Cycle 1
Health 2024-12-11 · Fire 2024-12-11
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Suttons Bay, MI
Medilodge of Leelanau
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
124 West 4th Street, Suttons Bay, MI
(231) 271-1200
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
72
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Medilodge
Operator or chain grouping
Approved since
1971-03-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.04
Registered nurse staffing
LPN hours / resident day
0.44
Licensed practical nurse staffing
Aide hours / resident day
1.87
Nurse aide staffing
Weekend hours
2.56
Weekend nurse staffing
RN turnover
56%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
95.0%
3.4 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.6% |
95.0%
0.6 pts better
|
95.5%
0.1 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.1%
0.3 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 5.8% |
4.1%
1.7 pts worse
|
11.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.8% |
5.5%
2.3 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.7% |
19.6%
7.1 pts worse
|
19.6%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
16.5%
3.1 pts better
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 2.4% |
0.1%
2.3 pts worse
|
0.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.4% |
13.9%
9.5 pts better
|
16.3%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.6% |
11.7%
8.1 pts better
|
14.9%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.9%
0.2 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.7% |
20.4%
1.3 pts worse
|
19.8%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
5.6%
0.5 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.3% |
82.8%
11.5 pts worse
|
81.7%
10.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
11.5%
2 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.5% |
79.5%
3 pts better
|
79.7%
2.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.0% |
24.2%
11.2 pts better
|
23.9%
10.9 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-23 · Fire 2024-01-23
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-12-15 · Fire 2022-12-15
13 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-12-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-12-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-11
E · Potential for more than minimal harm
2024-12-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-12-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-12-11
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-12-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-14
F · Potential for more than minimal harm
2022-12-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-19
E · Potential for more than minimal harm
2022-12-15
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 2023-01-19
E · Potential for more than minimal harm
2022-12-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-01-19
E · Potential for more than minimal harm
2022-12-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-21
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 2026-01-20
F · Potential for more than minimal harm
2024-12-11
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 2025-01-14
F · Potential for more than minimal harm
2024-12-11
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-11
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-11
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 2025-01-14
D · Potential for more than minimal harm
2024-12-11
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 2025-01-14
D · Potential for more than minimal harm
2024-12-11
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 2025-01-14
D · Potential for more than minimal harm
2024-12-11
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 2025-01-14
D · Potential for more than minimal harm
2024-12-11
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 2025-01-14
D · Potential for more than minimal harm
2024-09-13
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 2024-10-16
D · Potential for more than minimal harm
2024-09-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-16
F · Potential for more than minimal harm
2024-01-23
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 2024-02-26
F · Potential for more than minimal harm
2024-01-23
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 2024-02-26
E · Potential for more than minimal harm
2024-01-23
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-02-26
E · Potential for more than minimal harm
2024-01-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-26
E · Potential for more than minimal harm
2024-01-23
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 2024-02-26
E · Potential for more than minimal harm
2024-01-23
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 2024-02-26
D · Potential for more than minimal harm
2024-01-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-23
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 2024-02-26
C · Minimal harm
2024-01-23
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-02-26
E · Potential for more than minimal harm
2023-06-01
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-06-01
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 2023-07-06
D · Potential for more than minimal harm
2023-06-01
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 2023-07-06
F · Potential for more than minimal harm
2022-12-15
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 2023-01-19
F · Potential for more than minimal harm
2022-12-15
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 2023-01-19
F · Potential for more than minimal harm
2022-12-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-01-19
E · Potential for more than minimal harm
2022-12-15
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 2023-01-19
E · Potential for more than minimal harm
2022-12-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-15
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 2023-01-19
D · Potential for more than minimal harm
2022-12-15
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 2023-01-19
D · Potential for more than minimal harm
2022-12-15
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 2023-01-19
Penalties and ownership
What sits behind the stars
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
Nearby options
Other facilities in reach
#1
Orchard Creek Skilled Nursing
Traverse City, MI
4-star overall rating with 2-star inspections with abuse icon flag with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Maple Valley Nursing Home
Maple Valley, MI
1-star overall rating with 1-star inspections with $119,265 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Grand Traverse Pavilions
Traverse City, MI
2-star overall rating with 1-star inspections with abuse icon flag with $148,763 in total fines with 23 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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