Adrian Bay Rehabilitation and Nursing Center
700 Lakeshire Trail, Adrian, MI 49221 · Lenawee County · 117 certified beds · avg 96 residents/day · certified since May 1, 1976
Part of chain: AVON HEALTHCARE (9 facilities, chain avg rating 2.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jun 22, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 23, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 7, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 22, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 11, 2023 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 6, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 11, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 6, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (41)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 22, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 22, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 22, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Dec 9, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Dec 9, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Dec 9, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jun 12, 2025 | F · Potential for harm, facility-wide | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Jun 12, 2025 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 12, 2025 | B · Minimal risk, repeated | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Jul 19, 2024 | F · Potential for harm, facility-wide | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Jul 19, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jul 19, 2024 | D · Potential for harm, one-off | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. |
| Oct 24, 2023 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint |
| Oct 24, 2023 | F · Potential for harm, facility-wide | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. · from a complaint |
| Oct 24, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Oct 24, 2023 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Oct 24, 2023 | E · Potential for harm, repeated | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint |
| Oct 24, 2023 | D · Potential for harm, one-off | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. · from a complaint |
| Oct 24, 2023 | C · Minimal risk, facility-wide | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| Sep 7, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 11, 2023 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| May 11, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 11, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 11, 2023 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| May 11, 2023 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| May 11, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| May 11, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 11, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| May 11, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 11, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| May 11, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| May 11, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 11, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 11, 2023 | D · Potential for harm, one-off | The facility did not make sure its staff were vaccinated for COVID-19 in accordance with the federal requirements in effect at the time. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 22 | 3 | G ▲ |
| 2024 | 3 | 0 | F |
| 2025 | 13 | 0 | F |
| 2026 | 3 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $201,851.
| Date | Type | Amount / length |
|---|---|---|
| Sep 7, 2023 | Fine | $201,851 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Michigan avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.69 | 4.32 | 3.95 | bottom 19% in Michigan; bottom 46% in the U.S. |
| Registered Nurse hours | 0.51 | 0.84 | 0.69 | bottom 20% in Michigan; bottom 40% in the U.S. |
| Weekend total nurse staffing | 3.38 | 3.79 | 3.50 | bottom 31% in Michigan; top 49% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.27 | 0.49 | 0.48 | bottom 21% in Michigan; bottom 25% in the U.S. |
| Total nursing staff turnover (%) | 31.8 | 44.1 | 45.8 | top 18% in Michigan; top 18% in the U.S. |
| RN turnover (%) | 46.2 | 39.2 | 42.9 | bottom 36% in Michigan; bottom 42% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.42, RN 0.48, weekend 3.13. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Freund, Eliyahu | Individual | Direct Ownership Interest | NOT APPLICABLE | 07/31/2023 |
| Freund, Eliyahu | Individual | Indirect Ownership Interest | NOT APPLICABLE | 07/31/2023 |
| Gottlieb, Moshe | Individual | 5% or Greater Indirect Ownership Interest | 48% | 07/31/2023 |
| Springs Bay Op Holdco LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 07/31/2023 |
| Avon Springs Bay Management LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/31/2023 |
| Avon Springs Bay Management LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/09/2025 |
| Freund, Eliyahu | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/31/2023 |
| Freund, Eliyahu | Individual | ADP of the SNF | NOT APPLICABLE | 01/09/2025 |
| Gilbert, Christina | Individual | W-2 Managing Employee | NOT APPLICABLE | 07/31/2023 |
| Gilbert, Christina | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/20/2024 |
| Gottlieb, Moshe | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/31/2023 |
| Gottlieb, Moshe | Individual | ADP of the SNF | NOT APPLICABLE | 01/09/2025 |
| Gupta, Somil | Individual | Contracted Managing Employee | NOT APPLICABLE | 07/31/2023 |
| Gupta, Somil | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/02/2025 |
| Gupta, Somil | Individual | ADP of the SNF | NOT APPLICABLE | 01/09/2025 |
| Hoevemeyer, Amanda | Individual | W-2 Managing Employee | NOT APPLICABLE | 07/31/2023 |
| Hoevemeyer, Amanda | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/20/2024 |
| Hoevemeyer, Amanda | Individual | ADP of the SNF | NOT APPLICABLE | 01/09/2025 |
| Monroe Springs Property LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/09/2025 |
| Springs Bay Op Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/09/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Lynwood Manor Healthcare Center | 0.2 mi | Adrian, MI | ★★★☆☆ | 3/5 | |
| Springcreek Rehabilitation and Nursing Center | 1.9 mi | Adrian, MI | ★★☆☆☆ | 2/5 | |
| Lenawee Medical Care Facility | 2.0 mi | Adrian, MI | ★★★☆☆ | 2/5 | abuse |
| Otterbein Sunset Village | 19.4 mi | Sylvania, OH | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 235287.