700 Lakeshire Trail, Adrian, MI 49221 · Lenawee County · (517) 263-0781
117 certified beds, about 96 residents a day · For profit - Corporation · Medicare and Medicaid since 1976
CMS Care Compare ratings, data as of September 1, 2026 · CCN 235287 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on June 12, 2025, inspectors cited 10 health deficiencies (the Michigan average is 9.9, the national average 9.2).
Of 41 health citations since May 2023, 4 were rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.42 hours per resident per day, against 3.99 across Michigan and 3.86 nationally. Registered nurses accounted for 0.48 of those hours.
31.8% of nursing staff left within the year CMS measured (Michigan average 44.1%).
CMS links it to Avon Healthcare, an affiliated group of 9 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 41 health citations on file.
Inspectors wroteThis citation pertains to intake #3030201. Based on observation, interview and record review, the facility failed to ensure their transfer status was accurately following resident's plan of care to prevent fall to occur for one resident (R#2) of 3 sampled residents sustaining a fall resulting in a hospital transfer and admitted for Right Rib Fractures 5-10, Right Forehead Hematoma, Right non-displaced Humeral Fracture, and Right Superior Pubic Rami Fracture and pain.
Inspectors wroteThis citation pertains to Intake 2807029. Based on interview and record review, the facility failed to administer medications as ordered by the physician for one (R1) of three reviewed.
Inspectors wroteThis citation pertains to Intake 2807029. Based on interview and record review, the facility failed to ensure the accuracy of medical records for one (R1) of three reviewed.
Inspectors wroteThis citation pertains to intakes 2677539 and 2677568. Based on observation, interview, and record review, the facility failed to maintain accurate controlled substance and medication administration records for five residents (R1, R3, R4, R5, R6) of six reviewed and two medication carts of two reviewed.
Inspectors wroteThis citation pertains to intakes 2677539 and 2677568. Based on observation, interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for two (R3 and R7) of seven reviewed. Findings Include: Resident #3 (R3) Review of the medical record reflected R3 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included sepsis, osteoarthritis, low back pain and spinal stenosis. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/2/25, reflected R3 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/8/25 at 9:40 AM, R3 was observed in bed and reported taking Norco (opioid/controlled pain medication) as needed. [...]
Inspectors wroteThis citation pertains to intakes 2677539 and 2677568. Based on observation, interview, and record review, the facility failed to administer medications according to the physician's order for two (R4 and R5) of five reviewed.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to clean and maintain the physical plant effecting 80 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased illumination, and resident accidental falls and/or injury.
Inspectors wroteBased on interview and record review the facility failed to preserve the dignity for 5 of 5 members of the Resident Council.
Inspectors wroteThis citation pertains to intake MI00149511. Based on interview and record review, the facility failed to honor code status wishes for one (R333) of two reviewed.
Inspectors wroteBased on interview and record review, the facility failed to assess and monitor a change in condition timely for one (R38) of one reviewed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safe storage of smoking materials for one (R58) of one reviewed for smoking.
Inspectors wroteBased on observation, interview and record review, the facility failed to document blood sugars prior to holding or administering insulin for one (R10) of six reviewed for unnecessary medications.
Inspectors wroteDuring an observation on 6/11/25 at 11:28 am hall A medication cart was unlocked with no staff in area. One resident observed in area able to self propel in wheelchair. During an interview on 6/12/25 at 1:35 PM, Unit Manager (UM) M reported would expect medication carts to remain locked when staff not present and computer closed. Director of Nursing (DON) B joined interview and reported would expect medication carts to remain locked if nurse not present. UM M reported often monitors for secure medications carts and occasionally observes unlocked and performs education with staff. Based on observation, interview, and record review the facility failed to ensure proper storage of medication for one residents (R60) of 18 sampled residents and one medication cart of two medication carts reviewed for medication storage. Findings Included: [...]
Inspectors wroteThis citation pertains to intake MI00149511. Based on interview and record review, the facility failed to ensure a complete and accurate medical record for one (R333) of 18 reviewed.
