Cycle 1
Health 2024-11-22 · Fire 2024-11-22
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Jackson, MI
Vista Grande Villa
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2251 Springport Road, Jackson, MI
(517) 787-0226
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
60
Certified beds
Average residents
49
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-01-15
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
1.05
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.96
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.10
CMS adjusted RN staffing hours
Adjusted total hours
4.15
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,264
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9877
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.31% · Performance 22.70% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.55
Baseline 5.56% · Performance 6.47% · Measure score 4.55 · Achievement 4.55 · Improvement 0
Total nurse turnover
3.61
Baseline 45.65% · Performance 48.94% · Measure score 3.61 · Achievement 3.61 · Improvement 0
Adjusted total nurse staffing
5.21
Baseline 5.16 hours · Performance 4.56 hours · Measure score 5.21 · Achievement 5.21 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.39% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 222 · Observed rate 7.66% · Lower 95% interval 6.99% |
| Discharge to community | 63.16% |
50.57%
12.6 pts better
|
Better than the National Rate · Eligible stays 212 · Observed rate 59.91% · Lower 95% interval 56.32% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.82% |
95.27%
1.5 pts better
|
Numerator 152 · Denominator 157 |
| Falls with major injury | 1.91% |
0.77%
1.1 pts worse
|
Numerator 3 · Denominator 157 |
| Discharge self-care score | 68.42% |
53.69%
14.7 pts better
|
Numerator 78 · Denominator 114 |
| Discharge mobility score | 54.39% |
50.94%
3.5 pts better
|
Numerator 62 · Denominator 114 |
| Pressure ulcers or injuries, new or worsened | 3.82% |
2.29%
1.5 pts worse
|
Numerator 6 · Denominator 157 · Adjusted rate 4.51% |
| Healthcare-associated infections requiring hospitalization | 6.47% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 129 · Observed rate 4.65% · Lower 95% interval 4.12% |
| Staff COVID-19 vaccination coverage | 9.33% |
8.2%
1.1 pts better
|
Numerator 7 · Denominator 75 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 60.53% |
56.45%
4.1 pts better
|
Numerator 69 · Denominator 114 |
| Transfer of health information to provider | 96.77% |
95.95%
0.8 pts better
|
Numerator 60 · Denominator 62 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 80 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 42.31% |
25.2%
17.1 pts better
|
Numerator 33 · Denominator 78 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.7
0.6 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
95.0%
3.9 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.7% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.1%
1.4 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 4.3% · Q3 5.0% · Q4 0.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
4.1%
1.6 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
5.5%
0.4 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.3% |
19.6%
1.3 pts better
|
19.6%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 19.0% · 4Q avg 18.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.6% |
16.5%
14.9 pts better
|
16.7%
15.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% · 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 | 12.4% |
13.9%
1.5 pts better
|
16.3%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.7% |
11.7%
1 pts worse
|
14.9%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 23.8% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.1% |
0.9%
2.2 pts worse
|
1.0%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.1% · 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% · Q2 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 | 31.9% |
20.4%
11.5 pts worse
|
19.8%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 41.9% · Q4 13.6% · 4Q avg 31.9% |
| Percentage of long-stay residents with pressure ulcers | 8.1% |
5.6%
2.5 pts worse
|
5.1%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 4.8% · Q3 13.9% · Q4 5.0% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
82.8%
12.3 pts better
|
81.7%
13.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 94.6% · Q3 94.8% · Q4 94.0% · 4Q avg 95.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.1% |
11.5%
0.4 pts better
|
12.0%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 10.0% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.9% |
79.5%
14.4 pts better
|
79.7%
14.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
24.2%
0.5 pts better
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 20.7% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-18 · Fire 2023-10-18
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-09-21 · Fire 2022-09-21
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-06
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-09-11
F · Potential for more than minimal harm
2024-11-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-09
E · Potential for more than minimal harm
2024-11-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-09
E · Potential for more than minimal harm
2024-11-22
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2025-01-09
F · Potential for more than minimal harm
2023-10-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-28
F · Potential for more than minimal harm
2023-10-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-10-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-28
F · Potential for more than minimal harm
2022-09-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-21
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-19
E · Potential for more than minimal harm
2022-09-21
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-10-19
E · Potential for more than minimal harm
2022-09-21
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 2022-10-19
E · Potential for more than minimal harm
2022-09-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-19
D · Potential for more than minimal harm
2022-09-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-14
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 2025-12-23
D · Potential for more than minimal harm
2025-11-14
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 2025-12-23
D · Potential for more than minimal harm
2024-11-22
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 2025-01-09
D · Potential for more than minimal harm
2024-11-22
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 2025-01-09
D · Potential for more than minimal harm
2024-11-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-11-22
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 2025-01-09
D · Potential for more than minimal harm
2024-11-22
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 2025-01-09
D · Potential for more than minimal harm
2024-11-22
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-01-09
F · Potential for more than minimal harm
2023-10-18
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 2023-11-28
E · Potential for more than minimal harm
2023-10-18
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 2023-11-28
D · Potential for more than minimal harm
2023-10-18
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 2023-11-28
D · Potential for more than minimal harm
2023-10-18
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-18
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 2023-11-28
D · Potential for more than minimal harm
2023-10-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-18
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 2023-11-28
D · Potential for more than minimal harm
2023-07-24
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 2023-08-22
G · Actual harm
2022-09-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-19
F · Potential for more than minimal harm
2022-09-21
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 2022-10-19
E · Potential for more than minimal harm
2022-09-21
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 2022-10-19
Penalties and ownership
What sits behind the stars
Ownership
Dunigan, Joseph
Corporate Director · Individual
Eisele, Chelsea
Operational/Managerial Control · Individual
Eisele, Chelsea
W-2 Managing Employee · Individual
Kauhale Healthcare Management LLC
Operational/Managerial Control · Organization
Keatley, Ellen
Corporate Director · Individual
Keatley, Ellen
Corporate Officer · Individual
Markowski, Ronald
Corporate Director · Individual
Markowski, Ronald
Corporate Officer · Individual
Us Bank National Association
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Regency at Jackson
Jackson, MI
1-star overall rating with 2-star inspections with $15,593 in total fines with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Jackson County Medical Care Facility
Jackson, MI
5-star overall rating with 4-star inspections with $68,744 in total fines with 6 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
#3
Mission Point Health Campus of Jackson
Jackson, MI
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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