Cycle 1
Health 2026-01-08 · Fire 2026-01-08
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Belmont, MI
The Oaks at Belmont
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
6081 W River Drive, Belmont, MI
(906) 670-4451
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
60
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2021-06-23
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
1.19
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.17
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.99
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.64
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.83
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
1.07
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,518
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9895
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.93% · Performance 23.36% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
8.46
Baseline 7.54% · Performance 5.31% · Measure score 8.46 · Achievement 8.46 · Improvement 8.28
Total nurse turnover
3.95
Performance 47.54% · Measure score 3.95 · Achievement 3.95 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.97
Baseline 3.73 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 | 11.4% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 246 · Observed rate 11.79% · Lower 95% interval 8.46% |
| Discharge to community | 70.49% |
50.57%
19.9 pts better
|
Better than the National Rate · Eligible stays 218 · Observed rate 66.06% · Lower 95% interval 63.44% |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 181 · Denominator 181 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 181 |
| Discharge self-care score | 68.67% |
53.69%
15 pts better
|
Numerator 103 · Denominator 150 |
| Discharge mobility score | 68.67% |
50.94%
17.7 pts better
|
Numerator 103 · Denominator 150 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 181 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.31% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 148 · Observed rate 2.7% · Lower 95% interval 3.14% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 138 |
| Staff flu vaccination coverage | 46.83% |
42%
4.8 pts better
|
Numerator 96 · Denominator 205 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 100 · Denominator 150 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 146 · Denominator 146 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 46.99% |
25.2%
21.8 pts better
|
Numerator 39 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.0%
5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
95.0%
1.4 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.1%
2.1 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
4.1%
3 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
5.5%
2.8 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 9.5% · Q3 0.0% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.3% |
19.6%
5.7 pts worse
|
19.6%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 22.7% · Q3 30.0% · 4Q avg 25.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
16.5%
16.5 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.2% |
11.7%
3.5 pts better
|
14.9%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 10.0% · Q3 20.0% · 4Q avg 8.2% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.7%
0.6 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.6% |
20.4%
12.2 pts worse
|
19.8%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 41.6% · Q3 34.4% · 4Q avg 32.6% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
82.8%
16.6 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.7% · Q2 99.7% · Q3 98.7% · Q4 99.7% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
11.5%
1.6 pts worse
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 12.5% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.1% |
1.3%
1.2 pts better
|
1.6%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.6% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.6% |
79.5%
9.1 pts better
|
79.7%
8.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
24.2%
0.6 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 23.5% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-24 · Fire 2024-10-24
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-11-15 · Fire 2023-11-15
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2026-01-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-01-21
E · Potential for more than minimal harm
2026-01-08
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2026-01-21
E · Potential for more than minimal harm
2023-11-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-21
G · Actual harm
2025-08-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-27
F · Potential for more than minimal harm
2024-10-24
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 2024-11-08
D · Potential for more than minimal harm
2024-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-08
D · Potential for more than minimal harm
2023-11-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-05-31
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 2023-04-15
D · Potential for more than minimal harm
2023-05-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-14
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
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
Mehaffey, Todd
Corporate Officer · 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
Streiff, Mathieu
Corporate Officer · Individual
Stuever, Jana
Operational/Managerial Control · 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
Williamson, Bradley
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Michigan Veteran Homes at Grand Rapids
Grand Rapids, MI
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Medilodge of Grand Rapids
Grand Rapids, MI
1-star overall rating with 1-star inspections with $57,658 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Optalis Health & Rehabilitation at Leonard
Grand Rapids, MI
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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