Cycle 1
Health 2025-06-26 · Fire 2025-06-26
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Stephenson, MI
Roubal Care and Rehabilitation Center
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
N 306 Maple Street, Stephenson, MI
(906) 753-4981
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
39
Certified beds
Average residents
38
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-08-01
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
0.72
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.29
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
0.84
CMS adjusted RN staffing hours
Adjusted total hours
3.98
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 8.2% |
8.2%
About the same
|
Numerator 5 · Denominator 61 |
| Staff flu vaccination coverage | 1.61% |
42%
40.4 pts worse
|
Numerator 1 · Denominator 62 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.4% |
95.0%
4.6 pts worse
|
93.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 97.0% · Q3 97.0% · Q4 71.4% · 4Q avg 90.4% |
| 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 | 4.4% |
3.1%
1.3 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 3.0% · Q3 3.0% · Q4 2.9% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
4.1%
3.3 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
5.5%
1.7 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 11.5% · Q3 4.0% · Q4 7.4% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.4% |
19.6%
10.2 pts better
|
19.6%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 3.4% · Q3 11.5% · Q4 14.3% · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.1% |
16.5%
3.4 pts better
|
16.7%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 18.2% · Q3 9.1% · Q4 10.7% · 4Q avg 13.1% · 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 | 8.9% |
13.9%
5 pts better
|
16.3%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.1% |
11.7%
0.6 pts better
|
14.9%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 13.8% · Q3 7.7% · Q4 17.9% · 4Q avg 11.1% · 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 | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.8% |
20.4%
13.4 pts worse
|
19.8%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 29.8% · Q3 39.5% · Q4 28.3% · 4Q avg 33.8% |
| 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 0.0% · Q2 0.0% · Q3 2.9% · Q4 2.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.0% |
82.8%
4.8 pts worse
|
81.7%
3.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 78.0% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-15 · Fire 2024-05-15
9 health deficiencies
Top issue: Infection Control (4 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2023-06-16 · Fire 2023-06-16
6 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-26
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-06-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-06-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-06-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-06-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-06
F · Potential for more than minimal harm
2025-06-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-06-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-06-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-08-08
F · Potential for more than minimal harm
2024-05-15
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-05-15
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-05-15
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-05-15
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-05-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-05-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-05-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-05-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-05-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-05-15
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-05-15
K321 · Smoke Deficiencies
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 2024-06-21
E · Potential for more than minimal harm
2024-05-15
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-15
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2024-06-21
F · Potential for more than minimal harm
2023-06-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-14
F · Potential for more than minimal harm
2023-06-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-14
F · Potential for more than minimal harm
2023-06-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-14
F · Potential for more than minimal harm
2023-06-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-14
F · Potential for more than minimal harm
2023-06-16
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-07-14
F · Potential for more than minimal harm
2023-06-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-06-16
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-06-16
K321 · Smoke Deficiencies
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 2023-07-14
E · Potential for more than minimal harm
2023-06-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-14
Inspection history
Recent health citations
G · Actual harm
2025-06-26
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 2025-07-24
F · Potential for more than minimal harm
2025-06-26
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 2025-07-24
F · Potential for more than minimal harm
2025-06-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-26
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 2025-07-24
D · Potential for more than minimal harm
2025-06-26
F584 · Resident Rights Deficiencies
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 2025-07-24
D · Potential for more than minimal harm
2025-06-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-24
C · Minimal harm
2025-06-26
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-07-24
C · Minimal harm
2025-06-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-07-24
F · Potential for more than minimal harm
2024-05-15
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-05-15
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-05-15
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 2024-06-21
D · Potential for more than minimal harm
2024-05-15
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 2024-06-21
D · Potential for more than minimal harm
2024-05-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-15
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 2024-06-21
D · Potential for more than minimal harm
2024-05-15
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-15
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-21
F · Potential for more than minimal harm
2023-06-16
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-07-14
F · Potential for more than minimal harm
2023-06-16
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 2023-07-14
E · Potential for more than minimal harm
2023-06-16
F761 · Pharmacy Service Deficiencies
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 2023-07-14
E · Potential for more than minimal harm
2023-06-16
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-16
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 2023-07-14
D · Potential for more than minimal harm
2023-06-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-07-14
Penalties and ownership
What sits behind the stars
$0
2025-06-26
Payment Denial
Payment Denial · denial start 2025-07-25 · 14 days
14 day denial
Ownership
Friedman, Benjamin
5% Or Greater Direct Ownership Interest · Individual
Friedman, Benjamin
Corporate Director · Individual
Friedman, Benjamin
Corporate Officer · Individual
Friedman, Benjamin
W-2 Managing Employee · Individual
Nearby options
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4-star overall rating with 3-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Menominee Health Services
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4-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Newcare
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5-star overall rating with 4-star inspections with $10,062 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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