Ascension Providence Rochester Hospital
An acute care hospital in Rochester, Michigan 48307
1101 W University Drive, Rochester, Michigan 48307. (248) 652-5000.
- Medicare payments cut under the HAC Reduction Program (fiscal year 2026)
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The short answer
Record last released by CMS on Oct 20, 2026.
- 3of 5 CMS’s overall rating
- 2of 5 patient survey rating
- 3 deficiencies cited in the last three years
- 290 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 Jul 29, 2025: a complaint inspection.
3 deficiencies cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
3 deficiencies in 2 months of the last 36. Last cited Jul 2025. 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.
Jul 29, 2025: complaint inspection2 deficiencies
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Patient Rights: Care In Safe Setting
The inspectors’ words, 679 words
“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50585 Based on observation, interview, and record review, the facility failed to ensure fall risk prevention interventions were in place for 2 (P-1, P-2) of 4 patients reviewed, and that post fall interventions per facility policy were carried out for 1 (P-1) of 4 patients reviewed with high-risk fall precautions resulting in the increased likelihood of negative consequences for the patients. Findings include: On 5/16/2025, P-1 experienced an unwitnessed fall in the restroom prior to having a stress test performed. P-1 was 87 years-old, legally blind, and was considered a patient at high risk for falls. On 7/29/2025 at 0830, Nuclear Medicine Technologist Staff S was interviewed with Union Representative Staff BB about their role in caring for P-1. Staff S revealed P-1’s stretcher was near the restroom in the Nuclear Medicine department and P-1 “wanted to use restroom” and they “helped P-1 into restroom and stepped outside restroom door.” Staff S revealed they normally ask the patient if they required help but didn’t remember if that “was told.” Staff S proceeded to step outside restroom and stood at the door and at some point heard P-1 fall. Nuclear Medicine Technologist Staff L and Staff S went into the restroom and observed P-1 “in front of sink”. Staff S revealed that after P-1 fell, their “manager instructed” Staff S should have stayed “in the restroom” and Staff S revealed that they were “not aware of policy.” On 7/29/2025 at 0915, Cardiac Nurse Staff O was queried about their involvement in treating P-1. Staff O revealed after P-1 fell prior to their stress test, Staff O performed a mini-assessment of P-1 and noticed P-1 did not have a fall bracelet or yellow socks on. Staff O revealed they had to go to the Emergency Department to obtain and apply the bracelet and socks to P-1 and this information was “communicated” to the P-1’s inpatient nurse. According to a review of P-1’s medical record on 7/28/2025 at 1230, there was no post-fall order set and no post fall care plan initiated for P-1 by the nurse. On 7/28/2025 at 1210 during survey tour, current patient P-2 was having a stress test completed and Nuclear Medicine Technologist Staff L was queried to describe the communication process when an inpatient was transported to Radiology for a procedure, they brought forward a hand off form that listed patient information including whether the patient was a fall risk. P-2’s hand off communication form was reviewed and revealed the section for communicating Fall Risk status was not checked. On 7/28/2025 at 1300, P-2’s medical record was reviewed with Clinical Informatics Staff N and P-2 was identified as a high risk for falls. On 7/29/2025 at 1315, Director of Nursing Staff Y was queried and reviewed a copy of the P-2’s hand-off communication form and confirmed the section of Falls Risk should have been completed by the inpatient nurse. Staff Y was also asked if they expected staff to follow policies and procedures and they revealed “Absolutely.” According to the facility’s policy “Adult Fall Prevention,” dated 7/10/2025, for “Risk Directed Care,” “Caregiver to remain within arm’s reach of patient during toileting, 1. Includes bathroom and bedside toileting, 2. Safety is the priority.” The policy also revealed “Place fall risk identifiers such as armband/coordinating nonskid socks on the patient according to organization processes.” The policy also revealed that for “Post Fall Management Assessment and Documentation,” “Nurses initiate the post fall order set in the EHR (electronic health record) and implement a post fall care plan with the patient/family/caregiver.” According to the facility’s policy, “Handoff and Communication during Patient Transportation,” dated 8/23/2024, “This policy provides safety guidelines for handoff and communications between staff during the transportation of patients within the (facility). At the time of transport, the Healthcare Provider (HCP) caring for the patient: completes the “Patient Handoff Worksheet,” reviews it with the Transporter and the worksheet remains with the patient.””
