Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Bellbrook
Rochester Hills, MI · 36 certified beds · Last Life Safety survey February 18, 2026
CMS Certification Number 235470 · first certified July 1988
Ownership
Operated by TRINITY HEALTH · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MI
10 citations — more than 32% of the 422 certified nursing homes in MI. Compared within MI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 2.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens February 2027 — about 4 months from now. This facility’s last Life Safety survey was February 2026. Facilities in MI are typically surveyed 12–14 months after the last one (median 13), measured over 723 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
1 of the 10 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 10 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in MI, and nationally. Surveyors differ markedly between states, so the MI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 10 |
| Median facility in MI | 14 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 10, 2024 | 4 |
| December 17, 2024 | 1 |
| February 18, 2026 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | 1 | 2026-02-18 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2026-02-18 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2024-01-10 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2024-12-17 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-01-10 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2026-02-18 |
| K-0222 | 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. | 1 | 2026-02-18 |
| K-0753 | Have restrictions on the use of highly flammable decorations. | 1 | 2024-01-10 |
What the citations cover
- Smoke Deficiencies 4
- Egress Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 1
- Miscellaneous Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 4 |
| Egress Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 18, 2026 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0222 | 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. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (March 20, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 20, 2026) |
December 17, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (January 9, 2025) |
January 10, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (February 7, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 7, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (February 7, 2024) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (February 7, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.