Inspectors wroteBased on observation, interview, and record review the facility failed to maintain use of personal protective equipment during resident care for three residents (#45, #60, #70) out of 80 residents at the facility. Findings Included: [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Survey Book was easily accessible and readily available, and that the book was maintained to include the facility plan of correction for identified deficiencies. Resulting in the potential for residents and visitors to be uninformed. This had the potential to affect all 80 residents who resided in the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to install and maintain backflow protection devices and air gaps, resulting in the potential contamination of the facility potable water system, affecting all residents in the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services per standards of practice, facility policy, and per physician's orders for one resident (Resident #575) of one resident reviewed for respiratory services. This deficient practice resulted in respiratory distresss, increased anxiety, missed doses of physician orders nebulizer treatments, and the potential to result in hypoxia [below-normal level of blood oxygen], and respiratory/medical decline with the potential to effect a total of five residents who had nebulizer treatments in the facility.
Inspectors wroteBased on observation, interview and record review, the facility failed to serve the appropriate food consistency for one (Resident 44) of three reviewed for therapeutic diets, resulting in the potential for aspiration and/or choking and continued weight loss.
Inspectors wroteThis citation pertains to intake MI00140043 and MI00139259. Based on observation, interview, and record review, the facility failed to provide meals as planned and posted, in 2 of 11 residents reviewed for dining services (Resident #1 and #4), potentially affecting a census of 77 residents that received meal trays, resulting in decreased quality of life.
Inspectors wroteThis citation pertains to intake MI00139259. Based on observation, interview and record review, the facility failed to provide meals at scheduled times, in 3 of 11 residents reviewed for dining services (Resident #1, #3, & #5), potentially affecting 77 residents receiving meals from the kitchen (1 resident received nothing by mouth) , resulting in decreased quality of life, and the potential for weight loss and depression.
Inspectors wroteThis citation pertains to MI00139259. Based on observation, interview, and record review the facility failed to ensure proper label and dating of foods, documentation of food and beverage temperatures, and wearing of hair restraints with 77 residents receiving meals from the kitchen (1 resident receives nothing by mouth) resulting in increased the risk of contaminated foods and the risk of food borne illness.
Inspectors wroteBased on observation, interview and record review the facility failed to promote dignity during meals in 5 of 11 residents reviewed for dietary services (Resident #3, #4, #5, #9 & #10), resulting in decreased quality of life and an unhomelike dining experience.
Inspectors wroteThis citation pertains to intake MI00140043. Based on observation, interview and record review, the facility failed to honor food preferences in 5 of 11 residents reviewed for food preferences (Resident #1, #3, #4, #5, & #8), resulting in resident dissatisfaction and the potential for weight loss.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide therapeutic diets as ordered in 2 of 11 residents reviewed for dietary services (Resident #8 & #11), resulting in risk of not meeting nutrition needs (Resident #11), and fluid overload (Resident #8).
Inspectors wroteThis citation pertains to MI00140043. Based on interview and record review, the facility failed to have recipes available based on the current census of 78 residents upon entrance with 77 residents receiving meals from the kitchen (1 resident received nothing by mouth) which could potentially result in insufficient food, dissatisfaction with the meal experience, decreased food acceptance and weight loss. On 10/24/2023 at 7:40 AM, reviewed recipe book which revealed 3 columns, each for 75 servings of food. No other serving sizes were noted on the recipes. During an interview on 10/24/2023 at 10:50 AM, Dietary [NAME] (DC) H stated that she knows to increase the recipe from 75 in the book by at least 10 since some residents ask for extra servings of food and some residents get double portions. She said she knows how to increase the recipe since she was the normal morning cook. [...]
Inspectors wroteThis citation pertains to intake MI00138570. Based on observation, interview, and record review, the facility failed to provide care planned interventions to maintain functional strength to prevent falls, in one of three reviewed for falls (Resident #1), resulting in multiple falls and injuries including a fracture.
Inspectors wroteThis citation pertains to intake MI00131462. Based on observation, interview, and record review, the facility failed to implement pressure ulcer interventions and treatments for two (Resident #28 and Resident #29) of three reviewed, resulting in the worsening of a pressure ulcer for Resident #29 and the potential of a worsening pressure ulcer for Resident #28.
