Trinity Health Oakland Hospital
An acute care hospital in Pontiac, Michigan 48341
44405 Woodward Ave, Pontiac, Michigan 48341. (248) 858-3000.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 2of 5 CMS’s overall rating
- 3of 5 patient survey rating
- 1 deficiency cited in the last three years
- 395 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Apr 15, 2026: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited Jan 2024. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Jan 31, 2024: complaint inspection1 deficiency
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Patient Rights: Grievances
The inspectors’ words, 629 words
“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 45245 Based on interview and record review, the facility failed to follow their process for prompt resolution of patient grievances for 1 (P-1) of ten patients sampled for patient rights, resulting in the potential for poor outcomes for all patients, utilizing the grievance process. Review of the medical record for P-1 revealed a progress note authored by Staff L on 12/03/23 at 1720, stating, “Patient’s nurse (Staff L) came to charge and stated patient was making a complaint about being punched. House supervisor called and updated. This nurse went in to talk with the patient and make a report. Patient wrote on her white board that it was last night or the night before. She wrote it was a black fellow. She said she was punched in the stomach. Patient gown was pulled up and patient pointed to the area near her naval. No bruising or redness noticed. Patient’s nurse shown notes.” Review of facility’s event reporting system document titled “Current Summary”, dated 12/04/23 demonstrated that the facility documented the incident as ‘Harm/Abuse/Neglect.’ Further review also revealed under ‘Outcome Notes’, dated 12/04/23 (no time stamp, no author) states “This issue was addressed by the Clinical House Supervisor at the time of the complaint. No further information was provided to our office. Clinical House Supervisor did not send any needed follow-up by our office. We did not receive a call from the husband. Issue addressed at time of incident .” Review of facility complaint and grievance log revealed no entries under grievances regarding abuse allegations for P-1. An interview was conducted with patient advocate Staff P on 01/31/24 at approximately 1100. Staff P was queried if P-1’s allegation met the facilities definition of abuse. Staff P replied, “yes.” Staff P was next questioned why P-1’s ‘allegation of abuse’ was not a ‘grievance’. Staff P explained that “it was not escalated to her.” Staff P explained that in the past, she would receive an email from the house supervisor, who had investigated the complaint. Staff P stated that she did not receive an email from the house supervisor, which meant that the investigation ended with the house supervisor ‘not escalating it.’ Review of policy “Patient Complaint Grievance Process,” (no policy #) reviewed 08/31/21, states under ‘definitions’, paragraph #5, “A complaint is considered a grievance when it falls within one of the following criteria: (A.) verbal patient care complaint that is not resolved at the time of complaint by staff present, is postponed for later resolution, requires investigation and or further actions for resolution. (B.) The complaint is in writing. This includes faxes, e-mails, and comments on patient surveys when the patient requests resolution. (C.) Any written or verbal complaint regarding abuse or neglect, patient harm or hospital compliance with Center for Medicare and Medicaid (CMS) requirements.” Review of policy titled, “Alleged Abuse or Neglect of Patients by a Colleague, Volunteer, Physician or any Agent of the Hospital,” (no policy # or date) stated under ‘procedure D,’ “The Patient Advocate/ Care Experience Specialist or Risk Management will coordinate the investigation. E. The steps involved in handling an investigation may include but are not limited to: a. Review the complaint/allegation. B. Review the medical record. C. Interviews with key individuals involved in the complaint/allegation. D. Communication with the appropriate leadership.” On 01/31/23, an interview was conducted with Director of Quality Staff A. Staff A stated that the facility was actively looking for a form to document house supervisor complaint investigations. Staff A stated that an email may not be the ideal way to document patient/staff interactions.”
All 6 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Apr 15, 2026 | Complaint inspection | No deficiencies cited |
| Sep 16, 2025 | Complaint inspection | No deficiencies cited |
| Apr 30, 2025 | Complaint inspection | No deficiencies cited |
| Jan 7, 2025 | Complaint inspection | No deficiencies cited |
| Jan 31, 2024 | Complaint inspection | 1 deficiency cited |
| Dec 12, 2023 | Complaint inspection | No deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 2 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 8; safety of care, 2 better and 0 worse of 7; readmission, 0 better and 2 worse of 11.
- Patients rate it 3 of 5 in CMS’s patient survey (658 surveys completed, Oct 1, 2024 to Sep 30, 2025): 66% rated it 9 or 10 out of 10, and 66% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), no different than national benchmark; catheter urinary tract infections (CAUTI), better than the national benchmark; surgical site infections after colon surgery, no different than national benchmark; surgical site infections after abdominal hysterectomy, no different than national benchmark; MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 11.4%, heart failure 9.4%, pneumonia 14.7%, COPD 7.8%, stroke 12%, heart bypass surgery 2.8%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 14.1%, heart failure 19.5%, pneumonia 17.8%, COPD 19.5%, heart bypass surgery 11.1%, hip or knee replacement 7.4%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 200 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 1% left before being seen.
- 67% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.99 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 2 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 3 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1976.
- Ownership: voluntary non-profit - private.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- It has an inpatient rehabilitation unit of 30 beds, which CMS lists apart as a rehabilitation facility.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 2 of 5.
- 50% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Trinity Health-Michigan owns 100% directly since May 1, 2000.
- 20 owners or officers are people: William Morris (corporate director); Edmund F Hodge (corporate director); Spencer T Maidlow (corporate director); Michael Williams (corporate director); Linda J Werthman (corporate director); Sara Dolan (corporate director); Suzanne Mellon (corporate director); Paula Chermside (corporate director); Shannon Striebich (corporate officer); Shannon Striebich (corporate director); Michael P Gusho (corporate officer); Joseph Fleck (corporate director); Melissa Karolak (managing employee (on the payroll)); Melissa Karolak (runs it (operational or managerial control)); Christian Schafer (corporate officer); Eric C Ferguson (corporate director); Jean M Nagelkerk (corporate officer); Jean M Nagelkerk (corporate director); Wayman P Britt (corporate officer); Wayman P Britt (corporate director).
- CMS’s Provider of Services file records 1 change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Trinity Health-Michigan | Owns 5% or more directly | 100% | May 1, 2000 |
| Trinity Health Corporation | Owns 5% or more through other companies | 100% | May 15, 2013 |
How does it compare nearby?
- Of the 14 hospitals CMS lists in Oakland County, 9 have an overall star rating from CMS: 2 rated 4 of 5, 5 rated 3 of 5, 2 rated 2 of 5.
- CMS rates this one 2 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.