Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bellbrook during CMS and state inspections, most recent first.
A resident admitted with bipolar disorder and receiving Abilify had no evidence of a current Level I PASARR screening in the record. The SW first provided an older PASARR from a prior admission, then confirmed that a new screening should have been completed but was not done. The Administrator stated the facility did not have a PASARR policy.
A resident with dementia experienced a significant change in condition, including inability to awaken for meals and medication, which was not promptly addressed by the facility. The LPN failed to notify the physician in a timely manner and did not conduct adequate monitoring or assessment. The Unit Manager was informed but delayed action due to meetings. The physician was eventually notified, but the resident passed away before diagnostic results were obtained.
The facility's kitchen operations were found deficient in maintaining sanitary conditions, with issues such as improperly cooled corned beef, food stored on the floor, inadequate cleaning, and improper sanitizer levels. These deficiencies were observed during a kitchen tour, with staff acknowledging the lapses in documentation and housekeeping.
A resident reported that a CNA was rude, disrespectful, and grabbed their wrist, but the facility failed to thoroughly investigate the allegation. Despite the resident's report to the Administrator, there was no documentation in the clinical record, and the CNA continued to work the following day. The grievance report lacked specific details, and the facility did not adhere to its policy of removing accused staff pending investigation.
The facility failed to transmit MDS assessments to CMS within the required 14 days for two residents. One resident's MDS was 120 days overdue due to incomplete sections, while another's was not signed or completed. The facility lacked a policy for MDS transmitting, and the MDS Nurse cited failures by Social Services and in signing and submitting as reasons for the delays.
A facility failed to complete and submit an Annual Resident Review (ARR) Level I screening for a resident requiring a Level II OBRA evaluation. The resident, with multiple mental health diagnoses, had no documented screenings for 2024. The facility's staff could not provide the necessary documents during the survey, and the Level I screening was only completed after being requested by the surveyor.
A facility failed to provide a resident-centered care plan with individualized interventions for a resident with depression, anxiety, and Alzheimer's disease. Despite being on multiple medications, the care plans lacked specific behaviors, mood concerns, or stressors, and there was no documentation of non-pharmacological interventions or monitoring of the resident's behaviors and mood changes. The facility's policy on behavior monitoring was not followed, leading to the deficiency.
Failure to Complete Required PASARR Screening
Penalty
Summary
The facility failed to ensure a Level I PASARR screening was completed for one resident admitted with diagnoses including bipolar disorder and who was receiving Abilify 15 mg daily. The resident had a prior Level I Screening Hospital Exemption Discharge completed for an earlier admission, but the medical record contained no evidence of a Level I screening for the current admission. During surveyor interviews, the Social Worker initially stated they would look into the resident’s most recent Level I PASARR screening and later provided the 2024 screening for review, then acknowledged that a new screening should have been completed for the current admission and that no Level I PASARR screening had been conducted for the resident. The Administrator stated the facility did not have a policy regarding PASARR and would follow current regulations.
Delayed Notification and Monitoring of Resident's Change in Condition
Penalty
Summary
The facility failed to timely notify the physician or practitioner of a change in condition for a resident, identified as R140, and did not adequately monitor or assess the resident after the change was noted. The resident, who had been admitted with diagnoses including dementia and required personal care assistance, experienced a significant change in condition that was not promptly addressed. The nursing notes indicated that the resident had difficulty during breakfast, with coughing episodes and poor appetite, and later was unable to be aroused for meals or medication administration throughout an entire shift. The Licensed Practical Nurse (LPN) responsible for the resident's care did not notify the physician or practitioner immediately after recognizing the change in condition. The LPN documented the resident's inability to awaken for meals and medication but failed to conduct additional monitoring or obtain further vital signs. The LPN also modified the nursing notes twice, changing the recorded respiration rate without clear justification. The delay in notifying the physician resulted in a lack of timely interventions and care for the resident. The Unit Manager (UM) was informed of the resident's condition but was occupied with meetings for most of the day. The UM eventually assisted in obtaining vital signs and notified the physician, who ordered immediate diagnostic tests. However, the resident passed away before the results were obtained. The facility's policy required prompt notification of the physician for significant changes in condition, which was not adhered to in this case, leading to a deficiency in care.