Cycle 1
Health 2025-02-13 · Fire 2025-02-13
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Gaylord, MI
Munson Healthcare Otsego Memorial Hospital LTCU
5-star overall rating with 4-star inspections with 4 recent health deficiencies
825 North Center Street, Gaylord, MI
(989) 731-2131
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
34
Certified beds
Average residents
31
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
1.63
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.11
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.26
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
1.12
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.81
CMS adjusted RN staffing hours
Adjusted total hours
4.73
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
859
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.90
Composite VBP score used to determine payment impact.
Payment multiplier
1.0177
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
5.36
Performance 6.23% · Measure score 5.36 · Achievement 5.36 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
5.32
Baseline 50.00% · Performance 41.94% · Measure score 5.32 · Achievement 5.32 · Improvement 2.71
Adjusted total nurse staffing
8.19
Performance 5.41 hours · Measure score 8.19 · Achievement 8.19 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.16% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 6.35% · Lower 95% interval 6.88% |
| Discharge to community | 64.45% |
50.57%
13.9 pts better
|
Better than the National Rate · Eligible stays 51 · Observed rate 68.63% · Lower 95% interval 53.63% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 75% |
95.27%
20.3 pts worse
|
Numerator 27 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 40.63% |
53.69%
13.1 pts worse
|
Numerator 13 · Denominator 32 |
| Discharge mobility score | 28.13% |
50.94%
22.8 pts worse
|
Numerator 9 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 36 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.23% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 0% · Lower 95% interval 2.97% |
| Staff COVID-19 vaccination coverage | 2.86% |
8.2%
5.3 pts worse
|
Numerator 1 · Denominator 35 |
| Staff flu vaccination coverage | 94.29% |
42%
52.3 pts better
|
Numerator 33 · Denominator 35 |
| Discharge function score | 25% |
56.45%
31.5 pts worse
|
Numerator 8 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 23.08% |
25.2%
2.1 pts worse
|
Numerator 6 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 80.0% |
95.0%
15 pts worse
|
95.5%
15.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.3% |
3.1%
6.2 pts worse
|
3.3%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 15.0% · Q3 9.5% · Q4 4.3% · 4Q avg 9.3% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 13.1% |
5.5%
7.6 pts worse
|
5.4%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.8% |
19.6%
11.8 pts better
|
19.6%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.4% |
16.5%
5.9 pts worse
|
16.7%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.4% · 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 need for help with daily activities has increased | 19.0% |
11.7%
7.3 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.0% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.6% |
20.4%
10.2 pts worse
|
19.8%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 24.5% · Q4 41.8% · 4Q avg 30.6% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
5.6%
3.1 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q3 0.0% · Q4 2.7% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
82.8%
12.9 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 97.0% · Q3 93.0% · Q4 95.8% · 4Q avg 95.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.2% |
11.5%
4.3 pts better
|
12.0%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.2% · Observed 6.8% · Expected 10.6% · 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 | 36.4% |
79.5%
43.1 pts worse
|
79.7%
43.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 36.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.0% |
24.2%
12.2 pts better
|
23.9%
11.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 11.4% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-27 · Fire 2024-03-27
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-05-11 · Fire 2023-05-11
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-27
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-05-03
F · Potential for more than minimal harm
2024-03-27
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-03-27
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-03-27
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 2024-05-03
D · Potential for more than minimal harm
2024-03-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-03
F · Potential for more than minimal harm
2023-05-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-11
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 2023-06-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-13
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-02-13
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 2025-03-31
D · Potential for more than minimal harm
2025-02-13
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-13
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-03-31
F · Potential for more than minimal harm
2024-03-27
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 2024-05-03
D · Potential for more than minimal harm
2024-03-27
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 2024-05-03
D · Potential for more than minimal harm
2024-03-27
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 2024-05-03
D · Potential for more than minimal harm
2024-03-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-27
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 2024-05-03
E · Potential for more than minimal harm
2023-05-11
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-11
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 2023-06-16
D · Potential for more than minimal harm
2023-05-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-16
Penalties and ownership
What sits behind the stars
Ownership
Munson Healthcare
5% Or Greater Direct Ownership Interest · Organization
Elliot, Benjamin
Operational/Managerial Control · Individual
Konopacki, Paul
Corporate Director · Individual
Korth-White, Kirsten
Operational/Managerial Control · Individual
Wisniewski, Steven
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Medilodge of Gaylord
Gaylord, MI
2-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Grandvue Medical Care Facility
East Jordan, MI
3-star overall rating with 2-star inspections with abuse icon flag with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Munson Healthcare Crawford Continuing Care Center
Grayling, MI
4-star overall rating with 3-star inspections with $27,600 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out