8 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Essexville, MI
3-star overall rating with 2-star inspections with abuse icon flag with $165,536 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
564 West Hampton Road, Essexville, MI
(989) 892-3591
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
161
Certified beds
Average residents
90
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
1.32
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.34
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.61
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
6.26
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.65
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
5.34
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.82
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.25
CMS adjusted RN staffing hours
Adjusted total hours
5.92
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Program rank
3,403
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9976
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 21.07% · Performance 24.11% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.57
Baseline 7.13% · Performance 6.77% · Measure score 3.57 · Achievement 3.57 · Improvement 1.2
Total nurse turnover
4.22
Baseline 34.42% · Performance 46.45% · Measure score 4.22 · Achievement 4.22 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.71 hours · Performance 6.29 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.84% |
10.72%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 133 · Observed rate 18.8% · Lower 95% interval 10.05% |
| Discharge to community | 47.23% |
50.57%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 123 · Observed rate 39.84% · Lower 95% interval 38.35% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.45% |
95.27%
0.2 pts better
|
Numerator 84 · Denominator 88 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 88 |
| Discharge self-care score | 15.52% |
53.69%
38.2 pts worse
|
Numerator 9 · Denominator 58 |
| Discharge mobility score | 22.41% |
50.94%
28.5 pts worse
|
Numerator 13 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 9.09% |
2.29%
6.8 pts worse
|
Numerator 8 · Denominator 88 · Adjusted rate 7.88% |
| Healthcare-associated infections requiring hospitalization | 6.77% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 5.95% · Lower 95% interval 3.44% |
| Staff COVID-19 vaccination coverage | 6.7% |
8.2%
1.5 pts worse
|
Numerator 15 · Denominator 224 |
| Staff flu vaccination coverage | 35.27% |
42%
6.7 pts worse
|
Numerator 97 · Denominator 275 |
| Discharge function score | 20.69% |
56.45%
35.8 pts worse
|
Numerator 12 · Denominator 58 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | 97.62% |
96.28%
1.3 pts better
|
Numerator 41 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 39.02% |
25.2%
13.8 pts better
|
Numerator 16 · Denominator 41 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.2 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.5
0.6 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
95.0%
4.7 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.1%
2.4 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
4.1%
1.4 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.1% · Q3 2.9% · Q4 1.6% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
5.5%
0.4 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 10.6% · Q3 8.7% · Q4 1.5% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.5% |
19.6%
7.9 pts worse
|
19.6%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 31.9% · Q3 29.0% · Q4 22.4% · 4Q avg 27.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
16.5%
1.7 pts better
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 15.3% · Q3 12.5% · Q4 13.0% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.7% |
13.9%
1.2 pts better
|
16.3%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.2% |
11.7%
2.5 pts better
|
14.9%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 13.8% · Q3 5.3% · Q4 1.8% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 0.7% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.7%
0.7 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.6% · Q3 1.3% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.8% |
20.4%
3.4 pts worse
|
19.8%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 26.4% · Q3 22.0% · Q4 18.7% · 4Q avg 23.8% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
5.6%
0.8 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 8.8% · Q3 4.3% · Q4 1.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
82.8%
11.1 pts better
|
81.7%
12.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 95.2% · Q3 93.0% · Q4 94.2% · 4Q avg 93.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
11.5%
1.2 pts worse
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 13.6% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.3%
0.9 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.8% · Q3 1.8% · Q4 1.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
79.5%
16.9 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.6% |
24.2%
4.4 pts worse
|
23.9%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.6% · Observed 34.1% · Expected 28.4% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-14
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-14
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-14
Fire Safety
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.
Corrected 2025-06-14
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-06-14
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-06-14
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-22
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-22
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-04-22
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-22
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-01
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-05-01
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-01
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-01
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-01
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-01
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-05-01
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-01
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-01
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-05-01
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-01
Inspection history
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-03-08
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-23
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-23
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-05-23
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-23
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-05-23
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-22
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-22
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-22
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-22
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-22
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-04-22
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-22
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-04-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-15
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-15
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-04-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-15
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-15
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-04-15
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2023-04-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-15
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-04-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-15
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-04-15
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-15
Penalties and ownership
Fine · fine $116,805
Fine
Payment Denial · denial start 2025-05-16 · 29 days
29 day denial
Fine · fine $48,731
Fine
Payment Denial · denial start 2024-04-11 · 11 days
11 day denial
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
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