Midland, MI

Stratford Pines Nursing and Rehabilitation Center

3-star overall rating with 3-star inspections with $16,801 in total fines with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

2121 Rockwell Drive, Midland, MI

(989) 633-5350

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

100

Certified beds

Average residents

91

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Peplinski Group

Operator or chain grouping

Approved since

2003-05-30

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.74

Registered nurse staffing

LPN hours / resident day

0.72

Licensed practical nurse staffing

Aide hours / resident day

2.70

Nurse aide staffing

Weekend hours

3.82

Weekend nurse staffing

RN turnover

56%

Annual RN turnover

Total nurse turnover

50%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.2
1.7
0.5 pts better
1.9
0.7 pts better
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 0.7
1.5
0.8 pts better
1.8
1.1 pts better
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 98.9%
95.0%
3.9 pts better
93.4%
5.5 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97.4%
95.0%
2.4 pts better
95.5%
1.9 pts better
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 0.4%
3.1%
2.7 pts better
3.3%
2.9 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 1.2%
4.1%
2.9 pts better
11.4%
10.2 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 6.8%
5.5%
1.3 pts worse
5.4%
1.4 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 30.4%
19.6%
10.8 pts worse
19.6%
10.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 9.0%
16.5%
7.5 pts better
16.7%
7.7 pts better
Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened 12.2%
13.9%
1.7 pts better
16.3%
4.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 13.3%
11.7%
1.6 pts worse
14.9%
1.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.7%
0.9%
0.2 pts better
1.0%
0.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 4.4%
1.7%
2.7 pts worse
1.7%
2.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 27.4%
20.4%
7 pts worse
19.8%
7.6 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 4.6%
5.6%
1 pts better
5.1%
0.5 pts better
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 83.8%
82.8%
1 pts better
81.7%
2.1 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 14.2%
11.5%
2.7 pts worse
12.0%
2.2 pts worse
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 2.9%
1.3%
1.6 pts worse
1.6%
1.3 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 90.3%
79.5%
10.8 pts better
79.7%
10.6 pts better
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 33.3%
24.2%
9.1 pts worse
23.9%
9.4 pts worse
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-30 · Fire 2025-01-30

16 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2023-11-30 · Fire 2023-11-30

3 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2022-11-22 · Fire 2022-11-22

12 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

5 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-30

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-06-24

E · Potential for more than minimal harm 2025-01-30

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2025-02-21

E · Potential for more than minimal harm 2025-01-30

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2025-02-14

E · Potential for more than minimal harm 2025-01-30

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-02-14

D · Potential for more than minimal harm 2025-01-30

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-02-21

F · Potential for more than minimal harm 2023-11-30

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-12-22

F · Potential for more than minimal harm 2023-11-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-12-22

F · Potential for more than minimal harm 2023-11-30

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-12-22

E · Potential for more than minimal harm 2023-11-30

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-12-22

F · Potential for more than minimal harm 2022-11-22

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2023-01-06

F · Potential for more than minimal harm 2022-11-22

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-01-06

F · Potential for more than minimal harm 2022-11-22

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-01-06

F · Potential for more than minimal harm 2022-11-22

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-01-06

E · Potential for more than minimal harm 2022-11-22

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 2023-01-06

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-05-08

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 2025-06-11

D · Potential for more than minimal harm 2025-05-08

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 2025-06-11

D · Potential for more than minimal harm 2025-05-08

F909 · Environmental Deficiencies

Health

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Corrected 2025-06-11

E · Potential for more than minimal harm 2025-01-30

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 2025-03-05

E · Potential for more than minimal harm 2025-01-30

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 2025-03-05

D · Potential for more than minimal harm 2025-01-30

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-03-05

D · Potential for more than minimal harm 2025-01-30

F553 · Resident Rights Deficiencies

Health

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Corrected 2025-03-05

D · Potential for more than minimal harm 2025-01-30

F578 · Resident Rights Deficiencies

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 2025-03-05

D · Potential for more than minimal harm 2025-01-30

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 2025-03-05

D · Potential for more than minimal harm 2025-01-30

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-03-05

D · Potential for more than minimal harm 2025-01-30

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2025-03-05

D · Potential for more than minimal harm 2025-01-30

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-03-05

D · Potential for more than minimal harm 2025-01-30

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2025-03-05

D · Potential for more than minimal harm 2025-01-30

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 2025-03-05

D · Potential for more than minimal harm 2025-01-30

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-03-05

D · Potential for more than minimal harm 2025-01-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-05

G · Actual harm 2024-12-04

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 2024-12-28

G · Actual harm 2023-11-30

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-11-30

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-12-22

D · Potential for more than minimal harm 2023-10-05

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-11-01

D · Potential for more than minimal harm 2023-10-05

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-11-01

F · Potential for more than minimal harm 2022-11-22

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 2023-01-06

E · Potential for more than minimal harm 2022-11-22

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 2023-01-06

E · Potential for more than minimal harm 2022-11-22

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 2023-01-06

D · Potential for more than minimal harm 2022-11-22

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 2023-01-06

D · Potential for more than minimal harm 2022-11-22

F578 · Resident Rights Deficiencies

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 2023-01-06

D · Potential for more than minimal harm 2022-11-22

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2023-01-06

D · Potential for more than minimal harm 2022-11-22

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-01-06

D · Potential for more than minimal harm 2022-11-22

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2023-01-06

D · Potential for more than minimal harm 2022-11-22

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-01-06

D · Potential for more than minimal harm 2022-11-22

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2023-01-06

Penalties and ownership

What sits behind the stars

$16,801 2024-12-04

Fine

Fine · fine $16,801

Fine

Ownership

Ackerman, Ricky

Operational/Managerial Control · Individual

0% 10 facilities 2016-05-01
Plante & Moran Pllc

Operational/Managerial Control · Organization

0% 8 facilities 2016-05-01
Schade, Jeffery

Operational/Managerial Control · Individual

0% 10 facilities 2016-05-01
Thompson, Brian

Operational/Managerial Control · Individual

0% 11 facilities 2016-05-01
Winkels, Kathy

Operational/Managerial Control · Individual

0% 10 facilities 2016-07-06
Woods, Aaron

Operational/Managerial Control · Individual

0% 1 facilities 2024-04-03

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