Cycle 1
Health 2025-03-26 · Fire 2025-03-26
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Shelby Townhip, MI
Shelby Crossing Health Campus
5-star overall rating with 5-star inspections with 2 recent health deficiencies
13794 21 Mile Road, Shelby Townhip, MI
(586) 532-2100
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
57
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2013-05-06
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
1.10
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.40
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.53
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.51
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.88
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.80
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.25
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
1.78
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,187
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9904
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.67% · Performance 23.35% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.86
Baseline 4.80% · Performance 6.98% · Measure score 2.86 · Achievement 2.86 · Improvement 0
Total nurse turnover
10
Baseline 40.28% · Performance 24.24% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
1.97
Baseline 3.60 hours · Performance 3.64 hours · Measure score 1.97 · Achievement 1.97 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.01% |
10.72%
2.3 pts worse
|
Worse than the National Rate · Eligible stays 837 · Observed rate 12.54% · Lower 95% interval 11.46% |
| Discharge to community | 70.03% |
50.57%
19.5 pts better
|
Better than the National Rate · Eligible stays 837 · Observed rate 66.07% · Lower 95% interval 66.92% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 440 · Denominator 440 |
| Falls with major injury | 0.45% |
0.77%
0.3 pts better
|
Numerator 2 · Denominator 440 |
| Discharge self-care score | 60.59% |
53.69%
6.9 pts better
|
Numerator 226 · Denominator 373 |
| Discharge mobility score | 66.22% |
50.94%
15.3 pts better
|
Numerator 247 · Denominator 373 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 440 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.98% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 482 · Observed rate 5.6% · Lower 95% interval 5.13% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 148 |
| Staff flu vaccination coverage | 39.25% |
42%
2.8 pts worse
|
Numerator 73 · Denominator 186 |
| Discharge function score | 58.98% |
56.45%
2.5 pts better
|
Numerator 220 · Denominator 373 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 141 · Denominator 141 |
| Transfer of health information to patient | 99.63% |
96.28%
3.3 pts better
|
Numerator 271 · Denominator 272 |
| Resident COVID-19 vaccinations up to date | 21% |
25.2%
4.2 pts worse
|
Numerator 42 · Denominator 200 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
95.0%
3.3 pts worse
|
93.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.1%
3.1 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
4.1%
0.1 pts worse
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 0.0% |
19.6%
19.6 pts better
|
19.6%
19.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.6%
5.6 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
82.8%
16.9 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.8% · Q2 99.7% · Q3 99.8% · Q4 99.5% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
11.5%
4.6 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 5.9% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.3%
1.1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.3% · Q2 0.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
79.5%
19.3 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
24.2%
0.7 pts worse
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 21.8% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-15 · Fire 2024-02-15
5 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-06 · Fire 2023-01-06
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-01-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-26
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 2025-04-18
D · Potential for more than minimal harm
2025-03-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-18
F · Potential for more than minimal harm
2024-02-15
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 2024-03-12
F · Potential for more than minimal harm
2024-02-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-15
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-15
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-03-12
D · Potential for more than minimal harm
2023-01-06
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 2023-02-08
D · Potential for more than minimal harm
2023-01-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-08
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
Barney, Leigh
Corporate Officer · Individual
Bryant, William
Corporate Officer · Individual
Bufford, Randall
Corporate Officer · Individual
Chua, Nelson
Operational/Managerial Control · Individual
Conner, Gregory
Corporate Officer · Individual
Continental Merger Sub LLC
5% Or Greater Indirect Ownership Interest · Organization
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
Keybank National Association
5% Or Greater Mortgage Interest · Organization
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
Streiff, Mathieu
Corporate Officer · Individual
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
Nearby options
Other facilities in reach
#1
Shelby Health and Rehabilitation Center
Shelby Township, MI
3-star overall rating with 2-star inspections with $41,847 in total fines with 15 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Lakeside Manor Nursing and Rehabilitation Center
Sterling Heights, MI
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with 12 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Medilodge of Shoreline
Sterling Heights, MI
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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