Cycle 1
Health 2025-08-27 · Fire 2025-08-27
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Coldwater, MI
Maple Lawn Medical Care Facility
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
50 Sanderson Lane, Coldwater, MI
(517) 279-9587
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
108
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
0.98
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.17
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.76
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.25
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.72
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.13
CMS adjusted RN staffing hours
Adjusted total hours
5.49
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,563
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.03
Composite VBP score used to determine payment impact.
Payment multiplier
1.0029
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.81% · Performance 22.10% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.55
Baseline 5.28% · Performance 5.88% · Measure score 6.55 · Achievement 6.55 · Improvement 0
Total nurse turnover
6.67
Baseline 35.66% · Performance 36.43% · Measure score 6.67 · Achievement 6.67 · Improvement 0
Adjusted total nurse staffing
6.40
Baseline 5.12 hours · Performance 4.90 hours · Measure score 6.40 · Achievement 6.40 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.69% |
10.72%
3 pts worse
|
No Different than the National Rate · Eligible stays 200 · Observed rate 14% · Lower 95% interval 9.93% |
| Discharge to community | 54.46% |
50.57%
3.9 pts better
|
No Different than the National Rate · Eligible stays 188 · Observed rate 53.72% · Lower 95% interval 45.61% |
| Medicare spending per beneficiary | 0.63 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 92 · Denominator 92 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 92 |
| Discharge self-care score | 47.78% |
53.69%
5.9 pts worse
|
Numerator 43 · Denominator 90 |
| Discharge mobility score | 48.89% |
50.94%
2 pts worse
|
Numerator 44 · Denominator 90 |
| Pressure ulcers or injuries, new or worsened | 3.26% |
2.29%
1 pts worse
|
Numerator 3 · Denominator 92 · Adjusted rate 3.73% |
| Healthcare-associated infections requiring hospitalization | 5.88% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 110 · Observed rate 2.73% · Lower 95% interval 3.25% |
| Staff COVID-19 vaccination coverage | 0.95% |
8.2%
7.2 pts worse
|
Numerator 2 · Denominator 211 |
| Staff flu vaccination coverage | 37.6% |
42%
4.4 pts worse
|
Numerator 91 · Denominator 242 |
| Discharge function score | 48.89% |
56.45%
7.6 pts worse
|
Numerator 44 · Denominator 90 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 16.98% |
25.2%
8.2 pts worse
|
Numerator 9 · Denominator 53 |
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 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
95.0%
4.2 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 100.0% · Q3 100.0% · Q4 97.9% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.1% |
95.0%
1.1 pts better
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.1%
0.3 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 3.2% · Q3 4.0% · Q4 2.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
4.1%
3.8 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
5.5%
1.7 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.1% · Q3 0.0% · Q4 10.8% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.0% |
19.6%
8.6 pts better
|
19.6%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 8.6% · Q3 10.3% · Q4 11.8% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.7% |
16.5%
1.8 pts better
|
16.7%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 18.5% · Q3 12.8% · Q4 13.1% · 4Q avg 14.7% · 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 | 20.1% |
13.9%
6.2 pts worse
|
16.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 22.4% · Q3 18.7% · Q4 20.4% · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.2% |
11.7%
8.5 pts worse
|
14.9%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 23.6% · Q3 22.0% · Q4 18.2% · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.9%
0.9 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.6% · Q3 2.7% · Q4 0.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.0% |
1.7%
2.3 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 5.4% · Q3 4.1% · Q4 4.2% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.2% |
20.4%
5.8 pts worse
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 25.2% · Q3 27.6% · Q4 29.4% · 4Q avg 26.2% |
| Percentage of long-stay residents with pressure ulcers | 8.7% |
5.6%
3.1 pts worse
|
5.1%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 11.1% · Q3 7.3% · Q4 9.0% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.9% |
82.8%
8.1 pts better
|
81.7%
9.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.8% · Q2 89.3% · Q3 92.1% · Q4 87.9% · 4Q avg 90.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
11.5%
7.2 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 4.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.3%
0.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 2.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.8% |
79.5%
5.3 pts better
|
79.7%
5.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.5% |
24.2%
8.7 pts better
|
23.9%
8.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 15.2% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
6 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-06-28 · Fire 2023-06-28
9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-24
F · Potential for more than minimal harm
2025-08-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-24
F · Potential for more than minimal harm
2024-08-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-17
F · Potential for more than minimal harm
2024-08-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-15
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-09-13
F · Potential for more than minimal harm
2023-06-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-11
F · Potential for more than minimal harm
2023-06-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-11
F · Potential for more than minimal harm
2023-06-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-11
F · Potential for more than minimal harm
2023-06-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-06-28
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 2023-08-11
Inspection history
Recent health citations
G · Actual harm
2025-08-27
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 2025-09-24
E · Potential for more than minimal harm
2025-08-27
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-24
D · Potential for more than minimal harm
2025-08-27
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 2025-09-24
D · Potential for more than minimal harm
2025-08-27
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-09-24
D · Potential for more than minimal harm
2025-06-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-05
D · Potential for more than minimal harm
2024-09-06
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-15
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-15
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 2024-09-13
D · Potential for more than minimal harm
2024-08-15
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 2024-09-13
C · Minimal harm
2024-08-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-13
D · Potential for more than minimal harm
2023-11-15
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 2023-12-08
D · Potential for more than minimal harm
2023-11-15
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 2023-12-08
E · Potential for more than minimal harm
2023-06-28
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-06-28
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-06-28
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 2023-07-31
D · Potential for more than minimal harm
2023-06-28
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 2023-07-31
D · Potential for more than minimal harm
2023-06-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-06-28
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 2023-07-31
D · Potential for more than minimal harm
2023-06-28
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 2023-07-31
Penalties and ownership
What sits behind the stars
Ownership
Sabaitis, Jayne
Operational/Managerial Control · Individual
Sabaitis, Jayne
Corporate Officer · Individual
Whitaker, Charles
Operational/Managerial Control · Individual
Worden, Jessica
Operational/Managerial Control · Individual
Zierle, Ashley
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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The Laurels of Coldwater
Coldwater, MI
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Hillsdale County Medical Care Facility
Hillsdale, MI
3-star overall rating with 2-star inspections with abuse icon flag with $145,217 in total fines with 13 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Hillsdale Hospital McGuire & Macritchie Long Term
Hillsdale, MI
5-star overall rating with 5-star inspections with 2 recent health deficiencies
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