Cycle 1
Health 2025-09-04 · Fire 2025-09-04
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lapeer, MI
McLaren Lapeer Region
5-star overall rating with 4-star inspections with 2 recent health deficiencies
1375 North Main Street, Lapeer, MI
(810) 667-5588
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
19
Certified beds
Average residents
15
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-07-08
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
4.56
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.51
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
6.86
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
5.06
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
5.87
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
3.71
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.35
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
4.17
CMS adjusted RN staffing hours
Adjusted total hours
6.28
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,136
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.54
Composite VBP score used to determine payment impact.
Payment multiplier
1.0147
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.79
Baseline 23.00% · Performance 19.84% · Measure score 4.79 · Achievement 3.43 · Improvement 4.79
Healthcare-associated infections
7.11
Baseline 7.98% · Performance 5.71% · Measure score 7.11 · Achievement 7.11 · Improvement 7.10
Total nurse turnover
5.97
Baseline 65.62% · Performance 39.29% · Measure score 5.97 · Achievement 5.97 · Improvement 5.96
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.45% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 201 · Observed rate 11.94% · Lower 95% interval 8.23% |
| Discharge to community | 74.42% |
50.57%
23.9 pts better
|
Better than the National Rate · Eligible stays 187 · Observed rate 74.33% · Lower 95% interval 67.7% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 101 · Denominator 101 |
| Falls with major injury | 0.99% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 101 |
| Discharge self-care score | 56.79% |
53.69%
3.1 pts better
|
Numerator 46 · Denominator 81 |
| Discharge mobility score | 50.62% |
50.94%
0.3 pts worse
|
Numerator 41 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 101 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.71% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 2% · Lower 95% interval 3.08% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 82 |
| Staff flu vaccination coverage | 32.56% |
42%
9.4 pts worse
|
Numerator 14 · Denominator 43 |
| Discharge function score | 55.56% |
56.45%
0.9 pts worse
|
Numerator 45 · Denominator 81 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 73 · Denominator 73 |
| Transfer of health information to patient | 96.3% |
96.28%
About the same
|
Numerator 26 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 25.49% |
25.2%
0.3 pts better
|
Numerator 13 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
82.8%
17 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
11.5%
2.3 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 8.6% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.3%
0.6 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 2.0% · Q4 1.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.8% |
79.5%
11.3 pts better
|
79.7%
11.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
24.2%
0.1 pts better
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 22.9% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-09 · Fire 2024-09-09
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-07-13 · Fire 2023-07-13
14 health deficiencies
Top issue: Nursing and Physician Services (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-04
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 2025-09-25
D · Potential for more than minimal harm
2025-09-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-25
F · Potential for more than minimal harm
2024-09-09
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-09-09
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 2024-09-26
D · Potential for more than minimal harm
2024-09-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-09-09
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 2024-09-26
D · Potential for more than minimal harm
2024-09-09
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
D · Potential for more than minimal harm
2024-09-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-26
E · Potential for more than minimal harm
2023-07-13
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 2023-08-11
E · Potential for more than minimal harm
2023-07-13
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 2023-08-11
D · Potential for more than minimal harm
2023-07-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-13
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 2023-08-11
D · Potential for more than minimal harm
2023-07-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-13
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 2023-08-11
D · Potential for more than minimal harm
2023-07-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-13
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-13
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-13
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 2023-08-11
D · Potential for more than minimal harm
2023-07-13
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-13
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-13
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 2023-08-11
Penalties and ownership
What sits behind the stars
Ownership
Mclaren Health Care Corporation
5% Or Greater Direct Ownership Interest · Organization
Burke, Michael
Corporate Director · Individual
Burrough, Eric
Corporate Director · Individual
Davis, Tiffany
Operational/Managerial Control · Individual
Davis, Tiffany
Corporate Officer · Individual
Grant, Chad
Corporate Director · Individual
Incarnati, Philip
Corporate Director · Individual
Mclaren Health Care Corporation
Operational/Managerial Control · Organization
Nounou, Majed
Corporate Director · Individual
Riehl, Robert
Corporate Director · Individual
Scott, Justus
Corporate Director · Individual
Sharma, Vishnu
Operational/Managerial Control · Individual
Sharma, Vishnu
Corporate Director · Individual
Smith, D. Wesley
Corporate Director · Individual
Vargas, Timothy
Operational/Managerial Control · Individual
Vargas, Timothy
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Lapeer County Medical Care Facility
Lapeer, MI
4-star overall rating with 3-star inspections with $68,445 in total fines with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
The Orchards at Lapeer
Lapeer, MI
2-star overall rating with 3-star inspections with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Stonegate Health Campus
Lapeer, MI
3-star overall rating with 3-star inspections with $66,414 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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