Cycle 1
Health 2024-12-20 · Fire 2024-12-20
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Charlotte, MI
Eaton County Medical Care Facility
4-star overall rating with 2-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
530 W Beech Street, Charlotte, MI
(517) 543-2940
Overall
4 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
142
Certified beds
Average residents
125
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
Hours and turnover
RN hours / resident day
1.00
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
4.28
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
6.41
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.12
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
5.38
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.03
CMS adjusted RN staffing hours
Adjusted total hours
6.64
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
33
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
95.25
Composite VBP score used to determine payment impact.
Payment multiplier
1.0276
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 19.36% · Performance 16.93% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
10
Baseline 5.08% · Performance 4.92% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
8.10
Performance 30.57% · Measure score 8.10 · Achievement 8.10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
10
Baseline 6.17 hours · Performance 6.42 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.44% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 184 · Observed rate 8.7% · Lower 95% interval 7.57% |
| Discharge to community | 65.22% |
50.57%
14.6 pts better
|
Better than the National Rate · Eligible stays 169 · Observed rate 65.09% · Lower 95% interval 57.6% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 103 · Denominator 103 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 103 |
| Discharge self-care score | 69.23% |
53.69%
15.5 pts better
|
Numerator 54 · Denominator 78 |
| Discharge mobility score | 74.36% |
50.94%
23.4 pts better
|
Numerator 58 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 0.97% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 103 · Adjusted rate 0.99% |
| Healthcare-associated infections requiring hospitalization | 4.92% |
7.12%
2.2 pts better
|
No Different than the National Rate · Eligible stays 118 · Observed rate 0.85% · Lower 95% interval 2.71% |
| Staff COVID-19 vaccination coverage | 3.66% |
8.2%
4.5 pts worse
|
Numerator 13 · Denominator 355 |
| Staff flu vaccination coverage | 56.25% |
42%
14.2 pts better
|
Numerator 234 · Denominator 416 |
| Discharge function score | 64.1% |
56.45%
7.6 pts better
|
Numerator 50 · Denominator 78 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 56 · Denominator 56 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 44.9% |
25.2%
19.7 pts better
|
Numerator 22 · Denominator 49 |
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 1.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.5
1.1 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
95.0%
4 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 97.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
95.0%
3.1 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.1%
0.6 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.9% · Q3 3.0% · Q4 2.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
4.1%
2.2 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.0% · Q3 1.1% · Q4 3.2% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
5.5%
3.8 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.1% · Q3 0.0% · Q4 3.3% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.1% |
19.6%
8.5 pts better
|
19.6%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 9.8% · Q3 9.4% · Q4 13.3% · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.7% |
16.5%
7.8 pts better
|
16.7%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 8.9% · Q3 8.5% · Q4 8.0% · 4Q avg 8.7% · 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 | 12.4% |
13.9%
1.5 pts better
|
16.3%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 10.8% · Q3 10.3% · Q4 15.1% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.7% |
11.7%
1 pts better
|
14.9%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 8.1% · Q3 5.0% · Q4 14.1% · 4Q avg 10.7% · 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 1.1% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
20.4%
4.1 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 22.2% · Q3 21.8% · Q4 26.5% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.6%
2.6 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.0% · Q3 2.3% · Q4 2.3% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
82.8%
16.5 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 99.4% · Q3 98.8% · Q4 99.4% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
11.5%
0.9 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 10.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.2% |
79.5%
14.7 pts better
|
79.7%
14.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
24.2%
7.6 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 15.0% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-01 · Fire 2023-11-01
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-09-15 · Fire 2022-09-15
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-20
K222 · Egress Deficiencies
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 2025-01-27
F · Potential for more than minimal harm
2024-12-20
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-20
K251 · Egress Deficiencies
Fire Safety
Conform to length requirements for dead end corridors.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-20
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-20
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-12-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-20
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-20
K379 · Smoke Deficiencies
Fire Safety
Have proper openings in smoke barrier doors.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-27
F · Potential for more than minimal harm
2023-11-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-15
F · Potential for more than minimal harm
2023-11-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-11-01
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2023-11-28
F · Potential for more than minimal harm
2022-09-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-21
E · Potential for more than minimal harm
2022-09-15
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2022-12-27
E · Potential for more than minimal harm
2022-09-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-10-21
D · Potential for more than minimal harm
2022-09-15
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 2022-10-21
D · Potential for more than minimal harm
2022-09-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-20
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 2025-01-27
F · Potential for more than minimal harm
2024-12-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-06
E · Potential for more than minimal harm
2024-12-20
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 2025-01-27
D · Potential for more than minimal harm
2024-12-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-06
E · Potential for more than minimal harm
2024-08-09
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-09-10
G · Actual harm
2023-11-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-28
F · Potential for more than minimal harm
2023-11-01
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 2023-11-28
D · Potential for more than minimal harm
2023-11-01
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-01
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 2023-11-28
D · Potential for more than minimal harm
2023-11-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-28
D · Potential for more than minimal harm
2022-09-15
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-10-17
Penalties and ownership
What sits behind the stars
Ownership
Eaton County Health And Rehabilitation Services
5% Or Greater Direct Ownership Interest · Organization
Richard, Martha
W-2 Managing Employee · Individual
Nearby options
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2-star overall rating with 2-star inspections with $54,280 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Regency at Lansing West
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4-star overall rating with 4-star inspections with $11,788 in total fines with 2 fire-safety deficiencies in the latest cycle
#3
Medilodge of Lansing
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5-star overall rating with 3-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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