Stratford Pines Nursing and Rehabilitation Center

Name: Stratford Pines Nursing and Rehabilitation Center
Address: 2121 Rockwell Drive, Midland, MI, 48642, US
Telephone: 9896335350

2121 Rockwell Drive, Midland, MI 48642 · Midland County · 100 certified beds · avg 94 residents/day · certified since May 30, 2003

Part of chain: THE PEPLINSKI GROUP (10 facilities, chain avg rating 2.1★)

2/5

Health inspection rating (on-site)

Serious findings on record

$16,801

Fines, last 3 years

4.50

Nurse hours/resident/day (adjusted)

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 · Dec 4, 2024 · 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: Dec 28, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Nov 30, 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: Dec 22, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (34)

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
Apr 1, 2026	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
Apr 1, 2026	E · Potential for harm, repeated	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Apr 1, 2026	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. · from a complaint
Apr 1, 2026	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. · from a complaint
Apr 1, 2026	D · Potential for harm, one-off	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint
Apr 1, 2026	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Apr 1, 2026	D · Potential for 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.
Apr 1, 2026	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. · from a complaint
Apr 1, 2026	D · Potential for harm, one-off	The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint
Apr 1, 2026	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.
Apr 1, 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
Apr 1, 2026	D · Potential for harm, one-off	The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.
Apr 1, 2026	D · Potential for harm, one-off	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
May 8, 2025	E · Potential for harm, repeated	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 8, 2025	D · Potential for harm, one-off	The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
May 8, 2025	D · Potential for harm, one-off	The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. · from a complaint
Jan 30, 2025	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jan 30, 2025	E · Potential for harm, repeated	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.
Jan 30, 2025	D · Potential for harm, one-off	The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Jan 30, 2025	D · Potential for harm, one-off	The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences.
Jan 30, 2025	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.
Jan 30, 2025	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.
Jan 30, 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.
Jan 30, 2025	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.
Jan 30, 2025	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.
Jan 30, 2025	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Jan 30, 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.
Jan 30, 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.
Jan 30, 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. · from a complaint
Dec 4, 2024	▲ 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
Nov 30, 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.
Nov 30, 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.
Oct 5, 2023	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
Oct 5, 2023	D · Potential for 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. · from a complaint

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (13 → 13).

Year	Citations	Serious (G–L)	Worst severity that year
2023	4	1	G ▲
2024	1	1	G ▲
2025	16	0	E
2026	13	0	E

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 $16,801.

Date	Type	Amount / length
Dec 4, 2024	Fine	$16,801

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)	4.50	4.32	3.95	top 28% in Michigan; top 23% in the U.S.
Registered Nurse hours	0.68	0.84	0.69	bottom 38% in Michigan; top 39% in the U.S.
Weekend total nurse staffing	4.13	3.79	3.50	top 24% in Michigan; top 19% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.37	0.49	0.48	bottom 41% in Michigan; bottom 46% in the U.S.
Total nursing staff turnover (%)	49.1	44.1	45.8	bottom 33% in Michigan; bottom 39% in the U.S.
RN turnover (%)	43.8	39.2	42.9	bottom 41% in Michigan; bottom 46% 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 4.15, RN 0.62, weekend 3.80. Staffing rating: 4/5.

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: 5/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Ackerman, Ricky	Individual	Direct Ownership Interest	NOT APPLICABLE	05/01/2016
Baumgarten, Michael	Individual	Direct Ownership Interest	NOT APPLICABLE	05/01/2016
Peplinski, Todd	Individual	Direct Ownership Interest	NOT APPLICABLE	05/01/2016
Schade, Jeffery	Individual	Direct Ownership Interest	NOT APPLICABLE	05/01/2016
Thompson, Brian	Individual	Direct Ownership Interest	NOT APPLICABLE	05/01/2016
Ackerman, Ricky	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2016
Ackerman, Ricky	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2016
Baumgarten, Michael	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2016
Peplinski, Todd	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2016
Plante & Moran PLLC	Organization	Operational/Managerial Control	NOT APPLICABLE	05/01/2016
Plante & Moran PLLC	Organization	ADP of the SNF	NOT APPLICABLE	04/14/2025
Potnis, Amarish	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2016
Schade, Jeffery	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2016
Schade, Jeffery	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2016
Stratford Pines Property Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2016
The Peplinski Group INC	Organization	ADP of the SNF	NOT APPLICABLE	03/24/2025
Thompson, Brian	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2016
Thompson, Brian	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2016
Winkels, Kathy	Individual	Operational/Managerial Control	NOT APPLICABLE	07/06/2016
Winkels, Kathy	Individual	ADP of the SNF	NOT APPLICABLE	07/06/2016

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?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"If my family member falls or their condition changes, exactly when and how will I be notified?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
"How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"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
Brittany Manor	1.1 mi	Midland, MI	★★★☆☆	2/5	abuse
Medilodge of Midland	6.1 mi	Midand, MI	★★★★★	4/5
Carriage House Nursing and Rehabilitation	10.6 mi	Bay City, MI	★★☆☆☆	2/5
Huron Woods Nursing Center	11.4 mi	Kawkawlin, MI	★★★☆☆	3/5
Caretel Inns of Tri-Cities	11.5 mi	Bay City, MI	★☆☆☆☆	1/5
Bay Shores Senior Care and Rehab Center	12.2 mi	Bay City, MI	★★★★☆	3/5
Healthsource Saginaw, INC	12.5 mi	Saginaw, MI	★★★☆☆	2/5
Great Lakes Rehabilitation Center	12.6 mi	Saginaw, MI	★★☆☆☆	2/5
Covenant Skilled Nursing and Rehabilitation at Wel	13.3 mi	Saginaw, MI	★★★★☆	3/5
Optalis Health and Rehabilitation at St. Francis	14.7 mi	Saginaw, MI	★★☆☆☆	1/5
Saginaw Senior Care and Rehabilitation Center, LLC	14.7 mi	Saginaw, MI	★★★★☆	3/5
Hampton Nursing and Rehabilitation	15.1 mi	Bay City, MI	★★★★☆	4/5

Compare this facility with the 3 closest →

All facilities in Midland →

Facility data as of CMS processing date 2026-08-01. CCN 235608.

The Care File

Visit checklist — Stratford Pines Nursing and Rehabilitation Center

2121 Rockwell Drive, Midland, MI 48642 · 9896335350

Health inspection rating 2/5 · CMS overall 2/5· Fines (3y): $16,801

Most serious findings on record:

▲ Dec 4, 2024 (F-0689, 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.
▲ Nov 30, 2023 (F-0686, 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.

Questions for the administrator:

☐ "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?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "If my family member falls or their condition changes, exactly when and how will I be notified?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
☐ "How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 235608 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)