Cycle 1
Health 2025-05-06 · Fire 2025-05-06
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Romeo, MI
Orchard Grove Health Campus
5-star overall rating with 4-star inspections with 3 recent health deficiencies
71150 Orchard Crossing Lane, Romeo, MI
(586) 336-0102
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
55
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2017-04-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 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
1.00
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.35
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.75
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.10
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.35
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.62
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.85
CMS adjusted RN staffing hours
Adjusted total hours
3.49
CMS adjusted total nurse staffing hours
Case-mix index
1.61
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
661
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.76
Composite VBP score used to determine payment impact.
Payment multiplier
1.0199
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.22
Baseline 18.48% · Performance 17.16% · Measure score 9.22 · Achievement 9.22 · Improvement 8.59
Healthcare-associated infections
7.16
Baseline 7.82% · Performance 5.70% · Measure score 7.16 · Achievement 7.16 · Improvement 7.02
Total nurse turnover
8.99
Baseline 35.29% · Performance 26.92% · Measure score 8.99 · Achievement 8.99 · Improvement 7.52
Adjusted total nurse staffing
0.93
Baseline 3.42 hours · Performance 3.34 hours · Measure score 0.93 · Achievement 0.93 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.56% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 279 · Observed rate 10.39% · Lower 95% interval 7.74% |
| Discharge to community | 71.17% |
50.57%
20.6 pts better
|
Better than the National Rate · Eligible stays 278 · Observed rate 66.55% · Lower 95% interval 63.66% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 177 · Denominator 177 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 177 |
| Discharge self-care score | 69.92% |
53.69%
16.2 pts better
|
Numerator 93 · Denominator 133 |
| Discharge mobility score | 75.19% |
50.94%
24.2 pts better
|
Numerator 100 · Denominator 133 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 177 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.69% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 201 · Observed rate 3.98% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 117 |
| Staff flu vaccination coverage | 34.34% |
42%
7.7 pts worse
|
Numerator 57 · Denominator 166 |
| Discharge function score | 72.93% |
56.45%
16.5 pts better
|
Numerator 97 · Denominator 133 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 140 · Denominator 140 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 21.65% |
25.2%
3.6 pts worse
|
Numerator 21 · Denominator 97 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
95.0%
2.6 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 95.7% · Q4 100.0% · 4Q avg 97.6% |
| 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 | 1.2% |
3.1%
1.9 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.6% |
4.1%
2.5 pts worse
|
11.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 6.6% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
5.5%
3.8 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.0% |
19.6%
15.4 pts worse
|
19.6%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.0% |
16.5%
6.5 pts better
|
16.7%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.0% · 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% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.7% |
13.9%
5.2 pts better
|
16.3%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.6% |
11.7%
8.1 pts better
|
14.9%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.6% · 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% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.7% |
20.4%
0.3 pts worse
|
19.8%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 28.0% · Q4 18.4% · 4Q avg 20.7% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.6%
3.5 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.6% · Q4 2.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
82.8%
16.1 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 99.5% · Q3 99.0% · Q4 97.7% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
11.5%
5.9 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 5.9% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
79.5%
19 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.3% |
24.2%
5.9 pts better
|
23.9%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 20.0% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-04 · Fire 2024-04-04
2 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-22 · Fire 2023-03-22
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-03-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-13
Inspection history
Recent health citations
G · Actual harm
2025-08-20
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 2025-09-09
D · Potential for more than minimal harm
2025-05-06
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 2025-05-21
D · Potential for more than minimal harm
2025-05-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-21
D · Potential for more than minimal harm
2024-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-04-04
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-04-20
F · Potential for more than minimal harm
2023-03-22
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 2023-04-13
D · Potential for more than minimal harm
2023-03-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-22
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 2023-04-13
Penalties and ownership
What sits behind the stars
Ownership
Trilogy Opco LLC
5% Or Greater Direct Ownership Interest · Organization
American Healthcare Reit Holdings LP
5% Or Greater Indirect Ownership Interest · Organization
American Healthcare Reit Inc
5% Or Greater Indirect Ownership Interest · Organization
Barber, Robin
Corporate Officer · Individual
Barney, Leigh
Corporate Officer · Individual
Bryant, William
Corporate Officer · Individual
Bufford, Randall
Corporate Officer · Individual
Corbin, Kathy
W-2 Managing Employee · Individual
Davis, David
Corporate Officer · Individual
Fightmaster, Lisa
W-2 Managing Employee · Individual
Gahc3 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Gahc4 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Griffin-American Healthcare Reit Iii, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Griffin-American Healthcare Reit Iv Holdings, LP
5% Or Greater Indirect Ownership Interest · Organization
Kesavan, Nirmal
Operational/Managerial Control · Individual
Northstar Healthcare Income Inc
5% Or Greater Indirect Ownership Interest · Organization
Northstar Healthcare Income Operating Partnership LP
5% Or Greater Indirect Ownership Interest · Organization
Prosky, Danny
Corporate Officer · Individual
Regions Bank
5% Or Greater Mortgage Interest · Organization
Streiff, Mathieu
Corporate Officer · Individual
Trilogy Health Services LLC
Operational/Managerial Control · Organization
Trilogy Healthcare Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Holdings Nt-Hci, LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Management Services LLC
Operational/Managerial Control · Organization
Trilogy Real Estate Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Reit Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Williamson, Bradley
Corporate Officer · Individual
Nearby options
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