Cycle 1
Health 2025-12-11 · Fire 2025-12-11
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Kingsford, MI
Freeman Nursing & Rehabilitation Community
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1805 Pyle Drive, Kingsford, MI
(906) 774-1530
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
39
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atrium Centers
Operator or chain grouping
Approved since
2004-04-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
26 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
0.77
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.52
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.08
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.65
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.51
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
0.90
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
20%
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
4,833
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9915
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.17
Baseline 19.18% · Performance 19.04% · Measure score 5.17 · Achievement 5.17 · Improvement 0.16
Healthcare-associated infections
0
Baseline 7.41% · Performance 7.94% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.52
Baseline 73.68% · Performance 29.63% · Measure score 8.52 · Achievement 8.33 · Improvement 8.52
Adjusted total nurse staffing
1.68
Baseline 3.19 hours · Performance 3.55 hours · Measure score 1.68 · Achievement 1.68 · Improvement 0.91
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.88% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 11.11% · Lower 95% interval 7.43% |
| Discharge to community | 48.54% |
50.57%
2 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 42% · Lower 95% interval 38.32% |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 24 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 14 · Denominator 21 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 12 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 1 · Denominator 24 · Adjusted rate 5.85% |
| Healthcare-associated infections requiring hospitalization | 7.93% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 4.06% |
| Staff COVID-19 vaccination coverage | 14.63% |
8.2%
6.4 pts better
|
Numerator 6 · Denominator 41 |
| Staff flu vaccination coverage | 61.54% |
42%
19.5 pts better
|
Numerator 32 · Denominator 52 |
| Discharge function score | 71.43% |
56.45%
15 pts better
|
Numerator 15 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · 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 | 98.1% |
95.0%
3.1 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.9% |
95.0%
2.1 pts worse
|
95.5%
2.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.1%
3.1 pts better
|
3.3%
3.3 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 who have depressive symptoms | 0.0% |
4.1%
4.1 pts better
|
11.4%
11.4 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 who lose too much weight | 4.8% |
5.5%
0.7 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.7% · Q3 0.0% · Q4 7.4% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.4% |
19.6%
5.2 pts better
|
19.6%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 19.2% · Q3 16.0% · Q4 11.1% · 4Q avg 14.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.1% |
16.5%
15.4 pts better
|
16.7%
15.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · 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 | 15.2% |
13.9%
1.3 pts worse
|
16.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.0% |
11.7%
2.7 pts better
|
14.9%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 8.0% · Q3 16.7% · Q4 3.8% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · 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 | 8.4% |
20.4%
12 pts better
|
19.8%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 3.9% · Q3 7.3% · Q4 7.0% · 4Q avg 8.4% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
5.6%
0.6 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 13.1% · Q3 6.6% · Q4 0.0% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.7% |
82.8%
0.1 pts worse
|
81.7%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 73.0% · Q2 75.0% · Q3 86.8% · Q4 94.9% · 4Q avg 82.7% |
| 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 9.1% · Expected 9.2% · 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 | 72.2% |
79.5%
7.3 pts worse
|
79.7%
7.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.9% |
24.2%
10.3 pts better
|
23.9%
10 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 9.1% · Expected 15.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-23 · Fire 2024-10-23
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-12-01 · Fire 2023-12-01
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-01-06
E · Potential for more than minimal harm
2025-12-11
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 2026-01-06
F · Potential for more than minimal harm
2024-10-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-23
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 2024-11-15
F · Potential for more than minimal harm
2023-12-01
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-12-29
F · Potential for more than minimal harm
2023-12-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-29
F · Potential for more than minimal harm
2023-12-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-29
F · Potential for more than minimal harm
2023-12-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-29
Inspection history
Recent health citations
G · Actual harm
2025-12-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-06
F · Potential for more than minimal harm
2025-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-12-11
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 2026-01-06
E · Potential for more than minimal harm
2024-10-23
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 2024-11-18
D · Potential for more than minimal harm
2024-10-23
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 2024-11-18
D · Potential for more than minimal harm
2024-10-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-23
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 2024-11-18
D · Potential for more than minimal harm
2024-10-23
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-23
F917 · Environmental Deficiencies
Health
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
Corrected 2024-11-18
F · Potential for more than minimal harm
2023-12-01
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 2023-12-29
F · Potential for more than minimal harm
2023-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-29
E · Potential for more than minimal harm
2023-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-01
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 2023-12-29
D · Potential for more than minimal harm
2023-12-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-01
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 2023-12-29
D · Potential for more than minimal harm
2023-12-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-01
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-12-29
C · Minimal harm
2023-12-01
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-12-29
C · Minimal harm
2023-12-01
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-12-29
Penalties and ownership
What sits behind the stars
Ownership
Atrium Centers, Inc.
5% Or Greater Direct Ownership Interest · Organization
Albright Ross, Susan
Corporate Officer · Individual
Atrium Centers Management LLC
Operational/Managerial Control · Organization
Bailey, Essel
Corporate Officer · Individual
Finney, Donald
Corporate Officer · Individual
Lockhart, Dennis
W-2 Managing Employee · Individual
Rocca, Michael
Corporate Director · Individual
Nearby options
Other facilities in reach
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Optalis Health and Rehabilitation of Kingsford
Kingsford, MI
1-star overall rating with 1-star inspections with $139,667 in total fines with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Maryhill Manor
Niagara, WI
5-star overall rating with 3-star inspections with $50,606 in total fines with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Florence Health Services
Florence, WI
1-star overall rating with 2-star inspections with 18 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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