Cycle 1
Health 2025-12-22 · Fire 2025-12-22
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Hillsdale, MI
Hillsdale Hospital McGuire & Macritchie Long Term
5-star overall rating with 5-star inspections with 2 recent health deficiencies
168 South Howell Street, Hillsdale, MI
(517) 437-5440
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
38
Certified beds
Average residents
34
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-02-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.20
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.34
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.09
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
5.63
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.53
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.87
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.22
CMS adjusted RN staffing hours
Adjusted total hours
5.71
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,451
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.71
Composite VBP score used to determine payment impact.
Payment multiplier
1.0037
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.28
Baseline 20.32% · Performance 20.38% · Measure score 2.28 · Achievement 2.28 · Improvement 0
Healthcare-associated infections
5.30
Baseline 4.76% · Performance 6.25% · Measure score 5.30 · Achievement 5.30 · Improvement 0
Total nurse turnover
4.10
Baseline 38.30% · Performance 46.94% · Measure score 4.10 · Achievement 4.10 · Improvement 0
Adjusted total nurse staffing
8.21
Baseline 4.71 hours · Performance 5.41 hours · Measure score 8.21 · Achievement 8.21 · Improvement 6.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.73% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 143 · Observed rate 10.49% · Lower 95% interval 7.93% |
| Discharge to community | 72.06% |
50.57%
21.5 pts better
|
Better than the National Rate · Eligible stays 128 · Observed rate 73.44% · Lower 95% interval 63.97% |
| Medicare spending per beneficiary | 0.65 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 85 · Denominator 85 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 85 |
| Discharge self-care score | 25.37% |
53.69%
28.3 pts worse
|
Numerator 17 · Denominator 67 |
| Discharge mobility score | 22.39% |
50.94%
28.5 pts worse
|
Numerator 15 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 5.88% |
2.29%
3.6 pts worse
|
Numerator 5 · Denominator 85 · Adjusted rate 6.51% |
| Healthcare-associated infections requiring hospitalization | 6.25% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 2.94% · Lower 95% interval 3.22% |
| Staff COVID-19 vaccination coverage | 11.76% |
8.2%
3.6 pts better
|
Numerator 12 · Denominator 102 |
| Staff flu vaccination coverage | 61.19% |
42%
19.2 pts better
|
Numerator 82 · Denominator 134 |
| Discharge function score | 22.39% |
56.45%
34.1 pts worse
|
Numerator 15 · Denominator 67 |
| Transfer of health information to provider | 98.59% |
95.95%
2.6 pts better
|
Numerator 70 · Denominator 71 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 6.38% |
25.2%
18.8 pts worse
|
Numerator 3 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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% · 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 | 8.6% |
3.1%
5.5 pts worse
|
3.3%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 5.0% · Q4 9.5% · 4Q avg 8.6% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
5.5%
3.6 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.6% |
19.6%
16 pts better
|
19.6%
16 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
16.5%
6.9 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.6% · 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% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.4% |
13.9%
2.5 pts worse
|
16.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
11.7%
13.3 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 12.0% |
0.9%
11.1 pts worse
|
1.0%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q4 4.8% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.1% |
20.4%
0.7 pts worse
|
19.8%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.1% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
5.6%
2.2 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q4 9.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
82.8%
16.1 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 99.3% · Q3 98.6% · Q4 98.3% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
11.5%
1.5 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 10.0% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.3%
0.1 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.3% · Q3 1.3% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| 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 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.6% |
24.2%
4.6 pts better
|
23.9%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 18.8% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-04 · Fire 2024-10-04
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-10-04 · Fire 2023-10-04
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-10-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-30
F · Potential for more than minimal harm
2023-10-04
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-11-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-22
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-22
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-08
G · Actual harm
2024-10-04
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 2024-11-01
D · Potential for more than minimal harm
2024-10-04
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-04
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 2024-11-01
D · Potential for more than minimal harm
2024-10-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-04
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-11-01
F · Potential for more than minimal harm
2023-10-04
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 2023-11-20
D · Potential for more than minimal harm
2023-10-04
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 2023-11-20
Penalties and ownership
What sits behind the stars
$0
2024-10-04
Payment Denial
Payment Denial · denial start 2024-10-31 · 1 days
1 day denial
Ownership
Gross, Mark
Corporate Officer · Individual
Hodshire, Jeremiah
Corporate Officer · Individual
Kimball, Lawrence
Operational/Managerial Control · Individual
Masarik, Tricia
Operational/Managerial Control · Individual
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#3
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