Cycle 1
Health 2025-12-04 · Fire 2025-12-04
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Ironwood, MI
Westgate Nursing & Rehabilitation Community
3-star overall rating with 3-star inspections with $59,566 in total fines with 6 recent health deficiencies
1500 North Lowell Street, Ironwood, MI
(906) 932-3867
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atrium Centers
Operator or chain grouping
Approved since
1995-12-13
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
0.68
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.69
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
4.45
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,575
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9854
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.47% · Performance 21.67% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.64
Baseline 5.54% · Performance 7.34% · Measure score 1.64 · Achievement 1.64 · Improvement 0
Total nurse turnover
6.14
Baseline 28.30% · Performance 38.60% · Measure score 6.14 · Achievement 6.14 · Improvement 0
Adjusted total nurse staffing
3.98
Baseline 3.41 hours · Performance 4.21 hours · Measure score 3.98 · Achievement 3.98 · Improvement 2.87
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.8% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 15.79% · Lower 95% interval 8.36% |
| Discharge to community | 39.23% |
50.57%
11.3 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 30.36% · Lower 95% interval 29.57% |
| Medicare spending per beneficiary | 1.46 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 93.33% |
95.27%
1.9 pts worse
|
Numerator 28 · Denominator 30 |
| Falls with major injury | 3.33% |
0.77%
2.6 pts worse
|
Numerator 1 · Denominator 30 |
| Discharge self-care score | 40.91% |
53.69%
12.8 pts worse
|
Numerator 9 · Denominator 22 |
| Discharge mobility score | 40.91% |
50.94%
10 pts worse
|
Numerator 9 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 1 · Denominator 30 · Adjusted rate 3.93% |
| Healthcare-associated infections requiring hospitalization | 7.34% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 7.89% · Lower 95% interval 3.74% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 82 |
| Staff flu vaccination coverage | 28.57% |
42%
13.4 pts worse
|
Numerator 24 · Denominator 84 |
| Discharge function score | 45.45% |
56.45%
11 pts worse
|
Numerator 10 · Denominator 22 |
| 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 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.7 |
1.5
3.2 pts worse
|
1.8
2.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.7 · Observed 4.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
95.0%
3.6 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 96.4% · Q3 100.0% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
95.0%
3.3 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.1% |
3.1%
4 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 9.1% · Q3 7.5% · Q4 6.0% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.7% |
4.1%
2.6 pts worse
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.2% · Q3 4.2% · Q4 6.8% · 4Q avg 6.7% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.5%
1.6 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.6% · Q3 2.0% · Q4 2.2% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.2% |
19.6%
2.4 pts better
|
19.6%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 16.7% · Q3 16.0% · Q4 21.3% · 4Q avg 17.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.3% |
16.5%
17.8 pts worse
|
16.7%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 31.1% · Q3 32.6% · Q4 44.4% · 4Q avg 34.3% · 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 | 14.5% |
13.9%
0.6 pts worse
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 14.9% · Q3 16.6% · Q4 17.3% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.3% |
11.7%
4.6 pts worse
|
14.9%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 25.0% · Q3 22.9% · Q4 13.0% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.7%
0.7 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.8% · Q3 1.9% · Q4 4.1% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.2% |
20.4%
1.2 pts better
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 24.1% · Q3 19.4% · Q4 17.7% · 4Q avg 19.2% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
5.6%
3.9 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 4.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.5% |
82.8%
3.7 pts better
|
81.7%
4.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 72.0% · Q2 87.5% · Q3 95.7% · Q4 90.6% · 4Q avg 86.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 28.2% |
11.5%
16.7 pts worse
|
12.0%
16.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.2% · Observed 28.0% · Expected 11.1% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.9% |
79.5%
5.6 pts worse
|
79.7%
5.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.1% |
24.2%
12.9 pts worse
|
23.9%
13.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.1% · Observed 36.0% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-11 · Fire 2024-09-11
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-09-14 · Fire 2023-09-14
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-11
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-09-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-04
F · Potential for more than minimal harm
2023-09-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-09-14
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-09-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-09-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-09-14
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-14
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 2023-10-10
E · Potential for more than minimal harm
2023-09-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-14
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2023-10-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-04
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 2026-01-06
E · Potential for more than minimal harm
2025-12-04
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 2026-01-06
E · Potential for more than minimal harm
2025-12-04
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-12-04
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 2026-01-06
D · Potential for more than minimal harm
2025-12-04
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
2025-06-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-01
G · Actual harm
2024-09-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-09-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-20
D · Potential for more than minimal harm
2024-09-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-07
G · Actual harm
2023-09-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-10
G · Actual harm
2023-09-14
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 2023-10-10
F · Potential for more than minimal harm
2023-09-14
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 2023-10-10
E · Potential for more than minimal harm
2023-09-14
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-14
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 2023-10-10
D · Potential for more than minimal harm
2023-09-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-14
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 2023-10-10
D · Potential for more than minimal harm
2023-09-14
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 2023-10-10
C · Minimal harm
2023-09-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-10
Penalties and ownership
What sits behind the stars
$44,680
2024-09-11
Fine
Fine · fine $44,680
Fine
$7,443
2023-09-14
Fine
Fine · fine $7,443
Fine
$7,443
2023-09-14
Fine
Fine · fine $7,443
Fine
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 Director · Individual
Finney, Donald
Corporate Officer · Individual
Lockhart, Dennis
W-2 Managing Employee · Individual
Watt, Heather
Operational/Managerial Control · Individual
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#3
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