Marlette Community Hospital LTCU

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 39 beds and averages 36.1 residents a day — about 93% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.25 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.04 hrs/resident/day on weekends vs 5.19 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.78 to 1.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 22% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

• Potential for harm · Fcited before2025-08-07 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure food was properly labeled, dated and stored to maintain best practices resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings include:On 8/5/25 at 9:00 AM, observations and interview during Initial kitchen include: On the prep table there was a large plastic container with an open blue bag in it, the container had no label, no open or expiration date on it. During interview with dietary supervisor “C”, when asked what the product was, Dietary Supervisor C stated it was rice, and acknowledged there is no dates or label present, but reports “there should be”. Walk in freezer with (2) Large plastic baggies of pepperonis that have been opened and have no open/expiration dating on them and sitting on shelf near a box of sealed pepperonis. On another shelf there is an open bag of frozen sugar snap peas no open date, closed with a rubber band. In the dry storage line in the kitchen, there is a box of cream of wheat and pancake mix both open in…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-08-07 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to maintain a comprehensive infection control program, resulting in the facility not mapping infections or completing audits and the potential for infection clusters to go unnoticed. Findings include: DPS 2 Based on interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the residents in the facility. Findings include:On 08/07/2025 at 1:13PM, an interview was conducted with the Director of Nursing (DON). The DON acts in the role of the infection preventionist. During record review of the monthly infection control reports, it was noted that there was no mapping of infections being completed by the facility and minimal audits being completed for infection control. The DON was asked if the facility is mapping…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-07 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to evaluate and document the clinical rationale for the continuation of a PRN (as needed) anti-anxiety medication beyond 14 days and failed to identify a stop date of the medication for one resident (R6) of five residents reviewed for unnecessary psychotropic medication use, resulting in potential for overuse of the medication.Facts and Findings include: Record review of R6 quarterly minimum data Set (MDS) revealed Brief Interview of Mental Status (BIMS) of 2, defined as cognitively severely impaired never/rarely made decisions. Medical diagnosis included: Alzheimer's, COPD, Anxiety, Residual Schizophrenia, ASHD, Colon cancerRecord review of R6 physician order from 04/09/2025 for Ativan 0.5 mg tablet by mouth daily PRN (as needed for) anxiety, may give 1/2 hour prior to showers. Signed by NP F. There is no stop date / review date for this order.Record review of drugs.com internet search for Ativan (lorazepam) drug class: benzodiazepine anticonvulsant is used for anxiety disorders and insomnia.Record review of the latest…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-07 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a baseline care plan for one resident (R25) of two reviewed, resulting in the lack of a baseline care plan for oxygen administration. Findings include: R25 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include chronic respiratory failure with hypoxia, hypertensive heart disease with heart failure, congestive heart failure and pulmonary fibrosis.On 08/06/2025 at 8:56AM, R25 was observed sitting in bed receiving oxygen via nasal cannula. R25 stated that she usually receives 7 liters per minute (LPM) of oxygen, but due to having different tubing she is now having to receive 8LPM and her oxygen saturation isn't nearly as high as it usually is. On 08/06/2025 at 2:33PM, record review revealed a physician's order for administration of oxygen at 7LPM, dated 7/24/25. Record review revealed there is a care plan is in place for oxygen use, it is dated 8/6/25. On 08/06/2025 at 2:46PM, record review of care plans revealed that…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-07 · tag F0791 — failed to provide routine dental services — isolated
