Powers, MI

Pinecrest Medical Care Facility

4-star overall rating with 3-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

N15995 Main Street, Powers, MI

(906) 497-5244

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

68

Average occupied residents

Ownership

Government

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

0.65

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.84

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

2.88

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

4.37

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.49

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

3.72

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.29

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

0.77

CMS adjusted RN staffing hours

Adjusted total hours

5.22

CMS adjusted total nurse staffing hours

Case-mix index

1.15

Higher values indicate more complex resident acuity

RN turnover

22%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

35%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,252

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

Performance score

40.68

Composite VBP score used to determine payment impact.

Payment multiplier

0.9936

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

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

3.68

Baseline 51.48% · Performance 48.65% · Measure score 3.68 · Achievement 3.68 · Improvement 0.56

Adjusted total nurse staffing

4.46

Baseline 5.25 hours · Performance 4.35 hours · Measure score 4.46 · Achievement 4.46 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 10%
10.72%
0.7 pts better
No Different than the National Rate · Eligible stays 35 · Observed rate 5.71% · Lower 95% interval 6.38%
Discharge to community 55.35%
50.57%
4.8 pts better
No Different than the National Rate · Eligible stays 31 · Observed rate 51.61% · Lower 95% interval 40.72%
Medicare spending per beneficiary 0.87
1.02
0.2 pts better
Drug regimen review with follow-up 80%
95.27%
15.3 pts worse
Numerator 24 · Denominator 30
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 30
Discharge self-care score 25%
53.69%
28.7 pts worse
Numerator 6 · Denominator 24
Discharge mobility score 58.33%
50.94%
7.4 pts better
Numerator 14 · Denominator 24
Pressure ulcers or injuries, new or worsened 0%
2.29%
2.3 pts better
Numerator 0 · Denominator 30 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization Not Available
7.12%
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage 11.48%
8.2%
3.3 pts better
Numerator 14 · Denominator 122
Staff flu vaccination coverage Not Available
42%
Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score 54.17%
56.45%
2.3 pts worse
Numerator 13 · Denominator 24
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 12 · 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 19 · 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 1.0
1.7
0.7 pts better
1.9
0.9 pts better
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 2.9
1.5
1.4 pts worse
1.8
1.1 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.1 · Expected 1.2 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 99.6%
95.0%
4.6 pts better
93.4%
6.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 89.7%
95.0%
5.3 pts worse
95.5%
5.8 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.7%
Percentage of long-stay residents experiencing one or more falls with major injury 4.7%
3.1%
1.6 pts worse
3.3%
1.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 5.4% · Q3 5.0% · Q4 4.6% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 0.9%
4.1%
3.2 pts better
11.4%
10.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 1.7% · 4Q avg 0.9%
Percentage of long-stay residents who lose too much weight 6.7%
5.5%
1.2 pts worse
5.4%
1.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 14.8% · Q3 5.1% · Q4 1.6% · 4Q avg 6.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 25.6%
19.6%
6 pts worse
19.6%
6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 27.3% · Q3 23.7% · Q4 21.3% · 4Q avg 25.6%
Percentage of long-stay residents who received an antipsychotic medication 24.1%
16.5%
7.6 pts worse
16.7%
7.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 22.2% · Q3 26.1% · Q4 19.1% · 4Q avg 24.1% · 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 17.1%
13.9%
3.2 pts worse
16.3%
0.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 15.9% · Q3 19.3% · Q4 9.4% · 4Q avg 17.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 22.9%
11.7%
11.2 pts worse
14.9%
8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 35.4% · Q2 26.9% · Q3 22.6% · Q4 8.8% · 4Q avg 22.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 5.8%
0.9%
4.9 pts worse
1.0%
4.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.4% · Q3 7.4% · Q4 5.3% · 4Q avg 5.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 3.0%
1.7%
1.3 pts worse
1.7%
1.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.6% · Q3 0.0% · Q4 3.1% · 4Q avg 3.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 28.9%
20.4%
8.5 pts worse
19.8%
9.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 37.7% · Q2 36.9% · Q3 24.1% · Q4 18.8% · 4Q avg 28.9%
Percentage of long-stay residents with pressure ulcers 3.5%
5.6%
2.1 pts better
5.1%
1.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 4.6% · Q4 5.3% · 4Q avg 3.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 87.8%
82.8%
5 pts better
81.7%
6.1 pts better
Short Stay · 2024Q4-2025Q3 · Q1 72.5% · Q2 88.9% · Q3 94.3% · Q4 100.0% · 4Q avg 87.8%
Percentage of short-stay residents who had an outpatient emergency department visit 28.2%
11.5%
16.7 pts worse
12.0%
16.2 pts worse
Short Stay · 20240701-20250630 · Adjusted 28.2% · Observed 26.1% · Expected 10.3% · 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% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 53.2%
79.5%
26.3 pts worse
79.7%
26.5 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 53.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 20.2%
24.2%
4 pts better
23.9%
3.7 pts better
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 17.4% · Expected 20.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-17 · Fire 2025-07-17

