Cycle 1
Health 2025-12-03 · Fire 2025-12-03
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Warren, MI
The Orchards at Warren
1-star overall rating with 2-star inspections with $21,273 in total fines with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
12250 East 12 Mile Road, Warren, MI
(586) 751-6200
Overall
1 / 5
CMS overall stars
Health inspections
2 / 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
134
Certified beds
Average residents
118
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Orchards Michigan
Operator or chain grouping
Approved since
1991-09-30
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
7,592
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9854
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.29
Baseline 18.60% · Performance 18.52% · Measure score 6.29 · Achievement 6.29 · Improvement 0.02
Healthcare-associated infections
0
Baseline 5.64% · Performance 7.88% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.61
Baseline 82.22% · Performance 58.67% · Measure score 3.61 · Achievement 1.23 · Improvement 3.61
Adjusted total nurse staffing
1.84
Baseline 2.68 hours · Performance 3.41 hours · Measure score 1.84 · Achievement 1.16 · Improvement 1.84
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.53% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 123 · Observed rate 14.63% · Lower 95% interval 8.14% |
| Discharge to community | 37.47% |
50.57%
13.1 pts worse
|
Worse than the National Rate · Eligible stays 113 · Observed rate 27.43% · Lower 95% interval 29.04% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 70% |
95.27%
25.3 pts worse
|
Numerator 56 · Denominator 80 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 80 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 26 · Denominator 52 |
| Discharge mobility score | 40.38% |
50.94%
10.6 pts worse
|
Numerator 21 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 1.25% |
2.29%
1 pts better
|
Numerator 1 · Denominator 80 · Adjusted rate 1.16% |
| Healthcare-associated infections requiring hospitalization | 7.88% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 10.39% · Lower 95% interval 5.22% |
| Staff COVID-19 vaccination coverage | 94.21% |
8.2%
86 pts better
|
Numerator 114 · Denominator 121 |
| Staff flu vaccination coverage | 31.94% |
42%
10.1 pts worse
|
Numerator 61 · Denominator 191 |
| Discharge function score | 38.46% |
56.45%
18 pts worse
|
Numerator 20 · Denominator 52 |
| Transfer of health information to provider | 88% |
95.95%
8 pts worse
|
Numerator 22 · Denominator 25 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 42 |
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 · Adjusted 1.2 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
95.0%
3.2 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 95.5% · Q3 100.0% · Q4 100.0% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.2% |
95.0%
12.8 pts worse
|
95.5%
13.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.1%
2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.9% · Q4 1.8% · 4Q avg 1.1% · 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 1.1% · Q2 0.0% · Q3 2.2% · Q4 1.1% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 11.9% |
5.5%
6.4 pts worse
|
5.4%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 14.3% · Q3 16.8% · Q4 10.3% · 4Q avg 11.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.3% |
19.6%
5.3 pts better
|
19.6%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 15.8% · Q3 14.4% · Q4 12.0% · 4Q avg 14.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.1% |
16.5%
1.4 pts better
|
16.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 19.2% · Q3 15.5% · Q4 10.3% · 4Q avg 15.1% · 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 | 23.7% |
13.9%
9.8 pts worse
|
16.3%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 27.6% · Q3 24.5% · Q4 24.9% · 4Q avg 23.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.0% |
11.7%
9.3 pts worse
|
14.9%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 24.4% · Q3 28.0% · Q4 17.2% · 4Q avg 21.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.6% |
20.4%
6.2 pts worse
|
19.8%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 26.7% · Q3 21.7% · Q4 29.1% · 4Q avg 26.6% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
5.6%
0.7 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 5.5% · Q3 7.4% · Q4 4.8% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.2% |
82.8%
13.6 pts worse
|
81.7%
12.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 48.8% · Q2 58.3% · Q3 78.0% · Q4 92.6% · 4Q avg 69.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.9% |
11.5%
7.6 pts better
|
12.0%
8.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.9% · Observed 4.2% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.7% |
1.3%
3.4 pts worse
|
1.6%
3.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 6.6% · Q3 1.6% · Q4 6.8% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 54.3% |
79.5%
25.2 pts worse
|
79.7%
25.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 54.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.6% |
24.2%
5.6 pts better
|
23.9%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 19.4% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-19 · Fire 2024-09-19
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-08-02 · Fire 2023-08-02
13 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-26
F · Potential for more than minimal harm
2025-12-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-26
F · Potential for more than minimal harm
2025-12-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-12-26
F · Potential for more than minimal harm
2025-12-03
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-12-26
F · Potential for more than minimal harm
2025-12-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-12-26
F · Potential for more than minimal harm
2025-12-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-12-03
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 2025-12-26
E · Potential for more than minimal harm
2025-12-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-26
E · Potential for more than minimal harm
2024-09-19
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 2024-10-04
E · Potential for more than minimal harm
2024-09-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-04
F · Potential for more than minimal harm
2023-08-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-17
F · Potential for more than minimal harm
2023-08-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-17
E · Potential for more than minimal harm
2023-08-02
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 2023-08-17
E · Potential for more than minimal harm
2023-08-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-17
E · Potential for more than minimal harm
2023-08-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-21
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 2026-01-23
D · Potential for more than minimal harm
2026-01-21
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2026-01-23
F · Potential for more than minimal harm
2025-12-03
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-12-19
E · Potential for more than minimal harm
2025-12-03
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-12-19
E · Potential for more than minimal harm
2025-12-03
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 2025-12-19
D · Potential for more than minimal harm
2025-12-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-03
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-03
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-03
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 2025-12-19
D · Potential for more than minimal harm
2025-12-03
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-01-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-11-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-09-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-09-19
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-09-19
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 2024-10-04
D · Potential for more than minimal harm
2024-09-19
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-19
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 2024-10-04
D · Potential for more than minimal harm
2024-09-19
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-19
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 2024-10-04
D · Potential for more than minimal harm
2024-09-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-01-17
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 2024-01-18
G · Actual harm
2023-08-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-17
G · Actual harm
2023-08-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-17
F · Potential for more than minimal harm
2023-08-02
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 2023-08-17
F · Potential for more than minimal harm
2023-08-02
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 2023-08-17
E · Potential for more than minimal harm
2023-08-02
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 2023-08-17
D · Potential for more than minimal harm
2023-08-02
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 2023-08-17
D · Potential for more than minimal harm
2023-08-02
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 2023-08-17
D · Potential for more than minimal harm
2023-08-02
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-08-02
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-08-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-05-30
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 2023-06-13
D · Potential for more than minimal harm
2023-05-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-13
Penalties and ownership
What sits behind the stars
$21,273
2023-08-02
Fine
Fine · fine $21,273
Fine
Ownership
Warren SNF Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Beaupre, Judith
W-2 Managing Employee · Individual
Gutman, Isaac
5% Or Greater Indirect Ownership Interest · Individual
Hoffman, Alexander
5% Or Greater Indirect Ownership Interest · Individual
Kornfeld, Robert
5% Or Greater Indirect Ownership Interest · Individual
Kornfeld, Robert
Corporate Officer · Individual
Lee, Myrna
W-2 Managing Employee · Individual
Mi Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Taub, Jacob
5% Or Greater Indirect Ownership Interest · Individual
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