Cycle 1
Health 2025-03-25 · Fire 2025-03-25
5 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cassopolis, MI
Cass County Medical Care Facility
4-star overall rating with 4-star inspections with $15,593 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
23770 Hospital St, Cassopolis, MI
(269) 228-4000
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
80
Certified beds
Average residents
71
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1977-10-08
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
0.68
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.58
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.81
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.28
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
5.22
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,818
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.97
Baseline 20.53% · Performance 20.52% · Measure score 1.97 · Achievement 1.97 · Improvement 0
Healthcare-associated infections
5.63
Baseline 5.73% · Performance 6.15% · Measure score 5.63 · Achievement 5.63 · Improvement 0
Total nurse turnover
0
Baseline 42.50% · Performance 97.22% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 4.61 hours · Performance 3.10 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.68% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 8.65% · Lower 95% interval 6.97% |
| Discharge to community | 64.47% |
50.57%
13.9 pts better
|
Better than the National Rate · Eligible stays 98 · Observed rate 57.14% · Lower 95% interval 54.93% |
| 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 47 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 48.65% |
53.69%
5 pts worse
|
Numerator 18 · Denominator 37 |
| Discharge mobility score | 54.05% |
50.94%
3.1 pts better
|
Numerator 20 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 47 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.15% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 4.55% · Lower 95% interval 3.33% |
| Staff COVID-19 vaccination coverage | 9.52% |
8.2%
1.3 pts better
|
Numerator 14 · Denominator 147 |
| Staff flu vaccination coverage | 36.42% |
42%
5.6 pts worse
|
Numerator 63 · Denominator 173 |
| Discharge function score | 45.95% |
56.45%
10.5 pts worse
|
Numerator 17 · Denominator 37 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.1 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.7 · 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 | 3.8% |
3.1%
0.7 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.1% · Q3 6.1% · Q4 3.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.1%
4.1 pts better
|
11.4%
11.4 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 who lose too much weight | 8.5% |
5.5%
3 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 6.6% · Q3 10.9% · Q4 7.0% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.1% |
19.6%
12.5 pts better
|
19.6%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 6.3% · Q3 4.6% · Q4 10.3% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.4% |
16.5%
14.1 pts better
|
16.7%
14.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 2.1% · Q4 6.0% · 4Q avg 2.4% · 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 | 23.2% |
13.9%
9.3 pts worse
|
16.3%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 35.4% · Q3 16.6% · Q4 27.1% · 4Q avg 23.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.2% |
11.7%
5.5 pts worse
|
14.9%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 15.3% · Q3 19.4% · Q4 17.9% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
1.7%
2.2 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.6% · Q3 4.5% · Q4 4.9% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.1% |
20.4%
7.7 pts worse
|
19.8%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 24.4% · Q3 36.4% · Q4 24.4% · 4Q avg 28.1% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
5.6%
0.6 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 7.7% · Q3 5.5% · Q4 3.1% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
82.8%
15.3 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 98.2% · Q3 100.0% · Q4 98.1% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.9% |
11.5%
6.6 pts better
|
12.0%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.9% · Observed 4.9% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short 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 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 | 32.0% |
24.2%
7.8 pts worse
|
23.9%
8.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.0% · Observed 29.3% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-25 · Fire 2024-04-25
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-03-22 · Fire 2023-03-22
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-27
F · Potential for more than minimal harm
2025-03-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-03-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-03-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-03-25
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-03-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-27
F · Potential for more than minimal harm
2024-04-25
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-04-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-04-25
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 2024-05-31
E · Potential for more than minimal harm
2024-04-25
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-31
F · Potential for more than minimal harm
2023-03-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-01
F · Potential for more than minimal harm
2023-03-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-01
F · Potential for more than minimal harm
2023-03-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-01
F · Potential for more than minimal harm
2023-03-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-01
F · Potential for more than minimal harm
2023-03-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-11
E · Potential for more than minimal harm
2023-03-22
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 2023-05-01
E · Potential for more than minimal harm
2023-03-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-01
E · Potential for more than minimal harm
2023-03-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-03-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-03-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
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 2025-12-17
D · Potential for more than minimal harm
2025-11-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-17
F · Potential for more than minimal harm
2025-03-25
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 2025-04-25
E · Potential for more than minimal harm
2025-03-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-25
D · Potential for more than minimal harm
2024-04-25
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-25
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-25
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-31
G · Actual harm
2024-03-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-13
G · Actual harm
2024-03-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-13
G · Actual harm
2023-03-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-01
G · Actual harm
2023-03-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-03-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-03-22
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-03-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-03-22
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 2023-05-01
D · Potential for more than minimal harm
2023-03-22
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-03-22
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 2023-05-01
D · Potential for more than minimal harm
2023-03-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-01
Penalties and ownership
What sits behind the stars
$7,796
2024-03-20
Fine
Fine · fine $7,796
Fine
$7,797
2024-03-20
Fine
Fine · fine $7,797
Fine
Ownership
County Of Cass
5% Or Greater Direct Ownership Interest · Organization
Lutes, Christian
Corporate Director · Individual
Lutes, Christian
W-2 Managing Employee · Individual
Seifert, Diane
Corporate Director · Individual
Vaughn, Vicki
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
The Timbers of Cass County
Dowagiac, MI
3-star overall rating with 2-star inspections with 18 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Niles Care Center, LLC
Niles, MI
2-star overall rating with 1-star inspections with Special Focus status with $82,810 in total fines with 16 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Riveridge Rehabilitation and Healthcare Center
Niles, MI
1-star overall rating with 1-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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