual
Martin, Peggy
Corporate Director · Individual
Mcgee, Maureen
W-2 Managing Employee · Individual
Mendelson, Barbara
Corporate Officer · Individual
Noone, John
Corporate Director · Individual
Propson, Paul
Corporate Director · Individual
Twohill, Patricia
Corporate Officer · Individual
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