3 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2024-07-25 · Fire 2024-07-25

14 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

3 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 3 Health 2023-07-27 · Fire 2023-07-27

23 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

7 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-07-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-09-08

F · Potential for more than minimal harm 2025-07-17

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-09-08

E · Potential for more than minimal harm 2025-07-17

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-09-08

F · Potential for more than minimal harm 2024-07-25

K132 · Construction Deficiencies

Fire Safety

Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

Corrected 2024-09-13

E · Potential for more than minimal harm 2024-07-25

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2024-09-13

D · Potential for more than minimal harm 2024-07-25

K925 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that sources of ignition are removed from patients receiving respiratory therapy.

Corrected 2024-09-13

F · Potential for more than minimal harm 2023-07-27

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-09-11

F · Potential for more than minimal harm 2023-07-27

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-09-11

F · Potential for more than minimal harm 2023-07-27

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2023-09-11

E · Potential for more than minimal harm 2023-07-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-09-11

D · Potential for more than minimal harm 2023-07-27

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-09-11

D · Potential for more than minimal harm 2023-07-27

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-09-11

D · Potential for more than minimal harm 2023-07-27

K925 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that sources of ignition are removed from patients receiving respiratory therapy.

Corrected 2023-09-11

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-07-17

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-08-20

D · Potential for more than minimal harm 2025-07-17

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2025-08-20

D · Potential for more than minimal harm 2025-07-17

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2025-08-20

F · Potential for more than minimal harm 2024-07-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-30

E · Potential for more than minimal harm 2024-07-25

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 2024-08-30

E · Potential for more than minimal harm 2024-07-25

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 2024-08-30

E · Potential for more than minimal harm 2024-07-25

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 2024-08-30

D · Potential for more than minimal harm 2024-07-25

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 2024-08-30

D · Potential for more than minimal harm 2024-07-25

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 2024-08-30

D · Potential for more than minimal harm 2024-07-25

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-07-25

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 2024-08-30

D · Potential for more than minimal harm 2024-07-25

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-07-25

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-07-25

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-07-25

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 2024-08-30

D · Potential for more than minimal harm 2024-07-25

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-07-25

F810 · Nutrition and Dietary Deficiencies

Health

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Corrected 2024-08-30

F · Potential for more than minimal harm 2024-01-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-02-06

G · Actual harm 2023-07-27

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-08-23

F · Potential for more than minimal harm 2023-07-27

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 2023-08-23

F · Potential for more than minimal harm 2023-07-27

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 2023-08-23

F · Potential for more than minimal harm 2023-07-27

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2023-08-23

F · Potential for more than minimal harm 2023-07-27

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2023-08-23

F · Potential for more than minimal harm 2023-07-27

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 2023-08-23

E · Potential for more than minimal harm 2023-07-27

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2023-08-23

E · Potential for more than minimal harm 2023-07-27

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 2023-08-23

E · Potential for more than minimal harm 2023-07-27

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-08-23

E · Potential for more than minimal harm 2023-07-27

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2023-08-23

E · Potential for more than minimal harm 2023-07-27

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 2023-08-23

E · Potential for more than minimal harm 2023-07-27

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 2023-08-23

D · Potential for more than minimal harm 2023-07-27

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 2023-08-23

D · Potential for more than minimal harm 2023-07-27

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2023-08-23

D · Potential for more than minimal harm 2023-07-27

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 2023-09-19

D · Potential for more than minimal harm 2023-07-27

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 2023-08-23

D · Potential for more than minimal harm 2023-07-27

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2023-08-23

D · Potential for more than minimal harm 2023-07-27

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2023-09-19

D · Potential for more than minimal harm 2023-07-27

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 2023-09-20

D · Potential for more than minimal harm 2023-07-27

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2023-08-23

D · Potential for more than minimal harm 2023-07-27

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 2023-08-23

D · Potential for more than minimal harm 2023-07-27

F776 · Administration Deficiencies

Health

Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Corrected 2023-08-23

Penalties and ownership

What sits behind the stars

$0 2023-07-27

Payment Denial

Payment Denial · denial start 2023-08-26 · 25 days

25 day denial

Ownership

Delta County

5% Or Greater Direct Ownership Interest · Organization

33% 1 facilities 1966-01-01
Dickinson County

5% Or Greater Direct Ownership Interest · Organization

33% 1 facilities 1966-01-01
Menominee County

5% Or Greater Direct Ownership Interest · Organization

33% 1 facilities 1966-01-01
Dean, Flora

Operational/Managerial Control · Individual

0% 3 facilities 2025-02-26
Dean, Flora

Corporate Director · Individual

0% 3 facilities 2025-02-26
Smith, Dana

Operational/Managerial Control · Individual

0% 2 facilities 2021-06-14
Smith, Dana

Corporate Officer · Individual

0% 2 facilities 2021-06-14

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