14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Rochester Hills, MI
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3500 West South Blvd, Rochester Hills, MI
(248) 852-7800
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
182
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-01-01
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
RN hours / resident day
0.52
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.66
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.58
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.17
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.02
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
4.99
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Program rank
3,504
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9971
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.51
Baseline 25.65% · Performance 21.33% · Measure score 4.51 · Achievement 0 · Improvement 4.51
Healthcare-associated infections
6.90
Baseline 5.99% · Performance 5.77% · Measure score 6.90 · Achievement 6.90 · Improvement 1.65
Total nurse turnover
3.10
Performance 50.99% · Measure score 3.10 · Achievement 3.10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.10
Baseline 3.69 hours · Performance 3.96 hours · Measure score 3.10 · Achievement 3.10 · Improvement 0.79
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.41% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 500 · Observed rate 11.4% · Lower 95% interval 9.33% |
| Discharge to community | 64.65% |
50.57%
14.1 pts better
|
Better than the National Rate · Eligible stays 462 · Observed rate 58.66% · Lower 95% interval 59.79% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.26% |
95.27%
4 pts better
|
Numerator 267 · Denominator 269 |
| Falls with major injury | 1.12% |
0.77%
0.4 pts worse
|
Numerator 3 · Denominator 269 |
| Discharge self-care score | 48.7% |
53.69%
5 pts worse
|
Numerator 94 · Denominator 193 |
| Discharge mobility score | 63.73% |
50.94%
12.8 pts better
|
Numerator 123 · Denominator 193 |
| Pressure ulcers or injuries, new or worsened | 2.23% |
2.29%
0.1 pts better
|
Numerator 6 · Denominator 269 · Adjusted rate 2.09% |
| Healthcare-associated infections requiring hospitalization | 5.77% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 238 · Observed rate 4.62% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 185 |
| Staff flu vaccination coverage | 97.35% |
42%
55.3 pts better
|
Numerator 220 · Denominator 226 |
| Discharge function score | 51.81% |
56.45%
4.6 pts worse
|
Numerator 100 · Denominator 193 |
| Transfer of health information to provider | 96% |
95.95%
About the same
|
Numerator 72 · Denominator 75 |
| Transfer of health information to patient | 98.75% |
96.28%
2.5 pts better
|
Numerator 158 · Denominator 160 |
| Resident COVID-19 vaccinations up to date | 14.94% |
25.2%
10.3 pts worse
|
Numerator 23 · Denominator 154 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.2 |
1.7
1.5 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.5
0.4 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
95.0%
3.5 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 100.0% · Q3 100.0% · Q4 98.8% · 4Q avg 98.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
95.0%
1.7 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.1%
About the same
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.9% · Q3 2.5% · Q4 2.5% · 4Q avg 3.1% · 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 | 5.6% |
5.5%
0.1 pts worse
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 9.2% · Q3 4.6% · Q4 1.5% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.2% |
19.6%
3.4 pts better
|
19.6%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 15.2% · Q3 14.7% · Q4 14.9% · 4Q avg 16.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.2% |
16.5%
6.3 pts better
|
16.7%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 9.3% · Q3 10.5% · Q4 10.7% · 4Q avg 10.2% · 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 | 9.3% |
13.9%
4.6 pts better
|
16.3%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 8.7% · Q3 4.8% · Q4 7.4% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.7% |
11.7%
4 pts better
|
14.9%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.8% · Q3 12.3% · Q4 9.2% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
0.9%
2 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 1.0% · Q3 2.9% · Q4 1.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.7%
0.5 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.8% · Q3 2.6% · Q4 1.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.7% |
20.4%
10.7 pts better
|
19.8%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 13.6% · Q3 1.5% · Q4 4.1% · 4Q avg 9.7% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
5.6%
0.6 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.9% · Q3 6.1% · Q4 3.6% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
82.8%
14 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 95.8% · Q3 95.8% · Q4 98.4% · 4Q avg 96.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
11.5%
2.1 pts worse
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 12.9% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.3% · Q3 1.4% · Q4 0.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
79.5%
16.6 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.7% |
24.2%
9.5 pts worse
|
23.9%
9.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.7% · Observed 30.2% · Expected 21.4% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (8 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-09
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-09
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-11
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-11
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-04-11
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-11
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-03-07
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-03-07
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-07
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-07
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-07
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-03-07
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-07
Inspection history
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-09-23
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-09-23
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-09
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-04-09
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-09
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 2025-04-09
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-09
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 2025-04-09
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-09
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-09
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-09
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-04
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-09
Health
Implement a program that monitors antibiotic use.
Corrected 2025-04-09
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-20
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-31
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-11
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-04-11
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-11
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-11
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 2024-04-11
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-11
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-11
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-11
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-11
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-04-11
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-04-11
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-23
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-05-23
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-07
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-07
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-03-07
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 2023-03-07
Health
Implement a program that monitors antibiotic use.
Corrected 2023-03-07
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-03-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-07
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-07
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-07
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-03-07
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-07
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-07
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-03-07
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
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