Cycle 1
Health 2025-04-17 · Fire 2025-04-17
5 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Crystal Falls, MI
Iron County Medical Care Facility
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1523 U.S. Highway 2, Crystal Falls, MI
(906) 875-6671
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
112
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-05-01
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
Staffing
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.81
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.20
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.38
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
0.82
CMS adjusted RN staffing hours
Adjusted total hours
5.02
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,474
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.39
Performance 6.82% · Measure score 3.39 · Achievement 3.39 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
2.26
Baseline 31.15% · Performance 54.44% · Measure score 2.26 · Achievement 2.26 · Improvement 0
Adjusted total nurse staffing
3.24
Baseline 4.62 hours · Performance 4 hours · Measure score 3.24 · Achievement 3.24 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.98% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 9.52% · Lower 95% interval 6.47% |
| Discharge to community | 41.71% |
50.57%
8.9 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 34.15% · Lower 95% interval 27.48% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.24% |
95.27%
About the same
|
Numerator 20 · Denominator 21 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4.76% |
2.29%
2.5 pts worse
|
Numerator 1 · Denominator 21 · Adjusted rate 6.04% |
| Healthcare-associated infections requiring hospitalization | 6.82% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 4% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 4.92% |
8.2%
3.3 pts worse
|
Numerator 9 · Denominator 183 |
| Staff flu vaccination coverage | 44.76% |
42%
2.8 pts better
|
Numerator 111 · Denominator 248 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.5
0.7 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.8 · Expected 1.3 · Used in QM five-star |
| 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% · Q3 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 | 5.7% |
3.1%
2.6 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.4% · Q3 4.6% · Q4 4.6% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.3% |
4.1%
3.2 pts worse
|
11.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 5.9% · Q3 9.6% · Q4 6.8% · 4Q avg 7.3% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
5.5%
0.1 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.1% · Q3 5.7% · Q4 6.1% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.5% |
19.6%
8.1 pts better
|
19.6%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 11.0% · Q3 10.4% · Q4 11.9% · 4Q avg 11.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.5% |
16.5%
5 pts worse
|
16.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 20.0% · Q3 18.9% · Q4 25.3% · 4Q avg 21.5% · 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 | 19.9% |
13.9%
6 pts worse
|
16.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 29.8% · Q3 5.6% · Q4 22.7% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.1% |
11.7%
14.4 pts worse
|
14.9%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.1% · Q2 24.7% · Q3 22.5% · Q4 23.3% · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
0.9%
1.2 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.8% · Q3 2.6% · Q4 2.4% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
1.7%
1.3 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.7% · Q3 0.9% · Q4 3.7% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
20.4%
5.4 pts worse
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 29.3% · Q3 28.6% · Q4 27.6% · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.6%
0.4 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 4.2% · Q3 7.7% · Q4 5.6% · 4Q avg 6.0% · 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 100.0% · Q2 96.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 30.4% |
11.5%
18.9 pts worse
|
12.0%
18.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.4% · Observed 26.1% · Expected 9.6% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
79.5%
16.2 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.5% |
24.2%
5.3 pts worse
|
23.9%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.5% · Observed 21.7% · Expected 17.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-24 · Fire 2024-04-24
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-04-20 · Fire 2023-04-20
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-17
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 2025-05-30
F · Potential for more than minimal harm
2025-04-17
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-04-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-30
F · Potential for more than minimal harm
2024-04-24
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-06-03
F · Potential for more than minimal harm
2024-04-24
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-06-03
F · Potential for more than minimal harm
2024-04-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-04-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-03
E · Potential for more than minimal harm
2024-04-24
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 2024-06-03
E · Potential for more than minimal harm
2024-04-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-03
E · Potential for more than minimal harm
2024-04-24
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-06-03
E · Potential for more than minimal harm
2024-04-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-03
D · Potential for more than minimal harm
2024-04-24
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-06-03
F · Potential for more than minimal harm
2023-04-20
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 2023-05-19
F · Potential for more than minimal harm
2023-04-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-19
F · Potential for more than minimal harm
2023-04-20
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 2023-05-19
F · Potential for more than minimal harm
2023-04-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-19
F · Potential for more than minimal harm
2023-04-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-19
E · Potential for more than minimal harm
2023-04-20
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-05-11
E · Potential for more than minimal harm
2023-04-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-04-20
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 2023-05-19
D · Potential for more than minimal harm
2023-04-20
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-05-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-17
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 2025-05-27
E · Potential for more than minimal harm
2025-04-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-04-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-04-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-27
F · Potential for more than minimal harm
2024-04-24
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-24
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-04-24
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 2024-05-10
D · Potential for more than minimal harm
2024-04-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-10
C · Minimal harm
2024-04-24
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-04-30
E · Potential for more than minimal harm
2023-04-20
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 2023-05-19
E · Potential for more than minimal harm
2023-04-20
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-20
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-19
E · Potential for more than minimal harm
2023-03-08
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 2023-03-31
D · Potential for more than minimal harm
2023-03-08
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 2023-03-31
Penalties and ownership
What sits behind the stars
Ownership
County Of Iron
5% Or Greater Direct Ownership Interest · Organization
Oman, Lynn
W-2 Managing Employee · Individual
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#3
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