Cycle 1
Health 2025-04-25 · Fire 2025-04-25
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Carson City, MI
The Laurels of Carson City
2-star overall rating with 2-star inspections with $121,908 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
620 North Second Street, Carson City, MI
(989) 584-6100
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ciena Healthcare/Laurel Health Care
Operator or chain grouping
Approved since
2007-12-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
84 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
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
1.00
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.40
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.64
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.23
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
3.96
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,684
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9961
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.63
Baseline 19.73% · Performance 20.68% · Measure score 1.63 · Achievement 1.63 · Improvement 0
Healthcare-associated infections
6.09
Baseline 6.50% · Performance 6.02% · Measure score 6.09 · Achievement 6.09 · Improvement 2.71
Total nurse turnover
7.20
Baseline 50.72% · Performance 34.25% · Measure score 7.20 · Achievement 7.20 · Improvement 5.87
Adjusted total nurse staffing
2.33
Baseline 3.98 hours · Performance 3.74 hours · Measure score 2.33 · Achievement 2.33 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.52% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 134 · Observed rate 9.7% · Lower 95% interval 7.09% |
| Discharge to community | 62.71% |
50.57%
12.1 pts better
|
Better than the National Rate · Eligible stays 120 · Observed rate 60% · Lower 95% interval 55.66% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.46% |
95.27%
3.2 pts better
|
Numerator 64 · Denominator 65 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 65 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 30 · Denominator 55 |
| Discharge mobility score | 72.73% |
50.94%
21.8 pts better
|
Numerator 40 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 6.15% |
2.29%
3.9 pts worse
|
Numerator 4 · Denominator 65 · Adjusted rate 7.22% |
| Healthcare-associated infections requiring hospitalization | 6.02% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 2.82% · Lower 95% interval 3.11% |
| Staff COVID-19 vaccination coverage | 1.72% |
8.2%
6.5 pts worse
|
Numerator 2 · Denominator 116 |
| Staff flu vaccination coverage | 10.18% |
42%
31.8 pts worse
|
Numerator 17 · Denominator 167 |
| Discharge function score | 70.91% |
56.45%
14.5 pts better
|
Numerator 39 · Denominator 55 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 45 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 25.71% |
25.2%
0.5 pts better
|
Numerator 9 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.7
0.8 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 1.8 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.5
0.5 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.4 · 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 98.3% · 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 | 90.8% |
95.0%
4.2 pts worse
|
95.5%
4.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.1%
1 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.2% · Q3 1.6% · Q4 1.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.6% |
4.1%
11.5 pts worse
|
11.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 15.8% · Q3 12.1% · Q4 19.6% · 4Q avg 15.6% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
5.5%
0.5 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 5.6% · Q3 5.5% · Q4 5.5% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.5% |
19.6%
1.9 pts worse
|
19.6%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 20.7% · Q3 17.9% · Q4 21.8% · 4Q avg 21.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.8% |
16.5%
3.7 pts better
|
16.7%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 20.5% · Q3 9.5% · Q4 4.7% · 4Q avg 12.8% · 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 | 9.9% |
13.9%
4 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 12.8% · Q3 3.4% · Q4 6.7% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.8% |
11.7%
3.9 pts better
|
14.9%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 5.6% · Q3 7.3% · Q4 9.3% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
20.4%
3.3 pts worse
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 30.8% · Q3 21.3% · Q4 25.8% · 4Q avg 23.7% |
| 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 3.9% · Q2 5.7% · Q3 4.4% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
82.8%
14.2 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 96.5% · Q3 96.8% · Q4 97.8% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.9% |
11.5%
4.4 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 16.2% · Expected 11.4% · 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 | 90.8% |
79.5%
11.3 pts better
|
79.7%
11.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
24.2%
0.2 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 22.1% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-02 · Fire 2024-05-02
15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-04-27 · Fire 2023-04-27
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-25
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 2025-05-14
E · Potential for more than minimal harm
2025-04-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-14
F · Potential for more than minimal harm
2024-05-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-05-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-02
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 2024-05-31
E · Potential for more than minimal harm
2024-05-02
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-31
F · Potential for more than minimal harm
2023-04-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-19
F · Potential for more than minimal harm
2023-04-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-19
E · Potential for more than minimal harm
2023-04-27
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-27
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 2023-05-19
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-25
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 2025-05-15
D · Potential for more than minimal harm
2025-04-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-25
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 2025-05-15
B · Minimal harm
2025-04-25
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 2025-05-15
D · Potential for more than minimal harm
2024-07-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-31
K · Immediate jeopardy
2024-05-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-31
H · Actual harm
2024-05-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-31
G · Actual harm
2024-05-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-05-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-18
F · Potential for more than minimal harm
2024-05-02
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 2024-05-31
E · Potential for more than minimal harm
2024-05-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-02
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 2024-05-31
E · Potential for more than minimal harm
2024-05-02
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 2024-05-31
E · Potential for more than minimal harm
2024-05-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-02
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-05-02
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 2024-05-31
D · Potential for more than minimal harm
2024-05-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-02
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-05-31
D · Potential for more than minimal harm
2023-11-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-01
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-04-27
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 2023-05-19
D · Potential for more than minimal harm
2023-04-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-19
Penalties and ownership
What sits behind the stars
$121,908
2024-05-02
Fine
Fine · fine $121,908
Fine
$0
2024-05-02
Payment Denial
Payment Denial · denial start 2024-06-05 · 13 days
13 day denial
Ownership
Ciena Healthcare Management Inc
Operational/Managerial Control · Organization
Estep, Billiejo
Operational/Managerial Control · Individual
Khan, Anis
Operational/Managerial Control · Individual
Qazi, Mohammad
Operational/Managerial Control · Individual
Smith, Garrett
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
The Laurels of Fulton
Perrinton, MI
3-star overall rating with 2-star inspections with $39,515 in total fines with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Michigan Masonic Home
Alma, MI
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Optalis Health & Rehabilitation of Ionia
Ionia, MI
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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