01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-02-18 | 1 | 2026-02-18 | 5 |
| Cycle 2 | 2024-12-17 | 5 | 2024-12-17 | 1 |
| Cycle 3 | 2024-01-10 | 2 | 2024-01-10 | 4 |
CMS CCN 2354702026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Bellbrook
873 W Avon Rd · Rochester Hills, MI 48307 · Oakland County
Certified beds36CMS provider file
Recent citation rows18current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
18 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 1 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-02-18 · FIREE0015Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Address subsistence needs for staff and patients.
Correction field: Deficient, Provider has date of correction · 2026-03-202026-02-18 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2026-03-052026-02-18 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-03-202026-02-18 · FIREK0291Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2026-03-202026-02-18 · FIREK0293Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2026-03-202026-02-18 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2026-03-202024-12-17 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2025-01-142024-12-17 · HEALTHF0640Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Correction field: Deficient, Provider has date of correction · 2025-01-142024-12-17 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2025-01-142024-12-17 · HEALTHF0740Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Correction field: Deficient, Provider has date of correction · 2025-01-142024-12-17 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-01-142024-12-17 · FIREK0914Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Correction field: Deficient, Provider has date of correction · 2025-01-092024-01-10 · HEALTHF0626Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Correction field: Deficient, Provider has date of correction · 2024-02-07 · complaint2024-01-10 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-02-072024-01-10 · FIREK0324Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-02-072024-01-10 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-02-072024-01-10 · FIREK0355Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2024-02-072024-01-10 · FIREK0753Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of highly flammable decorations.
Correction field: Deficient, Provider has date of correction · 2024-02-0703 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- TRINITY CONTINUING CARE SERVICESOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 07/01/1991
- CHE TRINITY INCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 07/01/2018
- CHANDLER, ALICIAIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 09/01/2017
- DELANEY, ELISABETHIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 07/01/2018
- KASTNER, STEVENIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 01/01/2017
- LATOVICK, PAMELAIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 01/01/2017
- CAPASSO, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2015
- CHANDLER, ALICIAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/01/2017
- HANDY, JOANNEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2015
- HENKEL, ARTHURIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2015
- JONES, BEVERLYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2016
- KASTNER, STEVENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2017
- LUNSMANN, KATHLEENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2015
- MCPHERSON, MARKIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2018
- MINNIX, WILLIAMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2018
- POOLE, LEJONIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2016
- TAG, ANNA MARIEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2018
- VILLARRUEL, ANTONIAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2016
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.46per resident day
RN hours1.53per resident day
Weekend nurse hours3.75per resident day
Staff turnover40.9%CMS reported field
06 / LOCAL RECORDS
Open the Rochester Hills ledger →