Bellaire, MI

Meadow Brook Medical Care Facility

2-star overall rating with 2-star inspections with abuse icon flag with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

4543 South M-88 Highway, Bellaire, MI

(231) 533-8661

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 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

133

Certified beds

Average residents

99

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1967-01-01

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

1.26

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.48

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

3.24

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

4.98

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.74

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

4.32

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.84

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

1.44

CMS adjusted RN staffing hours

Adjusted total hours

5.69

CMS adjusted total nurse staffing hours

Case-mix index

1.20

Higher values indicate more complex resident acuity

RN turnover

86%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

76%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,019

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

37.72

Composite VBP score used to determine payment impact.

Payment multiplier

0.9909

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.60

Performance 19.77% · Measure score 3.60 · Achievement 3.60 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

2.42

Performance 7.11% · Measure score 2.42 · Achievement 2.42 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

0

Baseline 33.33% · Performance 80.49% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

9.07

Baseline 6.12 hours · Performance 5.66 hours · Measure score 9.07 · Achievement 9.07 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.38%	10.72% 1.3 pts better	No Different than the National Rate · Eligible stays 55 · Observed rate 3.64% · Lower 95% interval 5.44%
Discharge to community	44.99%	50.57% 5.6 pts worse	No Different than the National Rate · Eligible stays 47 · Observed rate 38.3% · Lower 95% interval 32.07%
Medicare spending per beneficiary	0.94	1.02 0.1 pts better
Drug regimen review with follow-up	97.22%	95.27% 2 pts better	Numerator 35 · Denominator 36
Falls with major injury	2.78%	0.77% 2 pts worse	Numerator 1 · Denominator 36
Discharge self-care score	53.33%	53.69% 0.4 pts worse	Numerator 16 · Denominator 30
Discharge mobility score	46.67%	50.94% 4.3 pts worse	Numerator 14 · Denominator 30
Pressure ulcers or injuries, new or worsened	2.78%	2.29% 0.5 pts worse	Numerator 1 · Denominator 36 · Adjusted rate 4.05%
Healthcare-associated infections requiring hospitalization	7.11%	7.12% About the same	No Different than the National Rate · Eligible stays 45 · Observed rate 6.67% · Lower 95% interval 3.65%
Staff COVID-19 vaccination coverage	24.84%	8.2% 16.6 pts better	Numerator 39 · Denominator 157
Staff flu vaccination coverage	89.44%	42% 47.4 pts better	Numerator 161 · Denominator 180
Discharge function score	46.67%	56.45% 9.8 pts worse	Numerator 14 · Denominator 30
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 20 · Denominator 20
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 18 · 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	1.4	1.7 0.3 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.5 · 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	100.0%	95.0% 5 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
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	3.3%	3.1% 0.2 pts worse	3.3% About the same	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.5% · Q3 3.4% · Q4 5.7% · 4Q avg 3.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.6%	4.1% 1.5 pts worse	11.4% 5.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 3.9% · Q3 0.0% · Q4 9.3% · 4Q avg 5.6%
Percentage of long-stay residents who lose too much weight	5.5%	5.5% About the same	5.4% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 7.2% · Q3 5.6% · Q4 7.9% · 4Q avg 5.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.0%	19.6% 0.6 pts better	19.6% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 17.8% · Q3 19.0% · Q4 17.9% · 4Q avg 19.0%
Percentage of long-stay residents who received an antipsychotic medication	19.8%	16.5% 3.3 pts worse	16.7% 3.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 20.6% · Q3 18.7% · Q4 19.2% · 4Q avg 19.8% · 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	18.4%	13.9% 4.5 pts worse	16.3% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 15.8% · Q3 13.7% · Q4 25.0% · 4Q avg 18.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	31.0%	11.7% 19.3 pts worse	14.9% 16.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 31.0% · Q3 32.1% · Q4 35.1% · 4Q avg 31.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	0.9% About the same	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 0.0% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.6%	1.7% 0.1 pts better	1.7% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 1.2% · Q4 2.3% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.3%	20.4% 1.9 pts worse	19.8% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 21.2% · Q3 18.7% · Q4 23.5% · 4Q avg 22.3%
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 · Q1 5.2% · Q2 0.0% · Q3 2.9% · Q4 1.5% · 4Q avg 2.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.4%	82.8% 14.6 pts better	81.7% 15.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 98.0% · Q3 98.0% · Q4 96.4% · 4Q avg 97.4%
Percentage of short-stay residents who had an outpatient emergency department visit	12.9%	11.5% 1.4 pts worse	12.0% 0.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 12.5% · Expected 10.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.8%	1.3% 0.5 pts better	1.6% 0.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.8% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.0%	79.5% 18.5 pts better	79.7% 18.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 98.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	15.0%	24.2% 9.2 pts better	23.9% 8.9 pts better	Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 12.5% · Expected 19.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-25 · Fire 2025-09-25

5 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

2 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 2 Health 2024-10-30 · Fire 2024-10-30

4 health deficiencies

Top issue: Administration (1 deficiency)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2024-01-10 · Fire 2024-01-10

0 health deficiencies

No concentrated health issue counts in this cycle.

4 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-09-25

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-11-23

E · Potential for more than minimal harm 2025-09-25

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2026-02-18

F · Potential for more than minimal harm 2024-10-30

K343 · Smoke Deficiencies

Fire Safety

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Corrected 2025-03-24

F · Potential for more than minimal harm 2024-10-30

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-12-20

E · Potential for more than minimal harm 2024-10-30

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2024-12-20

F · Potential for more than minimal harm 2024-01-10

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2024-03-08

F · Potential for more than minimal harm 2024-01-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-03-08

F · Potential for more than minimal harm 2024-01-10

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2024-03-08

D · Potential for more than minimal harm 2024-01-10

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2024-03-08

Inspection history

Recent health citations

G · Actual harm 2025-09-25

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 2025-09-01

G · Actual harm 2025-09-25

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 2025-11-03

D · Potential for more than minimal harm 2025-09-25

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 2025-11-03

D · Potential for more than minimal harm 2025-09-25

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 2025-11-03

D · Potential for more than minimal harm 2025-09-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-11-03

D · Potential for more than minimal harm 2024-10-30

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 2024-12-06

D · Potential for more than minimal harm 2024-10-30

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 2024-12-06

D · Potential for more than minimal harm 2024-10-30

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 2024-12-06

B · Minimal harm 2024-10-30

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2024-12-06

Penalties and ownership

What sits behind the stars

$0 2025-09-25

Payment Denial

Payment Denial · denial start 2025-10-24 · 30 days

30 day denial

Ownership

Antrim County

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 1967-01-01

Clore, Maureen