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect all residents consuming food from there. During an initial tour, a pan of cooked corned beef was found uncovered and undated in the walk-in cooler, with an internal temperature ranging from 99-102 degrees Fahrenheit. Dietary Staff C indicated that the corned beef had been cooked earlier that morning, but it was not logged on the cooling log, and no explanation was provided for this omission. According to the 2017 FDA Food Code, cooked potentially hazardous food must be cooled within specific time and temperature parameters, which were not adhered to in this instance. Additional observations included six cans of various food items stored on the floor behind the can racks, contrary to the FDA Food Code requirements for food storage. The dry storage room had crumbs, food debris, and packages on the floor, and there was standing water with a slimy surface under the dish machine, indicating inadequate cleaning. A red sanitizer bucket in the main kitchen area was tested and found to have no detectable level of sanitizer. Furthermore, a bin of thickener was found with the scoop handle resting inside the powder, violating the FDA guidelines for in-use utensil storage. DM B confirmed the corned beef should have been documented on the cooling log and acknowledged the housekeeping concerns, noting that the strongest porters were not scheduled on weekends.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to thoroughly and accurately investigate an allegation of staff-to-resident physical and verbal abuse involving a resident who was receiving physical therapy following a fall. The resident, who was cognitively intact, reported that a male CNA was rude, disrespectful, and grabbed their wrist. Despite the resident having reported the incident to the Administrator, there were no documents in the resident's clinical record addressing the allegations. The facility's initial response to a request for investigation reports and grievances did not include any mention of the incident. Upon further inquiry, the Administrator provided a grievance report indicating that the resident had expressed concerns about the CNA's attitude and requested that the CNA not work with them. However, the grievance report lacked specific details about the alleged rough and rude behavior. The CNA's personnel record did not reflect any documentation of the incident or any actions taken to prevent further occurrences. Additionally, the facility's schedule showed that the CNA continued to work the day after the allegation, contrary to the facility's policy requiring immediate removal of staff accused of abuse pending investigation.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required 14 days after completion for two residents. According to the CMS Resident Assessment Instrument (RAI) Manual, MDS records must be submitted within 14 days of the MDS Completion Date. However, the facility did not have a policy in place for MDS transmitting, which contributed to the delay. For one resident, identified as R311, the MDS was 120 days overdue because sections C, D, E, Q, and Z were not completed. This resident had been admitted with diagnoses including Atrial Fibrillation and diabetes type II and was discharged without the MDS being submitted. For another resident, identified as R333, the MDS was not signed or completed, specifically section Z. This resident had been admitted with diagnoses including an acute fracture and Atrial Fibrillation. The facility's MDS Nurse, during an interview, attributed the delay for R311 to the Social Services department's failure to complete their portions of the MDS. For R333, the issue was a failure to sign and submit the MDS. These inactions led to the deficiency in timely submission of the required assessments.
Failure to Complete Timely PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure that an Annual Resident Review (ARR) Level I screening was completed and submitted annually for a resident requiring a Level II OBRA evaluation. The resident, identified as R2, was observed in a wheelchair and was easily awakened with verbal stimuli. The medical record review revealed that R2 was admitted with multiple diagnoses, including dementia and various mental health disorders. The last documented Level I screening was dated 7/26/2023, and a Level II screening exemption was noted with a physician's electronic signature on the same date. However, there was no completed or submitted Level I or Level II screening for the year 2024 in the medical record. During the survey, the Social Worker Technician and Social Worker Helper were unable to provide the necessary PASARR screenings for 2024, indicating a backlog of documents needing to be scanned into resident charts. The Administrator and Director of Nursing later provided the 2023 documents but could not produce the 2024 screenings. The Administrator claimed that R2's annual submission to OBRA was pending a response for the Level II determination, but the Level I screening dated 12/17/2024 was only provided after the surveyor's request, indicating it was not completed timely. No further documentation or explanation was provided by the end of the survey.
Failure to Implement Individualized Behavioral Health Care Plan
Penalty
Summary
The facility failed to implement a resident-centered care plan with individualized interventions for a resident identified as R13, who was reviewed for unnecessary medications. R13 was observed to have memory issues and was on multiple medications for depression, anxiety, and Alzheimer's disease. Despite consultations indicating depression, anxiety, and mood disturbances, the care plans lacked specific behaviors, mood concerns, or stressors for R13. There were no documented non-pharmacological interventions or monitoring of the resident's behaviors and mood changes. The facility's policy on behavior monitoring and management was not followed, as there was no documentation of targeted behaviors or individualized interventions for R13. During an interview, unit managers and a clinical coordinator were unable to provide documentation of identified behaviors or mood concerns for R13. The lack of a comprehensive care plan and monitoring for R13's behavioral health needs led to the deficiency identified by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rochester Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellbridge Of Rochester Hills | 0.9 mi | ★★★★★ | 13 | 0 |
| The Springs At Rochester Hills Rehab And Nursing C | 1.2 mi | ★★★★★ | 27 | 0 |
| Optalis Health And Rehabilitation Of Troy | 3 mi | ★★★★★ | 16 | 0 |
| Pomeroy Living Rochester Skilled Rehabilitation | 4.1 mi | ★★★★★ | 13 | 0 |
| Regency At Shelby Township | 5.6 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.