Cycle 1
Health 2025-09-15 · Fire 2025-09-15
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Saint Johns, MI
Hazel I Findlay Country Manor
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1101 S Scott Road, Saint Johns, MI
(989) 224-8936
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
96
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-03-01
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
0.65
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.90
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.18
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.67
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.31
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
0.70
CMS adjusted RN staffing hours
Adjusted total hours
4.55
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,416
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.89
Composite VBP score used to determine payment impact.
Payment multiplier
1.0039
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.17
Baseline 18.77% · Performance 19.96% · Measure score 3.17 · Achievement 3.17 · Improvement 0
Healthcare-associated infections
5.02
Baseline 5.96% · Performance 6.33% · Measure score 5.02 · Achievement 5.02 · Improvement 0
Total nurse turnover
7.58
Baseline 39.22% · Performance 32.69% · Measure score 7.58 · Achievement 7.58 · Improvement 4.04
Adjusted total nurse staffing
4.18
Baseline 4.53 hours · Performance 4.27 hours · Measure score 4.18 · Achievement 4.18 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.15% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 87 · Observed rate 12.64% · Lower 95% interval 7.72% |
| Discharge to community | 49.67% |
50.57%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 42.67% · Lower 95% interval 39.08% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.85% |
95.27%
3.6 pts better
|
Numerator 86 · Denominator 87 |
| Falls with major injury | 1.15% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 87 |
| Discharge self-care score | 31.82% |
53.69%
21.9 pts worse
|
Numerator 21 · Denominator 66 |
| Discharge mobility score | 34.85% |
50.94%
16.1 pts worse
|
Numerator 23 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 87 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.33% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 3.85% · Lower 95% interval 3.28% |
| Staff COVID-19 vaccination coverage | 3.76% |
8.2%
4.4 pts worse
|
Numerator 7 · Denominator 186 |
| Staff flu vaccination coverage | 42.06% |
42%
0.1 pts better
|
Numerator 98 · Denominator 233 |
| Discharge function score | 34.85% |
56.45%
21.6 pts worse
|
Numerator 23 · Denominator 66 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 48 · Denominator 48 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 15 · Denominator 60 |
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 1.2 · 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 2.2 · Expected 1.4 · 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 98.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
95.0%
2.3 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.1%
About the same
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.3% · Q3 3.9% · Q4 1.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.1% |
4.1%
About the same
|
11.4%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.2% · Q3 5.7% · Q4 3.8% · 4Q avg 4.1% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
5.5%
0.9 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.4% · Q3 6.6% · Q4 1.4% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.2% |
19.6%
9.4 pts better
|
19.6%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 10.3% · Q3 10.9% · Q4 11.3% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.2% |
16.5%
1.7 pts worse
|
16.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 16.7% · Q3 15.4% · Q4 24.6% · 4Q avg 18.2% · 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 | 21.3% |
13.9%
7.4 pts worse
|
16.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 24.8% · Q3 18.4% · Q4 14.6% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.3% |
11.7%
10.6 pts worse
|
14.9%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 18.5% · Q3 25.8% · Q4 18.8% · 4Q avg 22.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
0.9%
2.1 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.4% · Q3 2.7% · Q4 3.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.7%
About the same
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 2.7% · Q4 1.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.5% |
20.4%
6.1 pts worse
|
19.8%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 29.6% · Q3 22.1% · Q4 20.3% · 4Q avg 26.5% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.6%
2.5 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 2.4% · Q4 6.2% · 4Q avg 3.1% · 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 90.6% · Q2 92.6% · Q3 95.3% · Q4 97.4% · 4Q avg 94.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
11.5%
2.1 pts worse
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 14.1% · Expected 11.6% · 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 | 66.9% |
79.5%
12.6 pts worse
|
79.7%
12.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.3% |
24.2%
5.9 pts better
|
23.9%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 17.9% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-29 · Fire 2024-08-29
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-06-06 · Fire 2023-06-06
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 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
2025-09-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-06
F · Potential for more than minimal harm
2024-08-29
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-29
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-08-29
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-08-29
F · Potential for more than minimal harm
2023-06-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-07
E · Potential for more than minimal harm
2023-06-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-07
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-15
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 2025-10-06
D · Potential for more than minimal harm
2025-09-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-15
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 2025-10-06
D · Potential for more than minimal harm
2025-09-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-09-15
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 2025-10-06
D · Potential for more than minimal harm
2024-08-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-09-17
D · Potential for more than minimal harm
2024-08-29
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 2024-09-17
D · Potential for more than minimal harm
2024-08-29
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 2024-09-17
D · Potential for more than minimal harm
2023-06-06
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 2023-06-16
D · Potential for more than minimal harm
2023-06-06
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 2023-06-16
Penalties and ownership
What sits behind the stars
Ownership
Boettger, Marylu
Corporate Director · Individual
Feldpausch, Claire
Operational/Managerial Control · Individual
Fossano, Sandra
Operational/Managerial Control · Individual
Higbie, Kimberly
Operational/Managerial Control · Individual
Kudwa, David
Corporate Director · Individual
Kudwa, Robert
Corporate Director · Individual
Minnick, Molly
Corporate Director · Individual
Minnick, Paul
Operational/Managerial Control · Individual
Minnick, Paul
Corporate Director · Individual
O'connor, Ronald
Operational/Managerial Control · Individual
Robbins, Sarah
Corporate Director · Individual
Sodman-Orth, Kari
Operational/Managerial Control · Individual
Sodman-Orth, Kari
Corporate Officer · Individual
Soros, Allan
Corporate Director · Individual
Stoll, Amy
Operational/Managerial Control · Individual
Zimmerman, Bailey
Operational/Managerial Control · Individual
Nearby options
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2-star overall rating with 2-star inspections with $79,950 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
The Laurels of Fulton
Perrinton, MI
3-star overall rating with 2-star inspections with $39,515 in total fines with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Ashley Healthcare Center
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1-star overall rating with 1-star inspections with $116,787 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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