Cycle 1
Health 2025-02-21 · Fire 2025-02-21
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Battle Creek, MI
Calhoun County Medical Care Facility
2-star overall rating with 2-star inspections with abuse icon flag with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1150 E Michigan Avenue, Battle Creek, MI
(269) 962-5458
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
99
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1974-11-01
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
Hours and turnover
RN hours / resident day
0.70
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.92
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.34
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.74
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
4.88
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,340
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.01
Composite VBP score used to determine payment impact.
Payment multiplier
0.9857
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.94
Performance 19.60% · Measure score 3.94 · Achievement 3.94 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Baseline 5.98% · Performance 8.07% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.71
Baseline 37.21% · Performance 48.52% · Measure score 3.71 · Achievement 3.71 · Improvement 0
Adjusted total nurse staffing
4.35
Baseline 4.65 hours · Performance 4.32 hours · Measure score 4.35 · Achievement 4.35 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.24% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 7.14% · Lower 95% interval 7.07% |
| Discharge to community | 44.47% |
50.57%
6.1 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 42.65% · Lower 95% interval 36.81% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 85 · Denominator 85 |
| Falls with major injury | 1.18% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 85 |
| Discharge self-care score | 55.56% |
53.69%
1.9 pts better
|
Numerator 40 · Denominator 72 |
| Discharge mobility score | 45.83% |
50.94%
5.1 pts worse
|
Numerator 33 · Denominator 72 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 85 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.07% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 8.57% · Lower 95% interval 5.1% |
| Staff COVID-19 vaccination coverage | 8.01% |
8.2%
0.2 pts worse
|
Numerator 23 · Denominator 287 |
| Staff flu vaccination coverage | 58.93% |
42%
16.9 pts better
|
Numerator 198 · Denominator 336 |
| Discharge function score | 62.5% |
56.45%
6 pts better
|
Numerator 45 · Denominator 72 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 47 · Denominator 47 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 9.09% |
25.2%
16.1 pts worse
|
Numerator 4 · Denominator 44 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.0%
5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 3.4% |
3.1%
0.3 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.3% · Q3 3.5% · Q4 3.4% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
4.1%
2.6 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.4% · Q3 0.0% · Q4 2.6% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
5.5%
0.5 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 7.4% · Q3 3.4% · Q4 3.4% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.4% |
19.6%
15.8 pts worse
|
19.6%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 37.7% · Q3 34.5% · Q4 38.3% · 4Q avg 35.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.9% |
16.5%
11.4 pts worse
|
16.7%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 28.2% · Q3 32.4% · Q4 28.0% · 4Q avg 27.9% · 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 | 23.8% |
13.9%
9.9 pts worse
|
16.3%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 23.8% · Q3 33.2% · Q4 19.9% · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.6% |
11.7%
6.9 pts worse
|
14.9%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 17.6% · Q3 21.1% · Q4 20.7% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.3% |
20.4%
11.9 pts worse
|
19.8%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 29.2% · Q3 36.9% · Q4 31.2% · 4Q avg 32.3% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.6%
0.3 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 4.3% · Q3 5.3% · Q4 6.3% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
82.8%
11.2 pts better
|
81.7%
12.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 93.6% · Q3 95.8% · Q4 89.4% · 4Q avg 94.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
11.5%
1.8 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 8.4% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.1% |
79.5%
14.6 pts better
|
79.7%
14.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
24.2%
2 pts better
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 19.3% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-27 · Fire 2024-02-27
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-12-08 · Fire 2022-12-08
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-21
F · Potential for more than minimal harm
2024-02-27
K321 · Smoke Deficiencies
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 2024-03-18
F · Potential for more than minimal harm
2022-12-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-05
E · Potential for more than minimal harm
2022-12-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-12-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-05
Inspection history
Recent health citations
G · Actual harm
2025-11-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-09
F · Potential for more than minimal harm
2025-02-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-02-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-21
F761 · Pharmacy Service Deficiencies
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 2025-03-21
D · Potential for more than minimal harm
2025-02-21
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-21
D · Potential for more than minimal harm
2024-02-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-18
D · Potential for more than minimal harm
2024-02-27
F688 · Quality of Life and Care Deficiencies
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 2024-03-18
F · Potential for more than minimal harm
2022-12-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-12-08
F657 · Resident Assessment and Care Planning Deficiencies
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 2023-01-05
D · Potential for more than minimal harm
2022-12-08
F690 · Quality of Life and Care Deficiencies
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 2023-01-05
D · Potential for more than minimal harm
2022-12-08
F758 · Pharmacy Service Deficiencies
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 2023-01-05
Penalties and ownership
What sits behind the stars
Ownership
Calhoun County Medical Care Facility
5% Or Greater Direct Ownership Interest · Organization
Chung, Younho
Operational/Managerial Control · Individual
Cornish, Stephanie
Operational/Managerial Control · Individual
Sedore, Misty
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Pinnacle Care of Battle Creek
Battle Creek, MI
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $140,507 in total fines with 37 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
The Oaks at Battle Creek
Battle Creek, MI
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Majestic Care of Battle Creek
Battle Creek, MI
2-star overall rating with 2-star inspections with $76,538 in total fines with 15 recent health deficiencies
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