Cycle 1
Health 2025-01-16 · Fire 2025-01-16
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Mt. Pleasant, MI
Isabella County Medical Care Facility
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1222 North Drive, Mt. Pleasant, MI
(989) 772-2957
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
100
Certified beds
Average residents
83
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
1.15
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.88
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
5.96
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.08
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
5.37
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.82
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
1.23
CMS adjusted RN staffing hours
Adjusted total hours
6.36
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
678
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.44
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
5.48
Baseline 18.16% · Performance 18.89% · Measure score 5.48 · Achievement 5.48 · Improvement 0
Healthcare-associated infections
5.07
Baseline 6.37% · Performance 6.32% · Measure score 5.07 · Achievement 5.07 · Improvement 0
Total nurse turnover
6.97
Baseline 45.08% · Performance 35.19% · Measure score 6.97 · Achievement 6.97 · Improvement 4.39
Adjusted total nurse staffing
8.65
Baseline 6.43 hours · Performance 5.54 hours · Measure score 8.65 · Achievement 8.65 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.12% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 7.63% · Lower 95% interval 7.38% |
| Discharge to community | 53.94% |
50.57%
3.4 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 55.38% · Lower 95% interval 46.79% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.24% |
95.27%
About the same
|
Numerator 80 · Denominator 84 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 84 |
| Discharge self-care score | 19.44% |
53.69%
34.2 pts worse
|
Numerator 14 · Denominator 72 |
| Discharge mobility score | 12.5% |
50.94%
38.4 pts worse
|
Numerator 9 · Denominator 72 |
| Pressure ulcers or injuries, new or worsened | 2.38% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 84 · Adjusted rate 2.85% |
| Healthcare-associated infections requiring hospitalization | 6.32% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 3.37% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 3.81% |
8.2%
4.4 pts worse
|
Numerator 8 · Denominator 210 |
| Staff flu vaccination coverage | 41.34% |
42%
0.7 pts worse
|
Numerator 117 · Denominator 283 |
| Discharge function score | 13.89% |
56.45%
42.6 pts worse
|
Numerator 10 · Denominator 72 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.55% |
96.28%
0.3 pts better
|
Numerator 56 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 46.34% |
25.2%
21.1 pts better
|
Numerator 19 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
95.0%
2.7 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 97.3% · Q3 98.4% · Q4 96.6% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.2% |
95.0%
1.8 pts worse
|
95.5%
2.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.1%
2.5 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 6.8% · Q3 6.2% · Q4 3.4% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
4.1%
0.3 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.4% · Q3 1.9% · Q4 6.8% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
5.5%
0.6 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 7.0% · Q3 7.0% · Q4 3.8% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
19.6%
2 pts better
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 19.4% · Q3 19.0% · Q4 17.3% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
16.5%
8.2 pts better
|
16.7%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 7.7% · Q3 8.0% · Q4 8.7% · 4Q avg 8.3% · 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 | 25.2% |
13.9%
11.3 pts worse
|
16.3%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q2 20.3% · Q3 20.4% · Q4 26.3% · 4Q avg 25.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.1% |
11.7%
12.4 pts worse
|
14.9%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 26.3% · Q3 26.9% · Q4 27.7% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.7% |
1.7%
3 pts worse
|
1.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.9% · Q3 4.8% · Q4 1.7% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.1% |
20.4%
9.7 pts worse
|
19.8%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 33.9% · Q3 34.9% · Q4 23.6% · 4Q avg 30.1% |
| 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 4.2% · Q2 3.0% · Q3 5.0% · Q4 12.7% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.0% |
82.8%
9.2 pts better
|
81.7%
10.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.6% · Q2 95.5% · Q3 92.1% · Q4 88.1% · 4Q avg 92.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
11.5%
2.8 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 12.7% · Expected 9.9% · 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 | 91.4% |
79.5%
11.9 pts better
|
79.7%
11.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.8% |
24.2%
9.4 pts better
|
23.9%
9.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.8% · Observed 11.4% · Expected 18.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-11-02 · Fire 2022-11-02
0 health deficiencies
No concentrated health issue counts in this cycle.
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-24
F · Potential for more than minimal harm
2025-01-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-24
F · Potential for more than minimal harm
2025-01-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-24
E · Potential for more than minimal harm
2025-01-16
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 2025-02-24
E · Potential for more than minimal harm
2023-11-16
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 2023-12-13
E · Potential for more than minimal harm
2023-11-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-13
E · Potential for more than minimal harm
2023-11-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-13
F · Potential for more than minimal harm
2022-11-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-02
F · Potential for more than minimal harm
2022-11-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-08
F · Potential for more than minimal harm
2022-11-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-12-08
F · Potential for more than minimal harm
2022-11-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-03
F · Potential for more than minimal harm
2022-11-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-08
F · Potential for more than minimal harm
2022-11-02
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2023-01-02
F · Potential for more than minimal harm
2022-11-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-08
E · Potential for more than minimal harm
2022-11-02
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-02
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-12-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-16
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 2025-02-24
D · Potential for more than minimal harm
2023-11-16
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 2023-12-13
D · Potential for more than minimal harm
2023-11-16
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 2023-12-13
Penalties and ownership
What sits behind the stars
Ownership
Haynak, Alissa
Corporate Director · Individual
Isabella County
Operational/Managerial Control · Organization
Pickens, Steven
Corporate Director · Individual
Stalter, Sarah
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
The Laurels of Mt. Pleasant
Mt. Pleasant, MI
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Medilodge of Mt. Pleasant
Mt. Pleasant, MI
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Riverside Healthcare Center
St. Louis, MI
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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