Cycle 1
Health 2025-02-27 · Fire 2025-02-27
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lincoln, MI
Lincoln Haven Nursing & Rehabilitation Community
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
950 Barlow Road, Lincoln, MI
(989) 736-8481
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
39
Certified beds
Average residents
29
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atrium Centers
Operator or chain grouping
Approved since
1993-11-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
26 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
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
0.74
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.34
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
4.14
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,436
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9843
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.61
Performance 20.22% · Measure score 2.61 · Achievement 2.61 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.63
Performance 6.75% · Measure score 3.63 · Achievement 3.63 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
2.08
Baseline 50.00% · Performance 55.17% · Measure score 2.08 · Achievement 2.08 · Improvement 0
Adjusted total nurse staffing
2.38
Baseline 3.57 hours · Performance 3.75 hours · Measure score 2.38 · Achievement 2.38 · Improvement 0.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.62% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 17.24% · Lower 95% interval 7.55% |
| Discharge to community | 42.43% |
50.57%
8.1 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 32.14% · Lower 95% interval 29.96% |
| Medicare spending per beneficiary | 1.52 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 82.61% |
95.27%
12.7 pts worse
|
Numerator 19 · Denominator 23 |
| Falls with major injury | 8.7% |
0.77%
7.9 pts worse
|
Numerator 2 · Denominator 23 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 23 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.75% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 3.7% · Lower 95% interval 3.43% |
| Staff COVID-19 vaccination coverage | 2.38% |
8.2%
5.8 pts worse
|
Numerator 1 · Denominator 42 |
| Staff flu vaccination coverage | 15.15% |
42%
26.9 pts worse
|
Numerator 10 · Denominator 66 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| 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 10 · 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 | 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 | 4.6% |
3.1%
1.5 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 4.5% · Q3 4.3% · Q4 0.0% · 4Q avg 4.6% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 12.3% |
5.5%
6.8 pts worse
|
5.4%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.0% |
19.6%
8.4 pts worse
|
19.6%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.0% |
16.5%
8.5 pts worse
|
16.7%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.0% · 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 | 9.6% |
13.9%
4.3 pts better
|
16.3%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.1% |
11.7%
3.6 pts better
|
14.9%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
0.9%
2.3 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 3.2% · 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 0.0% · Q2 10.0% · Q3 4.3% · Q4 4.5% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.4% |
20.4%
18 pts better
|
19.8%
17.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.4% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.6%
5.6 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
82.8%
16.3 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.3% |
79.5%
12.8 pts better
|
79.7%
12.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-22 · Fire 2024-02-22
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-03-02 · Fire 2023-03-02
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-02-27
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 2025-03-27
E · Potential for more than minimal harm
2025-02-27
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 2025-03-27
E · Potential for more than minimal harm
2025-02-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-27
F · Potential for more than minimal harm
2024-02-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-19
F · Potential for more than minimal harm
2023-03-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-02
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-04-07
E · Potential for more than minimal harm
2023-03-02
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 2023-04-07
D · Potential for more than minimal harm
2023-03-02
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 2023-04-07
D · Potential for more than minimal harm
2023-03-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-27
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 2025-03-27
F · Potential for more than minimal harm
2024-06-05
F801 · Nutrition and Dietary Deficiencies
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 2024-07-12
F · Potential for more than minimal harm
2024-06-05
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-05
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-05
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 2024-07-12
F · Potential for more than minimal harm
2024-02-22
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 2024-03-19
E · Potential for more than minimal harm
2024-02-22
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 2024-03-19
D · Potential for more than minimal harm
2024-02-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-02-22
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 2024-03-19
D · Potential for more than minimal harm
2024-02-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-02-06
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2024-03-20
F · Potential for more than minimal harm
2023-05-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-14
E · Potential for more than minimal harm
2023-03-02
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 2023-04-07
D · Potential for more than minimal harm
2023-03-02
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 2023-04-07
D · Potential for more than minimal harm
2023-03-02
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 2023-04-07
D · Potential for more than minimal harm
2023-03-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-07
Penalties and ownership
What sits behind the stars
Ownership
Atrium Centers, Inc.
5% Or Greater Direct Ownership Interest · Organization
Bailey, Essel
5% Or Greater Indirect Ownership Interest · Individual
Finney, Donald
5% Or Greater Indirect Ownership Interest · Individual
Albright Ross, Susan
Operational/Managerial Control · Individual
Albright Ross, Susan
Corporate Officer · Individual
Atrium Centers Management LLC
Operational/Managerial Control · Organization
Bailey, Essel
Corporate Director · Individual
Ferkany, James
Corporate Officer · Individual
Finney, Donald
Corporate Director · Individual
Gustafson, Paul
Operational/Managerial Control · Individual
Lockhart, Dennis
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Jamieson Nursing Home
Harrisville, MI
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Medilodge of Alpena
Alpena, MI
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Medilodge of Green View
Alpena, MI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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