Cycle 1
Health 2025-01-27 · Fire 2025-01-27
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Jackson, MI
Jackson County Medical Care Facility
5-star overall rating with 4-star inspections with $68,744 in total fines with 6 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
524 Lansing Avenue, Jackson, MI
(517) 782-8500
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
194
Certified beds
Average residents
186
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
0.89
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.21
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
5.08
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.87
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.60
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.96
CMS adjusted RN staffing hours
Adjusted total hours
5.52
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
3%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
20%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
205
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
78.16
Composite VBP score used to determine payment impact.
Payment multiplier
1.0254
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.21
Baseline 19.86% · Performance 18.09% · Measure score 7.21 · Achievement 7.21 · Improvement 5.75
Healthcare-associated infections
8.96
Baseline 5.78% · Performance 5.16% · Measure score 8.96 · Achievement 8.96 · Improvement 7.44
Total nurse turnover
7.42
Baseline 36.84% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 2.43
Adjusted total nurse staffing
7.67
Baseline 4.35 hours · Performance 5.26 hours · Measure score 7.67 · Achievement 7.67 · Improvement 5.86
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.19% |
10.72%
2.5 pts better
|
No Different than the National Rate · Eligible stays 244 · Observed rate 5.74% · Lower 95% interval 6.07% |
| Discharge to community | 59.79% |
50.57%
9.2 pts better
|
Better than the National Rate · Eligible stays 234 · Observed rate 55.98% · Lower 95% interval 53.62% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 162 · Denominator 162 |
| Falls with major injury | 1.85% |
0.77%
1.1 pts worse
|
Numerator 3 · Denominator 162 |
| Discharge self-care score | 41.67% |
53.69%
12 pts worse
|
Numerator 50 · Denominator 120 |
| Discharge mobility score | 56.67% |
50.94%
5.7 pts better
|
Numerator 68 · Denominator 120 |
| Pressure ulcers or injuries, new or worsened | 0.62% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 162 · Adjusted rate 0.52% |
| Healthcare-associated infections requiring hospitalization | 5.16% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 141 · Observed rate 2.13% · Lower 95% interval 3.26% |
| Staff COVID-19 vaccination coverage | 5.39% |
8.2%
2.8 pts worse
|
Numerator 18 · Denominator 334 |
| Staff flu vaccination coverage | 58.36% |
42%
16.4 pts better
|
Numerator 192 · Denominator 329 |
| Discharge function score | 55% |
56.45%
1.5 pts worse
|
Numerator 66 · Denominator 120 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 89 · Denominator 89 |
| Resident COVID-19 vaccinations up to date | 38.64% |
25.2%
13.4 pts better
|
Numerator 34 · Denominator 88 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
95.0%
4.8 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.4% · Q4 100.0% · 4Q avg 99.8% |
| 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 | 5.6% |
3.1%
2.5 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.5% · Q3 5.8% · Q4 3.7% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
4.1%
3.7 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
5.5%
2.5 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 9.9% · Q3 6.5% · Q4 6.8% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.9% |
19.6%
1.7 pts better
|
19.6%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 19.7% · Q3 18.4% · Q4 14.8% · 4Q avg 17.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.6% |
16.5%
1.1 pts worse
|
16.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 17.9% · Q3 17.9% · Q4 17.3% · 4Q avg 17.6% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.6% |
13.9%
9.7 pts worse
|
16.3%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.5% · Q2 21.6% · Q3 20.8% · Q4 17.4% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
11.7%
1.2 pts worse
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 11.9% · Q3 13.1% · Q4 11.3% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.6% · Q4 0.6% · 4Q avg 0.8% · 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 5.6% · Q2 4.5% · Q3 3.3% · Q4 4.4% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
20.4%
4.8 pts worse
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 27.3% · Q3 24.7% · Q4 26.5% · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
5.6%
4 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.2% · Q3 1.2% · Q4 2.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
82.8%
12.8 pts better
|
81.7%
13.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 96.1% · Q3 96.6% · Q4 93.4% · 4Q avg 95.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
11.5%
4.8 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 6.1% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.7% · Q4 0.0% · 4Q avg 0.4% · 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 | 14.7% |
24.2%
9.5 pts better
|
23.9%
9.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.7% · Observed 13.6% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-07 · Fire 2023-12-07
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-09-09 · Fire 2022-09-09
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-27
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-27
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-27
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-27
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-27
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-27
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-27
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-27
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-01-27
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 2025-03-17
E · Potential for more than minimal harm
2025-01-27
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 2025-03-17
E · Potential for more than minimal harm
2025-01-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-01-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-01-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-01-27
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-01-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-17
E · Potential for more than minimal harm
2023-12-07
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-12-07
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 2024-01-05
E · Potential for more than minimal harm
2023-12-07
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 2024-01-05
D · Potential for more than minimal harm
2023-12-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-05
F · Potential for more than minimal harm
2022-09-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-24
F · Potential for more than minimal harm
2022-09-09
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-09-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-09-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-24
E · Potential for more than minimal harm
2022-09-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-10-24
Inspection history
Recent health citations
G · Actual harm
2026-01-15
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 2026-02-16
D · Potential for more than minimal harm
2025-01-27
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 2025-03-08
D · Potential for more than minimal harm
2025-01-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-03-08
D · Potential for more than minimal harm
2025-01-27
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 2025-03-08
D · Potential for more than minimal harm
2025-01-27
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 2025-03-08
D · Potential for more than minimal harm
2025-01-27
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-03-08
D · Potential for more than minimal harm
2025-01-27
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 2025-03-08
H · Actual harm
2023-12-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-12-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-07
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 2024-01-05
D · Potential for more than minimal harm
2023-12-07
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 2024-01-05
D · Potential for more than minimal harm
2023-12-07
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-05
E · Potential for more than minimal harm
2022-09-09
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-09
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-09
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 2022-10-17
D · Potential for more than minimal harm
2022-09-09
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 2022-10-17
D · Potential for more than minimal harm
2022-09-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-10-17
Penalties and ownership
What sits behind the stars
$68,744
2023-12-07
Fine
Fine · fine $68,744
Fine
Ownership
Jackson County Medical Care Facility
5% Or Greater Direct Ownership Interest · Organization
Shong, Jennifer
Operational/Managerial Control · Individual
Wilkins, Destiny
Operational/Managerial Control · Individual
Yalavarthi, Jyothsna
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Regency at Jackson
Jackson, MI
1-star overall rating with 2-star inspections with $15,593 in total fines with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Vista Grande Villa
Jackson, MI
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Mission Point Health Campus of Jackson
Jackson, MI
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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