Cycle 1
Health 2025-12-04 · Fire 2025-12-04
5 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
North Muskegon, MI
Hillcrest Nursing and Rehabilitation Community
4-star overall rating with 3-star inspections with $33,813 in total fines with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
695 Mitzi Street, North Muskegon, MI
(231) 744-1641
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
39
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atrium Centers
Operator or chain grouping
Approved since
1992-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
26 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
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
0.60
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.89
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.26
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,171
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.61% · Performance 22.36% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.85
Baseline 6.07% · Performance 7.28% · Measure score 1.85 · Achievement 1.85 · Improvement 0
Total nurse turnover
4.03
Baseline 54.17% · Performance 47.22% · Measure score 4.03 · Achievement 4.03 · Improvement 1.87
Adjusted total nurse staffing
2.63
Baseline 3.74 hours · Performance 3.83 hours · Measure score 2.63 · Achievement 2.63 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.31% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 10.29% · Lower 95% interval 6.64% |
| Discharge to community | 63.61% |
50.57%
13 pts better
|
Better than the National Rate · Eligible stays 60 · Observed rate 63.33% · Lower 95% interval 50.61% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 87.23% |
95.27%
8 pts worse
|
Numerator 41 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 64.29% |
53.69%
10.6 pts better
|
Numerator 18 · Denominator 28 |
| Discharge mobility score | 25% |
50.94%
25.9 pts worse
|
Numerator 7 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 2.13% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 47 · Adjusted rate 2.46% |
| Healthcare-associated infections requiring hospitalization | 7.28% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 3.6% |
| Staff COVID-19 vaccination coverage | 6.35% |
8.2%
1.8 pts worse
|
Numerator 4 · Denominator 63 |
| Staff flu vaccination coverage | 6.11% |
42%
35.9 pts worse
|
Numerator 8 · Denominator 131 |
| Discharge function score | 42.86% |
56.45%
13.6 pts worse
|
Numerator 12 · Denominator 28 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 21 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 19.35% |
25.2%
5.8 pts worse
|
Numerator 6 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
95.0%
2.6 pts worse
|
93.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 88.5% · Q3 90.9% · Q4 100.0% · 4Q avg 92.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.5% |
95.0%
7.5 pts worse
|
95.5%
8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.1%
1.2 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · 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 · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.1% |
5.5%
4.4 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.7% |
19.6%
11.9 pts better
|
19.6%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 10.0% · Q3 4.8% · Q4 4.0% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
16.5%
1.7 pts better
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q3 15.0% · Q4 16.0% · 4Q avg 14.8% · 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 | 20.9% |
13.9%
7 pts worse
|
16.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
11.7%
1.4 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q3 0.0% · Q4 20.8% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.8% |
1.7%
4.1 pts worse
|
1.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 7.7% · Q3 9.1% · Q4 4.0% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.2% |
20.4%
5.2 pts better
|
19.8%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 23.9% · Q3 9.3% · Q4 7.9% · 4Q avg 15.2% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
5.6%
2.3 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 7.2% · Q3 6.4% · Q4 15.7% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.3% |
82.8%
1.5 pts worse
|
81.7%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.9% · Q2 81.8% · Q3 86.4% · Q4 77.3% · 4Q avg 81.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.2% |
11.5%
6.3 pts better
|
12.0%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.2% · Observed 5.1% · Expected 11.0% · 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 | 81.2% |
79.5%
1.7 pts better
|
79.7%
1.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.2% |
| 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 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-16 · Fire 2024-10-16
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-10-03 · Fire 2023-10-03
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2026-01-21
F · Potential for more than minimal harm
2025-12-04
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2026-01-21
E · Potential for more than minimal harm
2025-12-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-01-21
E · Potential for more than minimal harm
2025-12-04
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 2026-01-21
E · Potential for more than minimal harm
2025-12-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-21
E · Potential for more than minimal harm
2025-12-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-01-21
E · Potential for more than minimal harm
2025-12-04
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2026-01-21
E · Potential for more than minimal harm
2025-12-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-01-21
E · Potential for more than minimal harm
2024-10-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-15
F · Potential for more than minimal harm
2023-10-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-10-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-21
E · Potential for more than minimal harm
2025-12-04
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 2026-01-21
E · Potential for more than minimal harm
2025-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-01-21
G · Actual harm
2025-03-28
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 2025-04-24
D · Potential for more than minimal harm
2024-10-16
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 2024-11-15
D · Potential for more than minimal harm
2024-10-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-16
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 2024-11-15
D · Potential for more than minimal harm
2024-10-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
G · Actual harm
2024-03-11
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 2024-04-03
E · Potential for more than minimal harm
2024-03-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-05-08
F · Potential for more than minimal harm
2023-10-03
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 2023-11-09
D · Potential for more than minimal harm
2023-10-03
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 2023-11-09
D · Potential for more than minimal harm
2023-10-03
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-03
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 2023-11-09
D · Potential for more than minimal harm
2023-10-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-03
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-03
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-11-09
G · Actual harm
2023-05-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-05-05
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 2023-06-05
D · Potential for more than minimal harm
2023-05-05
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 2023-06-05
D · Potential for more than minimal harm
2023-05-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-05
Penalties and ownership
What sits behind the stars
$0
2024-03-11
Payment Denial
Payment Denial · denial start 2024-04-04 · 34 days
34 day denial
$33,813
2023-05-05
Fine
Fine · fine $33,813
Fine
Ownership
Amicus Capital Holdings Inc Esop
5% Or Greater Indirect Ownership Interest · Organization
Atrium Centers, Inc.
5% Or Greater Direct Ownership Interest · Organization
Albright Ross, Susan
Operational/Managerial Control · Individual
Atrium Centers Management LLC
Operational/Managerial Control · Organization
Bailey, Essel
Corporate Officer · Individual
Finney, Donald
Corporate Officer · Individual
Lockhart, Dennis
Corporate Director · Individual
Rocca, Michael
Corporate Officer · Individual
Wozniak, Kimberly
W-2 Managing Employee · Individual
Nearby options
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0-star overall rating with 0-star inspections with 6 fire-safety deficiencies in the latest cycle
#2
Lake Woods Nursing & Rehabilitation Center
Muskegon, MI
3-star overall rating with 2-star inspections with abuse icon flag with $67,541 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Optalis Health & Rehabilitation of Muskegon
Muskegon, MI
2-star overall rating with 2-star inspections with $131,810 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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