7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Harrisville, MI
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
790 S U.S. Highway 23, Box 369, Harrisville, MI
(989) 724-6889
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
39
Certified beds
Average residents
21
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-05-16
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
RN hours / resident day
0.86
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.68
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.04
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.82
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
29%
Annual nurse turnover · state 44% · national 46%
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 27.27% |
8.2%
19.1 pts better
|
Numerator 6 · Denominator 22 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
Quality measures
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.5% |
3.1%
5.4 pts worse
|
3.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.5% · 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 | 0.0% |
5.5%
5.5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.5% |
19.6%
12.1 pts better
|
19.6%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.3% |
16.5%
10.2 pts better
|
16.7%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 11.3% |
0.1%
11.2 pts worse
|
0.1%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.3% |
13.9%
10.4 pts worse
|
16.3%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.1% |
11.7%
11.4 pts worse
|
14.9%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.1% · 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 · 4Q avg 0.0% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.6% |
20.4%
13.8 pts better
|
19.8%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.6% |
| Percentage of long-stay residents with pressure ulcers | 14.6% |
5.6%
9 pts worse
|
5.1%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
82.8%
17.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
Survey summary
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-03-14
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 2025-03-14
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-14
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-14
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-14
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-14
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-26
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-26
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-26
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-03-26
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-02-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-15
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-02-15
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-02-15
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-02-15
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-02-15
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-15
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-14
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-14
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-03-14
Health
Ensure that paid feeding assistants have the training they need.
Corrected 2025-03-14
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-14
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 2025-03-14
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 2025-03-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-26
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-26
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 2024-03-26
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2024-03-26
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-26
Health
Post nurse staffing information every day.
Corrected 2023-02-15
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-02-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-15
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-02-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-15
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-02-15
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-15
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 2023-02-15
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-02-15
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
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