Cycle 1
Health 2024-11-20 · Fire 2024-11-20
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Tawas City, MI
Iosco County Medical Care Facility
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1201 Harris Avenue, Tawas City, MI
(989) 362-4424
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
78
Certified beds
Average residents
50
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
0.95
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
4.02
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
5.95
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
5.31
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
6.69
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
684
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.39
Composite VBP score used to determine payment impact.
Payment multiplier
1.0196
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.63
Performance 18.82% · Measure score 5.63 · Achievement 5.63 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.34
Performance 6.83% · Measure score 3.34 · Achievement 3.34 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
7.18
Baseline 55.71% · Performance 34.33% · Measure score 7.18 · Achievement 7.18 · Improvement 6.43
Adjusted total nurse staffing
10
Baseline 5.71 hours · Performance 6.56 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.32% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 11.67% · Lower 95% interval 8.05% |
| Discharge to community | 56.18% |
50.57%
5.6 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 54.55% · Lower 95% interval 45.49% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.44% |
95.27%
2.2 pts better
|
Numerator 38 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 41.38% |
53.69%
12.3 pts worse
|
Numerator 12 · Denominator 29 |
| Discharge mobility score | 48.28% |
50.94%
2.7 pts worse
|
Numerator 14 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 5.13% |
2.29%
2.8 pts worse
|
Numerator 2 · Denominator 39 · Adjusted rate 5.97% |
| Healthcare-associated infections requiring hospitalization | 6.83% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 4.55% · Lower 95% interval 3.95% |
| Staff COVID-19 vaccination coverage | 2.34% |
8.2%
5.9 pts worse
|
Numerator 3 · Denominator 128 |
| Staff flu vaccination coverage | 18.97% |
42%
23 pts worse
|
Numerator 33 · Denominator 174 |
| Discharge function score | 48.28% |
56.45%
8.2 pts worse
|
Numerator 14 · Denominator 29 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
95.0%
3.9 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.8% · Q3 100.0% · Q4 97.8% · 4Q avg 98.9% |
| 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 | 3.3% |
3.1%
0.2 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 2.2% · Q4 6.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.4% |
4.1%
2.3 pts worse
|
11.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.7% · Q3 4.4% · Q4 11.9% · 4Q avg 6.4% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
5.5%
0.6 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 6.2% · Q3 2.9% · Q4 3.0% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.4% |
19.6%
10.8 pts worse
|
19.6%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 37.5% · Q3 23.5% · Q4 31.4% · 4Q avg 30.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.0% |
16.5%
2.5 pts worse
|
16.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 17.9% · Q3 20.0% · Q4 16.1% · 4Q avg 19.0% · 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 | 33.5% |
13.9%
19.6 pts worse
|
16.3%
17.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.7% |
11.7%
19 pts worse
|
14.9%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 51.6% · Q3 19.4% · Q4 18.8% · 4Q avg 30.7% · 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 | 4.5% |
1.7%
2.8 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.7% · Q3 4.3% · Q4 6.8% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.8% |
20.4%
13.4 pts worse
|
19.8%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 37.3% · Q3 33.2% · Q4 35.5% · 4Q avg 33.8% |
| 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 · Q1 4.0% · Q2 4.0% · Q3 3.8% · Q4 5.3% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
82.8%
11.7 pts better
|
81.7%
12.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 92.7% · Q3 98.1% · Q4 98.2% · 4Q avg 94.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.2% |
11.5%
6.7 pts worse
|
12.0%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 17.1% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.6% |
79.5%
17.1 pts better
|
79.7%
16.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.0% |
24.2%
7.2 pts better
|
23.9%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 14.3% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-21 · Fire 2023-11-21
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-08-17 · Fire 2022-08-17
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Not marked corrected
F · Potential for more than minimal harm
2024-11-20
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 2024-12-23
E · Potential for more than minimal harm
2024-11-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-23
E · Potential for more than minimal harm
2023-11-21
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 2023-12-29
E · Potential for more than minimal harm
2023-11-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-29
F · Potential for more than minimal harm
2022-08-17
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-09-26
E · Potential for more than minimal harm
2022-08-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-26
E · Potential for more than minimal harm
2022-08-17
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-09-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-20
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 2024-12-23
D · Potential for more than minimal harm
2024-11-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-11-20
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 2024-12-23
D · Potential for more than minimal harm
2024-11-20
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 2024-12-23
D · Potential for more than minimal harm
2024-11-20
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 2024-12-23
G · Actual harm
2023-11-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-29
G · Actual harm
2023-11-21
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 2023-12-29
E · Potential for more than minimal harm
2023-11-21
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 2023-12-29
D · Potential for more than minimal harm
2023-11-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-21
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 2023-12-29
D · Potential for more than minimal harm
2023-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-21
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-21
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 2023-12-29
E · Potential for more than minimal harm
2023-08-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-18
F · Potential for more than minimal harm
2022-08-17
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 2022-09-26
E · Potential for more than minimal harm
2022-08-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-09-26
D · Potential for more than minimal harm
2022-08-17
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 2022-09-26
D · Potential for more than minimal harm
2022-08-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-26
D · Potential for more than minimal harm
2022-08-17
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 2022-09-26
D · Potential for more than minimal harm
2022-08-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-09-26
D · Potential for more than minimal harm
2022-08-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-09-26
D · Potential for more than minimal harm
2022-08-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-26
Penalties and ownership
What sits behind the stars
$0
2023-11-21
Payment Denial
Payment Denial · denial start 2023-12-22 · 7 days
7 day denial
Ownership
County Of Iosco
Operational/Managerial Control · Organization
Dargis, David
Operational/Managerial Control · Individual
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