Cycle 1
Health 2025-05-29 · Fire 2025-05-29
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
St. Ignace, MI
Mackinac Straits Long Term Care Unit
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1140 North State Street, St. Ignace, MI
(906) 643-0462
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
47
Average occupied residents
Ownership
Non-Profit
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
1.00
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.79
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
1.41
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.72
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.79
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.19
CMS adjusted RN staffing hours
Adjusted total hours
5.00
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
17%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
115
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
84.43
Composite VBP score used to determine payment impact.
Payment multiplier
1.0266
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
10
Baseline 42.86% · Performance 21.28% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
6.89
Baseline 5.72 hours · Performance 5.04 hours · Measure score 6.89 · Achievement 6.89 · Improvement 0
SNF QRP
Medicare quality reporting measures
| 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 5 · 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 4 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 4 · 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 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 79 |
| Staff flu vaccination coverage | 89.16% |
42%
47.2 pts better
|
Numerator 74 · Denominator 83 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · 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 1 · 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 | 99.5% |
95.0%
4.5 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.8% · 4Q avg 99.5% |
| 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 | 7.1% |
3.1%
4 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.5% · Q3 8.9% · Q4 6.7% · 4Q avg 7.1% · 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 | 8.4% |
5.5%
2.9 pts worse
|
5.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 8.9% · Q3 8.9% · Q4 11.4% · 4Q avg 8.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.8% |
19.6%
3.2 pts worse
|
19.6%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 24.4% · Q3 26.7% · Q4 22.2% · 4Q avg 22.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
16.5%
6 pts better
|
16.7%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 10.5% · Q3 12.8% · Q4 7.9% · 4Q avg 10.5% · 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 | 9.8% |
13.9%
4.1 pts better
|
16.3%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.2% |
11.7%
5.5 pts worse
|
14.9%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 10.0% · Q3 17.1% · Q4 20.9% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.0% |
0.9%
3.1 pts worse
|
1.0%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.7% · Q3 3.4% · Q4 7.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.5% |
1.7%
3.8 pts worse
|
1.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.7% · Q3 8.9% · Q4 4.5% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.0% |
20.4%
4.6 pts worse
|
19.8%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 22.3% · Q3 27.2% · Q4 30.4% · 4Q avg 25.0% |
| Percentage of long-stay residents with pressure ulcers | 14.5% |
5.6%
8.9 pts worse
|
5.1%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 13.4% · Q3 20.2% · Q4 11.6% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
82.8%
14.3 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 97.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-26 · Fire 2024-06-26
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-07-21 · Fire 2023-07-21
3 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-29
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-07-07
F · Potential for more than minimal harm
2025-05-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-07-07
F · Potential for more than minimal harm
2025-05-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-07
E · Potential for more than minimal harm
2025-05-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-07
F · Potential for more than minimal harm
2024-06-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-06-26
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 2024-07-25
F · Potential for more than minimal harm
2023-07-21
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-09-11
F · Potential for more than minimal harm
2023-07-21
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-09-11
F · Potential for more than minimal harm
2023-07-21
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-09-11
E · Potential for more than minimal harm
2023-07-21
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 2023-09-11
D · Potential for more than minimal harm
2023-07-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-09-11
D · Potential for more than minimal harm
2023-07-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-11
Inspection history
Recent health citations
G · Actual harm
2025-10-15
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 2025-11-10
D · Potential for more than minimal harm
2025-05-29
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-05-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-05-29
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 2025-07-07
D · Potential for more than minimal harm
2025-05-29
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-05-29
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 2025-07-07
D · Potential for more than minimal harm
2025-05-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-07
G · Actual harm
2024-06-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-26
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 2024-07-25
D · Potential for more than minimal harm
2023-07-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-04
D · Potential for more than minimal harm
2023-07-21
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-09-04
D · Potential for more than minimal harm
2023-07-21
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-09-04
Penalties and ownership
What sits behind the stars
Ownership
Mackinac Straits Health System Inc
5% Or Greater Direct Ownership Interest · Organization
Anderson, Jason
Corporate Director · Individual
Autore, Steven
Corporate Director · Individual
Brown, Prentiss
Corporate Director · Individual
Buhr, Lauren
Corporate Director · Individual
Cheeseman, Karen
Corporate Director · Individual
Cheeseman, Karen
Corporate Officer · Individual
Doud, Margaret
Corporate Director · Individual
Elmblad, Mark
Corporate Director · Individual
Mackinac Straits Health System Inc
Operational/Managerial Control · Organization
Massaway, Keith
Corporate Director · Individual
Mcelroy, Kevin
Corporate Director · Individual
Moffat, John
Operational/Managerial Control · Individual
North, James
Corporate Director · Individual
Shannon, Patrick
Corporate Director · Individual
Smith, Richard
Corporate Director · Individual
Strich, Susan
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Medilodge of Cheboygan
Cheboygan, MI
3-star overall rating with 2-star inspections with abuse icon flag with $29,348 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Bay Bluffs-Emmet County Medical Care Facility
Harbor Springs, MI
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
The Villa at the Bay
Petoskey, MI
1-star overall rating with 1-star inspections with $241,488 in total fines with 18 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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