Cycle 1
Health 2025-08-07 · Fire 2025-08-07
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Marlette, MI
Marlette Community Hospital LTCU
4-star overall rating with 3-star inspections with 5 recent health deficiencies
2770 Main Street, Marlette, MI
(989) 635-4000
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
39
Certified beds
Average residents
36
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.61
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.03
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.33
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.97
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.15
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
1.11
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.78
CMS adjusted RN staffing hours
Adjusted total hours
5.50
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 44% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.78% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 6.69% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.65 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 3 · 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 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.92% |
8.2%
6.3 pts worse
|
Numerator 1 · Denominator 52 |
| Staff flu vaccination coverage | 36.36% |
42%
5.6 pts worse
|
Numerator 20 · Denominator 55 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| 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 Not Available · Newly certified or not enough cases to report. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.5
0.1 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
95.0%
3.6 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.3% · Q3 100.0% · Q4 97.2% · 4Q avg 98.6% |
| 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 | 3.6% |
3.1%
0.5 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 5.7% · Q4 5.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.8% |
4.1%
3.7 pts worse
|
11.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 2.9% · Q3 10.0% · Q4 8.8% · 4Q avg 7.8% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.5%
1.8 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 5.9% · Q4 5.7% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.6% |
19.6%
12 pts worse
|
19.6%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 30.6% · Q3 35.3% · Q4 31.4% · 4Q avg 31.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.4% |
16.5%
0.9 pts worse
|
16.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 20.0% · Q3 17.9% · Q4 15.2% · 4Q avg 17.4% · 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 | 29.1% |
13.9%
15.2 pts worse
|
16.3%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 33.8% · 4Q avg 29.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.8% |
11.7%
12.1 pts worse
|
14.9%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 22.9% · Q3 38.7% · Q4 9.4% · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
0.9%
1 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 3.1% · Q4 2.3% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.7% |
1.7%
4 pts worse
|
1.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 2.7% · Q3 5.7% · Q4 5.6% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.0% |
20.4%
3.6 pts worse
|
19.8%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 21.3% · Q3 27.5% · Q4 27.9% · 4Q avg 24.0% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.6%
3.6 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.9% · Q3 0.0% · Q4 2.5% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.7% |
82.8%
6.9 pts better
|
81.7%
8 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 89.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-14 · Fire 2024-08-14
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-07-26 · Fire 2023-07-26
11 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-26
F · Potential for more than minimal harm
2024-08-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-08-14
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 2024-09-26
E · Potential for more than minimal harm
2023-07-26
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 2023-08-31
E · Potential for more than minimal harm
2023-07-26
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 2023-08-31
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-07
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 2025-09-05
F · Potential for more than minimal harm
2025-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-07
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 2025-09-05
D · Potential for more than minimal harm
2025-08-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-07
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-09-05
F · Potential for more than minimal harm
2024-08-14
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 2024-09-26
E · Potential for more than minimal harm
2024-08-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-08-14
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 2024-09-26
E · Potential for more than minimal harm
2024-08-14
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-14
F696 · Quality of Life and Care Deficiencies
Health
Provide appropriate care/assistance for a resident with a prosthesis.
Corrected 2024-09-26
F · Potential for more than minimal harm
2023-07-26
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-07-26
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 2023-08-31
F · Potential for more than minimal harm
2023-07-26
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 2023-08-31
E · Potential for more than minimal harm
2023-07-26
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 2023-08-31
E · Potential for more than minimal harm
2023-07-26
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 2023-08-31
D · Potential for more than minimal harm
2023-07-26
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 2023-08-31
D · Potential for more than minimal harm
2023-07-26
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 2023-08-31
D · Potential for more than minimal harm
2023-07-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-26
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-08-31
B · Minimal harm
2023-07-26
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 2023-08-31
Penalties and ownership
What sits behind the stars
Ownership
Bluewater Healthcare Network
Operational/Managerial Control · Organization
Brown, Judy
Corporate Director · Individual
Buttar, Nick
Operational/Managerial Control · Individual
Curtis, Patrick
Corporate Director · Individual
Daniels, Andrew
Corporate Director · Individual
Denton, Gail
Corporate Director · Individual
Ellis, Steven
Corporate Director · Individual
Fahrner, Faith
Corporate Director · Individual
Gentner, Kimberly
Corporate Director · Individual
Mcconnachie, Angela
Corporate Director · Individual
Meiburg, Victoria
Corporate Director · Individual
Messing, David
Corporate Director · Individual
Orr, Scott
Corporate Director · Individual
Rohling, Paul
Corporate Director · Individual
Stafford, Brooke
Operational/Managerial Control · Individual
Starling, Carol
Corporate Director · Individual
Tamlyn, Erik
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Sanilac Medical Care Facility
Sandusky, MI
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Fisher Senior Care and Rehabilitation
Mayville, MI
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Tuscola County Medical Care Facility
Caro, MI
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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