Cycle 1
Health 2025-03-20 · Fire 2025-03-20
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Lapeer, MI
The Orchards at Lapeer
2-star overall rating with 3-star inspections with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
239 South Main Street, Lapeer, MI
(810) 664-6611
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
87
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Orchards Michigan
Operator or chain grouping
Approved since
2011-07-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 2 overall / 3 health / 1 staffing / 4 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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
12,284
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.07% · Performance 21.99% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.34
Baseline 6.50% · Performance 7.14% · Measure score 2.34 · Achievement 2.34 · Improvement 0
Total nurse turnover
0
Performance 80.64% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.88
Baseline 3.55 hours · Performance 3.90 hours · Measure score 2.88 · Achievement 2.88 · Improvement 1.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.62% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 6.45% · Lower 95% interval 6.6% |
| Discharge to community | 44.43% |
50.57%
6.1 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 35.42% · Lower 95% interval 34.57% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 35% |
95.27%
60.3 pts worse
|
Numerator 14 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 48.28% |
53.69%
5.4 pts worse
|
Numerator 14 · Denominator 29 |
| Discharge mobility score | 65.52% |
50.94%
14.6 pts better
|
Numerator 19 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 1 · Denominator 40 · Adjusted rate 2.28% |
| Healthcare-associated infections requiring hospitalization | 7.14% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 3.46% |
| Staff COVID-19 vaccination coverage | 1.16% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 86 |
| Staff flu vaccination coverage | 11.35% |
42%
30.6 pts worse
|
Numerator 16 · Denominator 141 |
| Discharge function score | 62.07% |
56.45%
5.6 pts better
|
Numerator 18 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 35% |
25.2%
9.8 pts better
|
Numerator 7 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.1 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.7% |
95.0%
7.3 pts worse
|
93.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 88.7% · Q3 87.8% · Q4 83.7% · 4Q avg 87.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.3% |
95.0%
1.7 pts worse
|
95.5%
2.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.1%
0.2 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.8% · Q3 2.0% · Q4 2.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
4.1%
3.6 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
5.5%
1.1 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 2.4% · Q3 5.6% · Q4 0.0% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.8% |
19.6%
19.2 pts worse
|
19.6%
19.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 40.5% · Q3 43.2% · Q4 34.3% · 4Q avg 38.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.4% |
16.5%
5.9 pts worse
|
16.7%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 25.9% · Q3 25.0% · Q4 24.0% · 4Q avg 22.4% · 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 | 16.2% |
13.9%
2.3 pts worse
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.8% |
11.7%
2.9 pts better
|
14.9%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 17.9% · Q3 0.0% · Q4 3.1% · 4Q avg 8.8% · 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 | 1.0% |
1.7%
0.7 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.2% |
20.4%
8.8 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 22.5% · Q3 37.2% · Q4 27.1% · 4Q avg 29.2% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.6%
2.5 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.9% · Q3 3.8% · Q4 3.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.5% |
82.8%
20.3 pts worse
|
81.7%
19.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.6% · Q2 56.1% · Q3 40.0% · Q4 71.1% · 4Q avg 62.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.3% |
11.5%
6.8 pts worse
|
12.0%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 20.0% · Expected 12.2% · 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 5.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.1% |
79.5%
15.4 pts worse
|
79.7%
15.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.2% |
24.2%
12 pts better
|
23.9%
11.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 13.3% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-07 · Fire 2024-05-07
14 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-02-07 · Fire 2023-02-07
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-20
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-03-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-03-20
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-03-26
F · Potential for more than minimal harm
2024-05-07
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-05-10
F · Potential for more than minimal harm
2024-05-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-05-07
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 2024-05-10
F · Potential for more than minimal harm
2023-06-06
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-06-24
F · Potential for more than minimal harm
2023-06-06
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-06-24
E · Potential for more than minimal harm
2023-02-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-02-20
E · Potential for more than minimal harm
2023-02-07
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 2023-02-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-28
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-02-13
E · Potential for more than minimal harm
2025-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-03-20
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 2025-03-26
D · Potential for more than minimal harm
2025-03-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-03-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-03-20
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-03-20
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-03-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-03-20
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-03-20
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-03-20
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 2025-03-26
D · Potential for more than minimal harm
2025-03-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-13
G · Actual harm
2024-05-07
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 2024-05-10
E · Potential for more than minimal harm
2024-05-07
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 2024-05-10
E · Potential for more than minimal harm
2024-05-07
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-05-07
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 2024-05-10
E · Potential for more than minimal harm
2024-05-07
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-05-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-05-07
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-05-07
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-05-07
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 2024-05-10
D · Potential for more than minimal harm
2024-05-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-05-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-05-07
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-05-07
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-05-10
C · Minimal harm
2024-05-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-05-10
E · Potential for more than minimal harm
2023-02-07
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 2023-02-20
D · Potential for more than minimal harm
2023-02-07
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 2023-02-20
D · Potential for more than minimal harm
2023-02-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-02-07
F756 · Pharmacy Service Deficiencies
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 2023-02-20
D · Potential for more than minimal harm
2023-02-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-02-20
Penalties and ownership
What sits behind the stars
Ownership
Gutman, Isaac
5% Or Greater Direct Ownership Interest · Individual
Taub, Jacob
5% Or Greater Direct Ownership Interest · Individual
Hoffman, Alexander
5% Or Greater Direct Ownership Interest · Individual
Kornfeld, Robert
5% Or Greater Direct Ownership Interest · Individual
Applefield, Michael
Operational/Managerial Control · Individual
Gamble, Becky
Operational/Managerial Control · Individual
White Lake Healthcare LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Stonegate Health Campus
Lapeer, MI
3-star overall rating with 3-star inspections with $66,414 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
McLaren Lapeer Region
Lapeer, MI
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
Lapeer County Medical Care Facility
Lapeer, MI
4-star overall rating with 3-star inspections with $68,445 in total fines with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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