Inspectors wroteBased on observation, interview and record review, the facility failed to implement effective interventions to prevent falls for four (Resident #11, #13, #20, and #464) of five reviewed for accidents, resulting in reoccurring falls (Resident #13), falls with the potential for major injury (Resident #464) and falls with major injury (Resident #11 and #20). Findings Include: Resident #13 Review of an admission Record revealed Resident #13 (R13) admitted to the facility on [DATE] with pertinent diagnoses which included bilateral hearing loss, anxiety, osteoporosis, major depressive disorder, overactive bladder, delusional disorders, vascular dementia, and cognitive communication deficit. [...]
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 73 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 73 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.
Inspectors wroteBased on interview and record review, the facility failed to 1) ensure Do-Not-Resuscitate (DNR) documents were accurately and completely filled out for three (Resident #11, #28 and #42) of three reviewed; and 2) ensure updated and accurate letters of Guardianship were in the medical record for one (Resident #42) of one reviewed, resulting in the potential for code status wishes not being followed in an emergency situation and medical decisions not to be made by the legal Guardian of record.
Inspectors wroteBased on observation, interview, and record review the facility failed to accurately complete Minimum Data Set (MDS) assessments for two (Resident #28 and Resident #29) of 18 reviewed, resulting in inaccurate assessments and the potential for unmet care needs.
Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive Care Plans for two (Resident #11 and #27) of 18 reviewed, resulting in the potential for unmet care needs and adverse events.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 (Resident #13 and #34) out of 18 residents reviewed for care plans, had a comprehensive care plan that was revised for resident care needs, resulting in the potential for all care needs not being met. Findings Include: Resident #13 Review of an admission Record revealed Resident #13 (R13) admitted to the facility on [DATE] with pertinent diagnoses which included bilateral hearing loss, anxiety, osteoporosis, major depressive disorder, overactive bladder, delusional disorders, vascular dementia, and cognitive communication deficit. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/6/23, reflected R13 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to 1) follow their bowel management protocol for constipation; 2) ensure the accurate classification of a wound; 3) ensure comprehensive wound assessments were performed according to facility policy; and 4) ensure wound treatment and interventions were implemented timely and according to Physician recommendations for one (Resident #28) of 18 reviewed, resulting in constipation and the potential for delayed wound healing and/or worsening wounds.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate treatment and services for contracture management for one (Resident #27) of one reviewed, resulting in the potential for worsening contractures and pain.
Inspectors wroteBased on observation, interview and record review, the facility failed to justify rationale for clinically contraindicated gradual dose reductions (GDRs) of psychotropic medications for two (Resident #16 and #52) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when two medication errors were observed from a total of twenty-seven opportunities for one resident (Resident # 374) of six reviewed for medication administration, resulting in a medication error rate of 7.41% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper hand hygiene practices during wound care for one (Resident #28) and proper catheter tubing placement for one (Resident #34) of 18 reviewed for infection control practices, resulting in the potential for cross contamination, the spread of infection and delayed wound healing. Findings Include: Resident #34 Review of an admission Record revealed Resident #34 (R34) admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included acute cystitis with hematuria, disorder of the muscle, bradycardia (slow heart rate), hearing loss, syncope, and dementia. [...]
Inspectors wroteBased on interview and record review, the facility failed to accurately track and document staff COVID-19 vaccination status and implement a process ensuring all staff were fully vaccinated for COVID-19, resulting in an inaccurate vaccination matrix, staff who were not vaccinated or partially vaccinated, and the potential for the transmission of COVID-19.
