Cycle 1
Health 2025-01-16 · Fire 2025-01-16
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cheboygan, MI
Medilodge of Cheboygan
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
824 South Huron, Cheboygan, MI
(231) 627-4347
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Medilodge
Operator or chain grouping
Approved since
1995-07-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
50 facilities
Chain averages 3 overall / 3 health / 4 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
1.18
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.07
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.83
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.37
CMS adjusted RN staffing hours
Adjusted total hours
4.39
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,170
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.20
Baseline 20.30% · Performance 20.41% · Measure score 2.20 · Achievement 2.20 · Improvement 0
Healthcare-associated infections
0
Baseline 7.17% · Performance 9.29% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.02
Baseline 43.28% · Performance 59.52% · Measure score 1.02 · Achievement 1.02 · Improvement 0
Adjusted total nurse staffing
5.29
Baseline 4.60 hours · Performance 4.58 hours · Measure score 5.29 · Achievement 5.29 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.42% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 115 · Observed rate 6.96% · Lower 95% interval 7.15% |
| Discharge to community | 54.37% |
50.57%
3.8 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 50% · Lower 95% interval 43.52% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 92.41% |
95.27%
2.9 pts worse
|
Numerator 73 · Denominator 79 |
| Falls with major injury | 1.27% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 79 |
| Discharge self-care score | 63.16% |
53.69%
9.5 pts better
|
Numerator 36 · Denominator 57 |
| Discharge mobility score | 57.89% |
50.94%
7 pts better
|
Numerator 33 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 2.53% |
2.29%
0.2 pts worse
|
Numerator 2 · Denominator 79 · Adjusted rate 3.1% |
| Healthcare-associated infections requiring hospitalization | 9.29% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 13.64% · Lower 95% interval 6.27% |
| Staff COVID-19 vaccination coverage | 2.2% |
8.2%
6 pts worse
|
Numerator 2 · Denominator 91 |
| Staff flu vaccination coverage | 29.36% |
42%
12.6 pts worse
|
Numerator 32 · Denominator 109 |
| Discharge function score | 70.18% |
56.45%
13.7 pts better
|
Numerator 40 · Denominator 57 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.56% |
96.28%
1.3 pts better
|
Numerator 40 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 39.02% |
25.2%
13.8 pts better
|
Numerator 16 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.7
0.5 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| 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 | 2.3% |
3.1%
0.8 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 1.8% · Q3 1.9% · Q4 0.0% · 4Q avg 2.3% · 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 | 10.3% |
5.5%
4.8 pts worse
|
5.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 10.2% · Q3 13.3% · Q4 11.1% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
19.6%
2.8 pts better
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 16.0% · Q3 17.4% · Q4 18.4% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
16.5%
4.3 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 10.8% · Q3 5.4% · Q4 15.0% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.5% |
0.1%
0.4 pts worse
|
0.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.1% |
13.9%
0.8 pts better
|
16.3%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 10.9% · Q4 10.2% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.7% |
11.7%
About the same
|
14.9%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 12.2% · Q3 4.4% · Q4 14.6% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.7%
0.3 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.1% |
20.4%
2.3 pts better
|
19.8%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 21.7% · Q3 14.7% · Q4 21.9% · 4Q avg 18.1% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.6%
2 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.8% · Q3 2.6% · Q4 7.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.1% |
82.8%
0.3 pts better
|
81.7%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 92.8% · Q3 78.0% · Q4 69.9% · 4Q avg 83.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.6% |
11.5%
3.1 pts worse
|
12.0%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 15.4% · Expected 11.7% · Used in QM five-star |
| 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% · Q2 0.0% · Q3 0.0% · Q4 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 | 92.7% |
79.5%
13.2 pts better
|
79.7%
13 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.3% |
24.2%
4.9 pts better
|
23.9%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 20.0% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-07 · Fire 2024-02-07
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-18
E · Potential for more than minimal harm
2025-01-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-18
E · Potential for more than minimal harm
2025-01-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-18
F · Potential for more than minimal harm
2024-02-07
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-12
E · Potential for more than minimal harm
2024-02-07
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-03-12
E · Potential for more than minimal harm
2024-02-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-12
D · Potential for more than minimal harm
2024-02-07
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2024-03-12
F · Potential for more than minimal harm
2023-01-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-02-14
F · Potential for more than minimal harm
2023-01-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-02-14
F · Potential for more than minimal harm
2023-01-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-14
F · Potential for more than minimal harm
2023-01-12
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 2023-02-14
E · Potential for more than minimal harm
2023-01-12
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-02-14
E · Potential for more than minimal harm
2023-01-12
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 2023-02-14
D · Potential for more than minimal harm
2023-01-12
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-14
Inspection history
Recent health citations
G · Actual harm
2025-11-07
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 2025-10-31
E · Potential for more than minimal harm
2025-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-16
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 2025-02-18
D · Potential for more than minimal harm
2025-01-16
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 2025-02-18
D · Potential for more than minimal harm
2025-01-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-18
D · Potential for more than minimal harm
2025-01-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-18
G · Actual harm
2024-09-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-09-26
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-16
G · Actual harm
2024-03-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-02
D · Potential for more than minimal harm
2024-03-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-02
D · Potential for more than minimal harm
2024-02-07
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 2024-03-12
D · Potential for more than minimal harm
2024-02-07
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 2024-03-12
D · Potential for more than minimal harm
2024-02-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-02
D · Potential for more than minimal harm
2024-02-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-02
D · Potential for more than minimal harm
2024-02-07
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-03-12
F · Potential for more than minimal harm
2023-01-12
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 2023-02-14
E · Potential for more than minimal harm
2023-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-12
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 2023-02-15
D · Potential for more than minimal harm
2023-01-12
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 2023-02-15
D · Potential for more than minimal harm
2023-01-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-12
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 2023-02-14
D · Potential for more than minimal harm
2023-01-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-12
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 2023-02-14
Penalties and ownership
What sits behind the stars
$29,348
2024-09-26
Fine
Fine · fine $29,348
Fine
Ownership
Everest Opco Group LLC
5% Or Greater Direct Ownership Interest · Organization
B&Y Healthcare S Corp
5% Or Greater Indirect Ownership Interest · Organization
B&Y Trust
5% Or Greater Indirect Ownership Interest · Organization
Blossom Healthcare Management LLC
Operational/Managerial Control · Organization
Cody Healthcare S Corp
5% Or Greater Indirect Ownership Interest · Organization
Craig Flashner 2007 Trust
5% Or Greater Indirect Ownership Interest · Organization
Flashner, Craig
Operational/Managerial Control · Individual
Flashner, Craig
Corporate Director · Individual
Kirk, Kristine
W-2 Managing Employee · Individual
Norcross, Robert
Contracted Managing Employee · Individual
Perlstein, Yitzchok
Operational/Managerial Control · Individual
Perlstein, Yitzchok
Corporate Director · Individual
Prestige Administrative Services, LLC
Operational/Managerial Control · Organization
Rogers, Stacey
Contracted Managing Employee · Individual
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#2
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#3
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