Cycle 1
Health 2025-01-16 · Fire 2025-01-16
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Grayling, MI
Grayling Nursing & Rehabilitation Community
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
331 Meadows Drive, Grayling, MI
(989) 348-2801
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atrium Centers
Operator or chain grouping
Approved since
1984-07-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.80
Registered nurse staffing
LPN hours / resident day
0.52
Licensed practical nurse staffing
Aide hours / resident day
2.07
Nurse aide staffing
Weekend hours
3.03
Weekend nurse staffing
RN turnover
46%
Annual RN turnover
Total nurse turnover
44%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.7
0.8 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.1%
0.2 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.5%
2.5 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.0% |
19.6%
13.6 pts better
|
19.6%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
16.5%
10.8 pts better
|
16.7%
11 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.3% |
13.9%
6.6 pts better
|
16.3%
9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.1% |
11.7%
5.6 pts better
|
14.9%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.9%
0.2 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.7%
0.6 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.2% |
20.4%
18.2 pts better
|
19.8%
17.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
5.6%
1.3 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
82.8%
15.6 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.0% |
11.5%
13.5 pts worse
|
12.0%
13 pts worse
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.5%
20.5 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
24.2%
1.6 pts worse
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-14 · Fire 2024-02-14
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-01-05 · Fire 2023-01-05
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 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
2025-01-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-21
F · Potential for more than minimal harm
2025-01-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-01-16
K223 · Egress Deficiencies
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 2025-02-21
F · Potential for more than minimal harm
2024-02-14
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-03-13
F · Potential for more than minimal harm
2024-02-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-13
F · Potential for more than minimal harm
2024-02-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-13
F · Potential for more than minimal harm
2024-02-14
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-03-13
F · Potential for more than minimal harm
2024-02-14
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-03-13
F · Potential for more than minimal harm
2024-02-14
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-03-13
F · Potential for more than minimal harm
2024-02-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-13
F · Potential for more than minimal harm
2024-02-14
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-04-02
E · Potential for more than minimal harm
2024-02-14
K223 · Egress Deficiencies
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 2024-03-13
D · Potential for more than minimal harm
2024-02-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-13
F · Potential for more than minimal harm
2023-01-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-13
F · Potential for more than minimal harm
2023-01-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-13
F · Potential for more than minimal harm
2023-01-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-13
F · Potential for more than minimal harm
2023-01-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-13
F · Potential for more than minimal harm
2023-01-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-13
E · Potential for more than minimal harm
2023-01-05
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-02-13
E · Potential for more than minimal harm
2023-01-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-02-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-16
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-16
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-13
D · Potential for more than minimal harm
2025-01-16
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 2025-02-13
F · Potential for more than minimal harm
2024-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-14
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 2024-03-13
D · Potential for more than minimal harm
2024-02-14
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 2024-03-13
G · Actual harm
2024-01-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-08
D · Potential for more than minimal harm
2024-01-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-08
F · Potential for more than minimal harm
2023-01-05
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2023-02-13
E · Potential for more than minimal harm
2023-01-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-13
D · Potential for more than minimal harm
2023-01-05
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 2023-02-13
D · Potential for more than minimal harm
2023-01-05
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 2023-02-13
D · Potential for more than minimal harm
2023-01-05
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 2023-02-13
Penalties and ownership
What sits behind the stars
Ownership
Orion Operating Services LLC
5% Or Greater Direct Ownership Interest · Organization
Albright Ross, Susan
Operational/Managerial Control · Individual
Albright Ross, Susan
Corporate Officer · Individual
Amicus Capital Holdings Inc Esop
5% Or Greater Indirect Ownership Interest · Organization
Amicus Capital Holdings Inc Esop
Operational/Managerial Control · Organization
Atrium Centers Management LLC
Operational/Managerial Control · Organization
Atrium Centers, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Bailey, Essel
5% Or Greater Indirect Ownership Interest · Individual
Bailey, Essel
Corporate Director · Individual
Ferkany, James
Corporate Officer · Individual
Fifth Third Bank
Operational/Managerial Control · Organization
Fifth Third Bank
5% Or Greater Security Interest · Organization
Finney, Donald
5% Or Greater Indirect Ownership Interest · Individual
Finney, Donald
Corporate Director · Individual
Lockhart, Dennis
Operational/Managerial Control · Individual
Lockhart, Dennis
Corporate Director · Individual
Malcomson, Jennifer
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Munson Healthcare Crawford Continuing Care Center
Grayling, MI
4-star overall rating with 3-star inspections with $27,600 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Mission Point Nursing & Physical Rehabilitation of
Roscommon, MI
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Kalkaska Memorial Health Center
Kalkaska, MI
4-star overall rating with 2-star inspections with $10,364 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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