Standish, MI

MyMichigan Skilled Nursing Facility

5-star overall rating with 4-star inspections with $32,175 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

805 West Cedar, Standish, MI

(989) 846-4521

Compare this facility

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

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1970-02-28

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

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

2.04

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.10

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

3.91

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

6.05

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

2.14

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

5.31

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

1.44

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

2.23

CMS adjusted RN staffing hours

Adjusted total hours

6.60

CMS adjusted total nurse staffing hours

Case-mix index

1.25

Higher values indicate more complex resident acuity

RN turnover

20%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

19%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

408

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

70.58

Composite VBP score used to determine payment impact.

Payment multiplier

1.0227

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.18

Performance 19.03% · Measure score 5.18 · Achievement 5.18 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

5.99

Baseline 8.00% · Performance 6.05% · Measure score 5.99 · Achievement 5.98 · Improvement 5.99

Total nurse turnover

Baseline 37.93% · Performance 11.11% · Measure score 10 · Achievement 10 · Improvement 9

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	10.61%	10.72% 0.1 pts better	No Different than the National Rate · Eligible stays 62 · Observed rate 9.68% · Lower 95% interval 6.64%
Discharge to community	69.84%	50.57% 19.3 pts better	Better than the National Rate · Eligible stays 55 · Observed rate 74.55% · Lower 95% interval 57.89%
Medicare spending per beneficiary	0.76	1.02 0.3 pts better
Drug regimen review with follow-up	93.33%	95.27% 1.9 pts worse	Numerator 28 · Denominator 30
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 30
Discharge self-care score	41.38%	53.69% 12.3 pts worse	Numerator 12 · Denominator 29
Discharge mobility score	58.62%	50.94% 7.7 pts better	Numerator 17 · Denominator 29
Pressure ulcers or injuries, new or worsened	3.33%	2.29% 1 pts worse	Numerator 1 · Denominator 30 · Adjusted rate 3.54%
Healthcare-associated infections requiring hospitalization	6.05%	7.12% 1.1 pts better	No Different than the National Rate · Eligible stays 35 · Observed rate 0% · Lower 95% interval 3%
Staff COVID-19 vaccination coverage	1.96%	8.2% 6.2 pts worse	Numerator 1 · Denominator 51
Staff flu vaccination coverage	87.76%	42% 45.8 pts better	Numerator 43 · Denominator 49
Discharge function score	58.62%	56.45% 2.2 pts better	Numerator 17 · Denominator 29
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 26 · Denominator 26
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.5%	95.0% 3.5 pts better	93.4% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 98.5%
Percentage of long-stay residents experiencing one or more falls with major injury	1.5%	3.1% 1.6 pts better	3.3% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.8%	4.1% 2.3 pts better	11.4% 9.6 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 1.8%
Percentage of long-stay residents who lose too much weight	8.5%	5.5% 3 pts worse	5.4% 3.1 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 8.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	30.5%	19.6% 10.9 pts worse	19.6% 10.9 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 30.5%
Percentage of long-stay residents who received an antipsychotic medication	8.8%	16.5% 7.7 pts better	16.7% 7.9 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 8.8% · 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 · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	28.8%	13.9% 14.9 pts worse	16.3% 12.5 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 28.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	25.0%	11.7% 13.3 pts worse	14.9% 10.1 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 25.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	8.1%	0.9% 7.2 pts worse	1.0% 7.1 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 8.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	4.6%	1.7% 2.9 pts worse	1.7% 2.9 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 4.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	13.8%	20.4% 6.6 pts better	19.8% 6 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 13.8%
Percentage of long-stay residents with pressure ulcers	1.7%	5.6% 3.9 pts better	5.1% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	92.5%	82.8% 9.7 pts better	81.7% 10.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 95.9% · Q3 90.2% · Q4 91.5% · 4Q avg 92.5%
Percentage of short-stay residents who had an outpatient emergency department visit	8.2%	11.5% 3.3 pts better	12.0% 3.8 pts better	Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.1% · Expected 9.7% · 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	96.2%	79.5% 16.7 pts better	79.7% 16.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	14.0%	24.2% 10.2 pts better	23.9% 9.9 pts better	Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 10.7% · Expected 18.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-21 · Fire 2025-02-21

4 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2024-03-06 · Fire 2024-03-06

7 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 2023-02-22 · Fire 2023-02-22

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-24

F · Potential for more than minimal harm 2023-02-22

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-03-20

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-02-21

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-03-24

D · Potential for more than minimal harm 2025-02-21

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 2025-03-24

D · Potential for more than minimal harm 2025-02-21

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 2025-03-24

D · Potential for more than minimal harm 2025-02-21

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 2025-03-24

G · Actual harm 2024-03-06

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-04-03

G · Actual harm 2024-03-06

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 2024-04-03

F · Potential for more than minimal harm 2024-03-06

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 2024-04-03

D · Potential for more than minimal harm 2024-03-06

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-04-03

D · Potential for more than minimal harm 2024-03-06

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-04-03

D · Potential for more than minimal harm 2024-03-06

F758 · Pharmacy Service Deficiencies

Health

Corrected 2024-04-03

C · Minimal harm 2024-03-06

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-04-03

G · Actual harm 2023-11-15

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 2023-12-11

F · Potential for more than minimal harm 2023-02-22

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 2023-03-27