Cycle 1
Health 2025-09-11 · Fire 2025-09-11
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Southgate, MI
The Orchards at Southgate
3-star overall rating with 3-star inspections with $47,691 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
15400 Trenton Road, Southgate, MI
(734) 284-4620
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Orchards Michigan
Operator or chain grouping
Approved since
1975-11-01
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
9,226
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.44
Baseline 76.12% · Performance 61.05% · Measure score 2.44 · Achievement 0.64 · Improvement 2.44
Adjusted total nurse staffing
2.44
Baseline 3.04 hours · Performance 3.77 hours · Measure score 2.44 · Achievement 2.44 · Improvement 2.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.61% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 23.21% · Lower 95% interval 8.73% |
| Discharge to community | 32.74% |
50.57%
17.8 pts worse
|
Worse than the National Rate · Eligible stays 33 · Observed rate 15.15% · Lower 95% interval 22.03% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 90.63% |
95.27%
4.6 pts worse
|
Numerator 29 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 35% |
53.69%
18.7 pts worse
|
Numerator 7 · Denominator 20 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 10 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 32 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.92% |
8.2%
5.3 pts worse
|
Numerator 4 · Denominator 137 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 35% |
56.45%
21.5 pts worse
|
Numerator 7 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.5
0.1 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
95.0%
7.7 pts worse
|
93.4%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 61.8% · Q2 97.2% · Q3 94.7% · Q4 96.1% · 4Q avg 87.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
95.0%
3.7 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.1%
1.8 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 2.6% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
4.1%
3.4 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
5.5%
0.7 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 4.7% · Q3 7.6% · Q4 4.5% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.4% |
19.6%
12.8 pts worse
|
19.6%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 31.2% · Q3 34.8% · Q4 33.8% · 4Q avg 32.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.7% |
16.5%
8.2 pts worse
|
16.7%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 28.3% · Q3 22.5% · Q4 25.6% · 4Q avg 24.7% · 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 | 18.8% |
13.9%
4.9 pts worse
|
16.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 20.2% · Q3 30.8% · Q4 9.6% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
11.7%
0.7 pts better
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 9.5% · Q3 14.3% · Q4 10.6% · 4Q avg 11.0% · 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 | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 16.8% |
20.4%
3.6 pts better
|
19.8%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 11.9% · Q3 20.1% · Q4 18.4% · 4Q avg 16.8% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.6%
0.4 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.6% · Q3 4.9% · Q4 8.0% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.8% |
82.8%
19 pts worse
|
81.7%
17.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 56.1% · Q2 68.6% · Q3 66.7% · Q4 62.5% · 4Q avg 63.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.8% |
11.5%
7.7 pts better
|
12.0%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.8% · Observed 4.8% · Expected 13.9% · Used in QM five-star |
| 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 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.0% |
79.5%
13.5 pts worse
|
79.7%
13.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.6% |
24.2%
12.6 pts better
|
23.9%
12.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 14.3% · Expected 29.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-08 · Fire 2024-08-08
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2023-07-19 · Fire 2023-07-19
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-11
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-09-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-09-11
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-10-03
E · Potential for more than minimal harm
2025-09-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-10-03
E · Potential for more than minimal harm
2024-08-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-08-08
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-08-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-08-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-08-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-08-08
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-09-09
F · Potential for more than minimal harm
2023-07-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-27
F · Potential for more than minimal harm
2023-07-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-08-30
F · Potential for more than minimal harm
2023-07-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-03
F · Potential for more than minimal harm
2023-07-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-07-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-03
E · Potential for more than minimal harm
2023-07-19
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-07-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-19
E · Potential for more than minimal harm
2023-07-19
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 2023-07-20
D · Potential for more than minimal harm
2023-07-19
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-07-19
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 2023-07-31
D · Potential for more than minimal harm
2023-07-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-20
Inspection history
Recent health citations
G · Actual harm
2025-09-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-20
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 2025-09-05
F · Potential for more than minimal harm
2024-08-08
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 2024-09-09
F · Potential for more than minimal harm
2024-08-08
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 2024-09-09
D · Potential for more than minimal harm
2024-08-08
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 2024-09-09
D · Potential for more than minimal harm
2024-08-08
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-09-09
J · Immediate jeopardy
2024-01-31
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 2024-01-16
D · Potential for more than minimal harm
2023-09-12
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 2023-09-18
D · Potential for more than minimal harm
2023-09-12
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 2023-09-18
G · Actual harm
2023-07-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-07-19
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 2023-07-28
F · Potential for more than minimal harm
2023-07-19
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-07-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-07-19
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-07-19
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-19
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 2023-08-25
D · Potential for more than minimal harm
2023-07-19
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 2023-07-19
D · Potential for more than minimal harm
2023-07-19
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-19
Penalties and ownership
What sits behind the stars
$15,841
2024-01-31
Fine
Fine · fine $15,841
Fine
$7,962
2023-07-19
Fine
Fine · fine $7,962
Fine
$7,963
2023-07-19
Fine
Fine · fine $7,963
Fine
$15,925
2023-07-19
Fine
Fine · fine $15,925
Fine
$0
2023-07-19
Payment Denial
Payment Denial · denial start 2023-08-17 · 32 days
32 day denial
Ownership
Gutman, Isaac
5% Or Greater Direct Ownership Interest · Individual
Hoffman, Alexander
5% Or Greater Direct Ownership Interest · Individual
Taub, Jacob
5% Or Greater Direct Ownership Interest · Individual
Kornfeld, Robert
5% Or Greater Direct Ownership Interest · Individual
Barton, Donald
W-2 Managing Employee · Individual
Gutierrez, Juanita
W-2 Managing Employee · Individual
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#3
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