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Patient Rights: Restraint Or Seclusion
The inspectors’ words, 340 words
“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to follow national standards in evaluating patients after placing a patient in four-point locking restraints for 1 (P-11) of 3 patients reviewed for restraint and seclusion monitoring resulting in the loss of patient rights for the patient. Findings include: P-11 had four-point locking restraints ordered on 2/24/2025 at 1907 and discontinued on 2/24/2025 at 1938 and there was no documentation that the face-to-face medical evaluation was performed after initiation of the restraints. Clinical Informatics Nurse Staff N confirmed the findings at the time of discovery. According to the facility’s policy, “Restraint,” dated 5/8/2025, for “Physician Responsibilities,” “Perform an in-person evaluation of the patient in restraint within 1 hour after the initiation of restraint by a physician to evaluate at a minimum: This evaluation will include the patient’s: a. immediate situation b. reaction to the intervention c. medical and behavioral condition AND the need to continue or discontinue the restraint d. the patient’s physical and psychological status; e. the patient’s behavior that warranted the intervention, the intervention used; f. alternative or less restrictive measure attempted (if applicable) and the appropriateness of the intervention measures; g. the patients’ response to the intervention used, including rational for continued use; h. any complications resulting from, the intervention.” The policy also revealed that “A patient may be restrained prior to examination pursuant to an authorization. A qualified nurse may initiate a patient restraint to address violent behavior prior to a physician’s evaluation, A physician must personally examine the patient in person within 1 hour of the initiation of restraints, even if the restraints were removed within that first hour.””
Apr 17, 2025: complaint inspection1 deficiency
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Nursing Care Plan
The inspectors’ words, 313 words
“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 48772 Based on interview and record review, the facility failed to establish an individualized plan of care for 2 (P-3, P-4) of 11 patients reviewed, resulting in the potential for negative outcomes for these patients. Findings include: P-3: This 83-year-old female with a past medical history of hypertension, hyperlipidemia, diabetes, and cardiac artery disease with bypass presented to the emergency department on 4/13/25 with symptoms of shortness of breath and wheezing. During record review on 4/16/25, it was noted that the record failed to include a plan of care. P-4: This 77-year-old male with a past medical history of normal pressure hydrocephalus, stroke, moderate dementia, hypertension, overactive bladder, chronic back pain, and gastroesophageal reflux disease presented to the emergency department on 4/10/25 with new onset seizures. During record review on 4/16/25, it was noted that the nursing plan of care included fall prevention. There was no evidence the plan of care addressed new onset of seizures or any other chronic conditions, such as pain. These findings were reviewed and acknowledged by the 5 West Nurse Manager (Staff-K) at time of discovery. Policy 17214604 - Guidelines of Practice for Patient Care (Revised 1/3/2025). The Plan of Care (POC) shall be initiated for all patients within 24 hours of admission. The RN is responsible for determining the patient’s health care needs and initiating identified Multidisciplinary Care Plans (MCP’s) with anticipated goals. The MCP goals shall be reviewed and updated at least every 24 hours, and when the patient’s condition and/or Plan of Care changes.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jul 29, 2025 | Complaint inspection | 2 deficiencies cited |
| Apr 17, 2025 | Complaint inspection | 1 deficiency 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 3 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, 1 better and 0 worse of 3; readmission, 1 better and 0 worse of 9.
- Patients rate it 2 of 5 in CMS’s patient survey (867 surveys completed, Oct 1, 2024 to Sep 30, 2025): 57% rated it 9 or 10 out of 10, and 57% 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), no different than 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 12.6%, heart failure 11.4%, pneumonia 15.2%, COPD 8.7%, stroke 11.3%, heart bypass surgery 3.4%. 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 22.7%, pneumonia 17.8%, COPD 19.7%, heart bypass surgery 10.7%, hip or knee replacement 5.6%. 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; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 187 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025).
- 72% 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 1 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 | 3 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 2 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Aug 15, 1967.
- 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 17 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.
- CMS cut its Medicare payments by 1% for fiscal year 2026 under the Hospital-Acquired Condition Reduction Program, which does so for the quarter of hospitals that fare worst on conditions patients get in hospital.
- 3 deficiencies cited in the last three years came from inspections 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.
| Date | What | Detail |
|---|---|---|
| Medicare payment reduction (HAC Reduction Program) | Fiscal year 2026: 1% of Medicare payments |
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.
- 86% 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?
- 27 owners or officers are people: Daniel J. Phelan (corporate director); Charles Mcclure (corporate director); Robert R Lubera (corporate director); Barry G. Porter (corporate director); Steven Brian Bender (corporate officer); Gerardo Norcia (corporate director); Robert Riney (corporate director); Michael Rafferty (corporate director); Jeffrey Fall (corporate director); Farzan Siddiqui (corporate director); Rhonda M Medows (corporate director); David Breen (corporate director); Mary Ann Victor (corporate director); Jason Williams (corporate officer); Jason Williams (managing employee (on the payroll)); Anthony Rocco Tersigni (corporate director); Robin S. Damschroder (corporate officer); Robin S. Damschroder (runs it (operational or managerial control)); Gregory Pflum (corporate director); Edward D Callaghan (corporate director); John F. Harris (corporate director); Edgar Vann (corporate director); Lisa Fitzpatrick (corporate director); Joseph Richardson (corporate director); Gwendolyn M Mackenzie (corporate director); Jacalyn S. Goforth (corporate director); Eugene F Lovasco (corporate director).
- CMS’s Provider of Services file records no 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 |
|---|---|---|---|
| Henry Ford Health System | Owns 5% or more through other companies | 100% | Dec 18, 1987 |
| Henry Ford Health Parent | Owns 5% or more through other companies | 80% | Oct 1, 2024 |
| Ascension Health | Owns 5% or more through other companies | 20% | Oct 1, 2024 |
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 3 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.