Cycle 1
Health 2025-05-15 · Fire 2025-05-15
0 health deficiencies
No concentrated health issue counts in this cycle.
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Ishpeming, MI
Marquette County Medical Care Facility
5-star overall rating with 5-star inspections with 11 fire-safety deficiencies in the latest cycle
200 West Saginaw Street, Ishpeming, MI
(906) 485-1061
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
127
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-05-01
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
0.86
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.38
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
5.06
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.46
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
6.03
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
234
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
76.54
Composite VBP score used to determine payment impact.
Payment multiplier
1.0250
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
5.11
Baseline 6.90% · Performance 6.31% · Measure score 5.11 · Achievement 5.11 · Improvement 2.62
Total nurse turnover
7.85
Baseline 32.53% · Performance 31.58% · Measure score 7.85 · Achievement 7.85 · Improvement 0.74
Adjusted total nurse staffing
10
Baseline 5.65 hours · Performance 6.27 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.33% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 1.92% · Lower 95% interval 6.02% |
| Discharge to community | 53.02% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 51.02% · Lower 95% interval 39.15% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 45 · Denominator 45 |
| Falls with major injury | 2.22% |
0.77%
1.5 pts worse
|
Numerator 1 · Denominator 45 |
| Discharge self-care score | 65.79% |
53.69%
12.1 pts better
|
Numerator 25 · Denominator 38 |
| Discharge mobility score | 71.05% |
50.94%
20.1 pts better
|
Numerator 27 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 2.22% |
2.29%
0.1 pts better
|
Numerator 1 · Denominator 45 · Adjusted rate 2.73% |
| Healthcare-associated infections requiring hospitalization | 6.31% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 0% · Lower 95% interval 2.91% |
| Staff COVID-19 vaccination coverage | 4.18% |
8.2%
4 pts worse
|
Numerator 11 · Denominator 263 |
| Staff flu vaccination coverage | 43.53% |
42%
1.5 pts better
|
Numerator 121 · Denominator 278 |
| Discharge function score | 78.95% |
56.45%
22.5 pts better
|
Numerator 30 · Denominator 38 |
| 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 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 13 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.1 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.5
0.8 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.7 · 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 100.0% · Q2 99.1% · Q3 100.0% · Q4 99.1% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
95.0%
4.2 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.1%
3.1 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.2% · Q3 7.4% · Q4 7.0% · 4Q avg 6.2% · 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 | 3.5% |
5.5%
2 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.0% · Q3 2.1% · Q4 5.9% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.9% |
19.6%
10.7 pts better
|
19.6%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.9% · Q3 9.3% · Q4 8.8% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.0% |
16.5%
0.5 pts worse
|
16.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 19.5% · Q3 12.9% · Q4 11.6% · 4Q avg 17.0% · 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 | 17.5% |
13.9%
3.6 pts worse
|
16.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 17.8% · Q3 20.5% · Q4 13.5% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.5% |
11.7%
2.8 pts worse
|
14.9%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 14.9% · Q3 15.2% · Q4 12.4% · 4Q avg 14.5% · 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 | 1.8% |
1.7%
0.1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.9% · Q3 0.9% · Q4 2.6% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.1% |
20.4%
2.7 pts worse
|
19.8%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 26.4% · Q3 17.9% · Q4 22.9% · 4Q avg 23.1% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.6%
0.4 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.4% · Q3 7.7% · Q4 3.1% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
82.8%
14.6 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 96.9% · Q3 97.2% · Q4 98.6% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.8% |
11.5%
1.3 pts worse
|
12.0%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.8% · Observed 11.4% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.3%
0.7 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 4.3% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
79.5%
16 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.1% |
24.2%
6.1 pts better
|
23.9%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.1% · Observed 14.3% · Expected 18.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-05 · Fire 2024-06-05
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-06-29 · Fire 2023-06-29
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-15
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-06-05
F · Potential for more than minimal harm
2025-05-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-05-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-05-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-04
E · Potential for more than minimal harm
2025-05-15
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 2025-06-03
E · Potential for more than minimal harm
2025-05-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-05-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-16
E · Potential for more than minimal harm
2025-05-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-05-15
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-06-03
F · Potential for more than minimal harm
2024-06-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-06-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-06-05
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 2024-07-12
F · Potential for more than minimal harm
2023-06-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-20
F · Potential for more than minimal harm
2023-06-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-06-29
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 2023-07-20
E · Potential for more than minimal harm
2023-06-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-20
Inspection history
Recent health citations
G · Actual harm
2024-06-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-12
G · Actual harm
2024-06-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-12
G · Actual harm
2024-06-05
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 2024-07-12
D · Potential for more than minimal harm
2024-06-05
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-07-12
E · Potential for more than minimal harm
2023-06-29
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-29
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 2023-07-28
D · Potential for more than minimal harm
2023-06-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-07-28
Penalties and ownership
What sits behind the stars
Ownership
Marquette County Medical Care
Operational/Managerial Control · Organization
Perry, Denise
Operational/Managerial Control · Individual
Perry, Denise
Corporate Director · Individual
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