  Provide or obtain dental services for each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide routine dental services for one resident (R15) of one reviewed for dental services. Findings include: R15 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include malignant neoplasm of the pancreas, neuropathy, type 2 diabetes and hypertension. On 08/05/2025 at 12:01PM, R15 was observed in her room sitting on the edge of her bed. R15 was observed to not have any upper teeth, lower teeth were visible. R15 was asked about not having upper teeth in. R15 stated that she left her upper dentures at home and that they don't fit. R15 was asked if she had been seen by the dentist since being in the facility. R15 stated she was not sure if she sees the dentist here or not, but that she would like to. R15 stated that she would like to eat more salads but cannot eat them due to not having upper dentures. On 08/06/2025 at 12:38PM, an interview was conducted with Social Worker (SW) A. SW A was asked if they are the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-08-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to date mark potentially hazardous foods, maintain sanitary equipment, and maintain proper glove use and handwashing, resulting in an increased risk of foodborne illness, affecting all residents that consume food from the kitchen. Findings include: On 8/12/24 at 11:40 AM, during a kitchen inspection, assisted by Certified Dietary Manager (CDM) H, an opened bag of hard boiled eggs was observed to not be provided with a date mark to identify the discard date. On 8/12/24 at 11:45 AM, a chicken wrap, located in the reach-in deli cooler, was observed to not be provided with a date mark. At this time, CDM H stated the wrap was left over from the day before. According to the 2017 FDA Food Code Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-08-14 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% based on five medication errors of 34 medication administration opportunities. This deficient practice resulted in a medication error rate of 14.7%. Findings include: Registered Nurse (RN) A was observed administering medications on 8/13/24 at 10:15 a.m. RN A said she was passing the morning medications on the west hall. RN A prepared medications for Resident #31 (R31) consisting of 11 medications. The medications for R31 were ordered to be administered at 9:00 a.m. RN A documented the medications as administered at 10:19 a.m. on 8/13/24. RN A prepared medications for Resident #25 (R25) consisting of 17 medications. When the medications were prepared, RN A handed the medications to another nurse, RN B, to administer to R25 while RN A continued with preparing medications at the medication cart. The medications for R25 were ordered to be administered at 9:00 a.m. RN A documented the medications as administered at 10:28 a.m. on 8/13/24 despite not having…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-08-14 · tag F0761 — failed to label and store drugs safely — pattern
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to properly store and dispose of medications and ensure insulin pens and eye drops were labeled with dates when opened in two medication carts of two medication carts reviewed for medication storage and labeling. Findings include: On 8/13/24 at 10:35 a.m., Registered Nurse (RN) A attempted to administer medications to Resident #3 (R3). R3 told RN A she did not want the medications because she was on the phone. RN A returned to the medication cart with the medications and obtained a marking pen. RN A wrote R3's initials on the cup containing the medications and pulled open the top drawer of the medication cart. The Director of Nursing (DON) approached and asked RN A what she was doing. RN A told the DON R3 did not want her medications at that time. The DON told RN A to dispose of the medications in the medication cup and obtain new medications when R3 was ready to take the medications. RN A emptied the medications into a Sharps container (a wasted container for sharp medical instruments). The South Hall…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-08-14 · tag F0887 — pattern
  Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement tracking of Covid-19 (a highly contagious respiratory disease) immunizations to ensure appropriate education was offered and vaccinations administered or declined for four residents (R13, R17, R30 and R35) of five residents reviewed for immunization, resulting in the potential for residents and resident representatives to be uninformed of the benefits and potential side effects of Covid-19 vaccination and the potential for eligible residents to remain unvaccinated, increasing the risk of disease. Findings include: Resident #13 (R13): Review of R13's Minimum Data Set (MDS) assessment, dated 6/24/2024, revealed R13 was admitted to the facility on [DATE]. Review of R13's immunization history obtained from his electronic medical record (EMR) revealed the date of R13's most recent Covid-19 vaccination was documented as 5/04/2022. It was noted in review of the immunization history there was no documentation of R13 being offered an up to date…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to appropriately monitor for a change in condition per professional standards of practice for one resident (Resident #30) of one resident reviewed for hospitalizations, resulting in the potential for delayed treatment and a further deterioration of condition. Findings include: Resident #30 (R30): Review of R30's Minimum Data Set (MDS) assessment, dated 6/10/2024, revealed R30 was admitted to the facility on [DATE] and had diagnoses including hypertensive heart disease with heart failure, aortic valve stenosis, peripheral vascular disease, hypertension and dementia. Further review revealed R30 scored five out of 15 (5/15) on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. An observation on 8/12/2024 at 1:27 a.m. revealed R30 seated in a wheelchair in her room. R30 was observed to be receiving three liters per minute of oxygen via nasal cannula from a portable oxygen tank housed on the back of the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 23 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in MI