15 fire safety citations on file: 3 on June 12, 2025, 5 on July 19, 2024, 7 on May 11, 2023.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Michigan | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.42 | 3.99 | 3.86 |
| Registered nurses | 0.48 | 0.78 | 0.69 |
| All nursing staff on weekends | 3.13 | 3.50 | 3.42 |
| Nurse aides | 2.06 | ||
| Licensed practical nurses | 0.88 | ||
| Nursing staff turnover (share who left in a year) | 31.8% | 44.1% | 45.8% |
| Registered nurse turnover | 46.2% | 39.2% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.55 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.53 on weekdays and 3.13 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 9.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.55 in April to June 2025 to 3.42 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.42 | 0.48 | 3.53 | 3.13 | 9.8% | 0 of 90 | 96 |
| Oct to Dec 2025 | 3.52 | 0.47 | 3.63 | 3.25 | 1.6% | 0 of 92 | 85 |
| Jul to Sep 2025 | 3.55 | 0.48 | 3.68 | 3.21 | 7.6% | 0 of 92 | 89 |
| Apr to Jun 2025 | 3.55 | 0.57 | 3.71 | 3.14 | 0.1% | 0 of 91 | 81 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Michigan, Jan to Mar 2026 | 3.95 | 0.70 | 4.14 | 3.45 | 3.3% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Michigan, all employers | |||
| CNAs (nursing assistants) | $19.03 | $18.35 to $21.59 | 43,290 |
| LPNs and LVNs | $31.47 | $29.83 to $35.52 | 10,880 |
| Registered nurses | $45.34 | $39.46 to $49.74 | 104,950 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Michigan | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 13.6 | 10.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.4 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 4.5 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.4 | 3.0 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.6 | 1.1 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 14.8 | 12.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.4 | 5.1 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 12.4 | 14.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 19.0 | 24.0 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 15.3 | 11.7 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.6 | 1.8 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.8 | 1.6 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Adrian Bay Rehabilitation and Nursing Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (60.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
60.4% this home
No different from the national rate
US median of homes 51.5% · Michigan: 89 better, 22 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 96 eligible stays.
12.4% this home
No different from the national rate
US median of homes 10.7% · Michigan: 0 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 108 eligible stays.
6.0% this home
No different from the national rate
US median of homes 7.1% · Michigan: 1 better, 1 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 79 eligible stays.
64.2% this home
Median of homes: Michigan57.6% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 81 residents counted.
0.9% this home
Median of homes: Michigan0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 111 residents counted.
1.7% this home
Median of homes: Michigan1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 111 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Michigan99.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 6 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: ADRIAN BAY OPERATING LLC. CMS links this home to Avon Healthcare, a group of 9 nursing homes averaging 2.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Springs Bay Op Holdco LLC | 5% or greater direct ownership interest | Organization | 100% | 07/31/2023 |
| Freund, Eliyahu | Direct ownership interest | Individual | 07/31/2023 | |
| Gottlieb, Moshe | 5% or greater indirect ownership interest | Individual | 48% | 07/31/2023 |
| Freund, Eliyahu | Indirect ownership interest | Individual | 07/31/2023 | |
| Freund, Eliyahu | Managing control - governing body | Individual | 07/31/2023 | |
| Gottlieb, Moshe | Managing control - governing body | Individual | 07/31/2023 | |
| Gupta, Somil | Contracted managing employee | Individual | 07/31/2023 | |
| Gilbert, Christina | W-2 managing employee | Individual | 07/31/2023 | |
| Hoevemeyer, Amanda | W-2 managing employee | Individual | 07/31/2023 | |
| Avon Springs Bay Management LLC | Operational/managerial control | Organization | 07/31/2023 | |
| Gilbert, Christina | Operational/managerial control | Individual | 12/20/2024 | |
| Gupta, Somil | Operational/managerial control | Individual | 01/02/2025 | |
| Hoevemeyer, Amanda | Operational/managerial control | Individual | 12/20/2024 | |
| Avon Springs Bay Management LLC | Adp of the SNF | Organization | 01/09/2025 | |
| Monroe Springs Property LLC | Adp of the SNF | Organization | 01/09/2025 | |
| Springs Bay Op Holdco LLC | Adp of the SNF | Organization | 01/09/2025 | |
| Freund, Eliyahu | Adp of the SNF | Individual | 01/09/2025 | |
| Gottlieb, Moshe | Adp of the SNF | Individual | 01/09/2025 | |
| Gupta, Somil | Adp of the SNF | Individual | 01/09/2025 | |
| Hoevemeyer, Amanda | Adp of the SNF | Individual | 01/09/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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