Cycle 1
Health 2024-12-18 · Fire 2024-12-18
4 health deficiencies
Top issue: Environmental (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Alma, MI
Michigan Masonic Home
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1200 Wright Avenue, Alma, MI
(989) 463-3141
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
204
Certified beds
Average residents
94
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
Staffing
Hours and turnover
RN hours / resident day
1.54
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.34
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.55
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.43
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.88
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.92
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
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.37
CMS adjusted RN staffing hours
Adjusted total hours
3.95
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,272
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9935
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.69
Performance 18.79% · Measure score 5.69 · Achievement 5.69 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 8.69% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
5.79
Baseline 59.24% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 5.10
Adjusted total nurse staffing
4.77
Baseline 4.48 hours · Performance 4.43 hours · Measure score 4.77 · Achievement 4.77 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.78% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 6.67% · Lower 95% interval 6.38% |
| Discharge to community | 57.67% |
50.57%
7.1 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 59.09% · Lower 95% interval 43.36% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 39 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 40.63% |
53.69%
13.1 pts worse
|
Numerator 13 · Denominator 32 |
| Discharge mobility score | 43.75% |
50.94%
7.2 pts worse
|
Numerator 14 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 2.56% |
2.29%
0.3 pts worse
|
Numerator 1 · Denominator 39 · Adjusted rate 2.67% |
| Healthcare-associated infections requiring hospitalization | 8.69% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 13.95% · Lower 95% interval 4.98% |
| Staff COVID-19 vaccination coverage | 3.91% |
8.2%
4.3 pts worse
|
Numerator 10 · Denominator 256 |
| Staff flu vaccination coverage | 65.89% |
42%
23.9 pts better
|
Numerator 170 · Denominator 258 |
| Discharge function score | 56.25% |
56.45%
0.2 pts worse
|
Numerator 18 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.3 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.8 · 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 | 98.9% |
95.0%
3.9 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.1%
2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 3.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
4.1%
3.1 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 0.0% · Q4 1.4% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
5.5%
1.8 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.7% · Q3 5.0% · Q4 11.2% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.8% |
19.6%
3.8 pts better
|
19.6%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 17.9% · Q3 14.8% · Q4 11.2% · 4Q avg 15.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.8% |
16.5%
8.7 pts better
|
16.7%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 6.5% · Q3 8.7% · Q4 6.3% · 4Q avg 7.8% · 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 | 5.4% |
13.9%
8.5 pts better
|
16.3%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 3.5% · Q3 2.7% · Q4 4.9% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.7% |
11.7%
8 pts better
|
14.9%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.0% · Q3 4.3% · Q4 2.9% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.8% |
20.4%
1.6 pts better
|
19.8%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 15.0% · Q3 21.8% · Q4 22.7% · 4Q avg 18.8% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
5.6%
0.6 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.2% · Q3 4.4% · Q4 3.1% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
82.8%
16.6 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.1% |
11.5%
2.6 pts worse
|
12.0%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 15.9% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.3%
About the same
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.4% |
79.5%
6.9 pts better
|
79.7%
6.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.4% |
24.2%
8.8 pts better
|
23.9%
8.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 18.2% · Expected 28.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-27 · Fire 2022-10-27
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
11 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-12-18
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-12-18
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-12-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-18
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 2025-01-22
E · Potential for more than minimal harm
2024-12-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-22
F · Potential for more than minimal harm
2022-10-27
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-11-11
F · Potential for more than minimal harm
2022-10-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-02
F · Potential for more than minimal harm
2022-10-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-27
F · Potential for more than minimal harm
2022-10-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-16
F · Potential for more than minimal harm
2022-10-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-18
E · Potential for more than minimal harm
2022-10-27
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 2022-11-11
E · Potential for more than minimal harm
2022-10-27
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-11-14
E · Potential for more than minimal harm
2022-10-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-11-11
E · Potential for more than minimal harm
2022-10-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-11-03
E · Potential for more than minimal harm
2022-10-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-10-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-12-18
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-18
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 2025-01-22
D · Potential for more than minimal harm
2024-12-18
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 2025-01-22
D · Potential for more than minimal harm
2023-10-26
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 2023-11-21
D · Potential for more than minimal harm
2023-10-26
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 2023-11-21
F · Potential for more than minimal harm
2022-10-27
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 2022-11-25
D · Potential for more than minimal harm
2022-10-27
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 2022-11-25
D · Potential for more than minimal harm
2022-10-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-11-25
Penalties and ownership
What sits behind the stars
Ownership
Grand Lodge Of Free And Accepted Masons Of Michigan
5% Or Greater Indirect Ownership Interest · Organization
Michigan Masonic Home
5% Or Greater Direct Ownership Interest · Organization
Caswell, Bruce
Corporate Director · Individual
Conn, Kari
Operational/Managerial Control · Individual
Flores, Omar
Corporate Director · Individual
Goodrich, Monica
Operational/Managerial Control · Individual
Groat, James
Corporate Director · Individual
Groves, John
Corporate Director · Individual
Hanson, Scott
Operational/Managerial Control · Individual
Inscho, Larry
Corporate Director · Individual
Morrison Management Specialists Inc
Operational/Managerial Control · Organization
Paquet, Gary
Corporate Director · Individual
Roberts, Mike
Corporate Director · Individual
Sarvepalli, Prakash
Operational/Managerial Control · Individual
Sauget, William
Corporate Director · Individual
Snider, Jennifer
Corporate Director · Individual
Whitmore, Robin
Operational/Managerial Control · Individual
Whitmore, Robin
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Riverside Healthcare Center
St. Louis, MI
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Schnepp Senior Care and Rehabilitation Center
St. Louis, MI
4-star overall rating with 2-star inspections with abuse icon flag with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Isabella County Medical Care Facility
Mt. Pleasant, MI
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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