22 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Kalamazoo, MI
1-star overall rating with 1-star inspections with $18,274 in total fines with 22 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
8290 W C Ave, Kalamazoo, MI
(269) 343-2587
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
100
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avon Healthcare
Operator or chain grouping
Approved since
1976-06-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 2 overall / 2 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
RN hours / resident day
0.47
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Program rank
12,277
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.05
Performance 20.95% · Measure score 1.05 · Achievement 1.05 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Baseline 7.03% · Performance 8.54% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.01
Baseline 43.68% · Performance 59.55% · Measure score 1.01 · Achievement 1.01 · Improvement 0
Adjusted total nurse staffing
3.17
Baseline 4.50 hours · Performance 3.98 hours · Measure score 3.17 · Achievement 3.17 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.94% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 13.79% · Lower 95% interval 8.31% |
| Discharge to community | 45.31% |
50.57%
5.3 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 41.38% · Lower 95% interval 33.37% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.45% |
95.27%
0.2 pts better
|
Numerator 42 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 34.62% |
53.69%
19.1 pts worse
|
Numerator 9 · Denominator 26 |
| Discharge mobility score | 42.31% |
50.94%
8.6 pts worse
|
Numerator 11 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 44 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.54% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 11.9% · Lower 95% interval 4.79% |
| Staff COVID-19 vaccination coverage | 9.45% |
8.2%
1.2 pts better
|
Numerator 12 · Denominator 127 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 46.15% |
56.45%
10.3 pts worse
|
Numerator 12 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
95.0%
4.7 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| 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 | 4.9% |
3.1%
1.8 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 8.5% · Q3 4.3% · Q4 1.4% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
4.1%
0.8 pts worse
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 5.1% · Q3 4.8% · Q4 7.7% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.5%
0.2 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 7.5% · Q3 5.4% · Q4 0.0% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.8% |
19.6%
7.2 pts worse
|
19.6%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 28.3% · Q3 25.9% · Q4 27.4% · 4Q avg 26.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.1% |
16.5%
12.6 pts worse
|
16.7%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 31.6% · Q3 30.4% · Q4 23.9% · 4Q avg 29.1% · 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 | 10.4% |
13.9%
3.5 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 16.7% · Q3 6.8% · Q4 0.0% · 4Q avg 10.4% · 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 · Q1 24.1% · Q2 12.8% · Q3 11.3% · Q4 3.4% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 | 24.5% |
20.4%
4.1 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 28.6% · Q3 22.7% · Q4 23.0% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.6%
2 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.9% · Q3 1.4% · Q4 3.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
82.8%
11.6 pts better
|
81.7%
12.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.8% · Q2 96.4% · Q3 99.1% · Q4 99.1% · 4Q avg 94.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
11.5%
2.1 pts worse
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 14.6% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.3%
1 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.2% · Q3 2.8% · Q4 1.6% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.3% |
79.5%
18.8 pts better
|
79.7%
18.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
24.2%
0.6 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 24.4% · Expected 23.5% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
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 2025-04-02
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-02
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-02
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-02
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-04-02
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-02
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-27
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 2024-05-27
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-27
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-27
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-27
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 2024-05-27
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-27
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-12
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-12
Inspection history
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-07
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-11-19
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-15
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-05-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-26
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-26
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-05-15
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-26
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-26
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-26
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-26
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-03-26
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-26
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-26
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-15
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 2025-03-26
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-15
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 2025-03-26
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 2025-05-15
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-05-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-29
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-29
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-01-29
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-01-29
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-29
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-19
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 2024-09-19
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-09-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-19
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-09-19
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-05-27
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-05-27
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-05-27
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-27
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-27
Health
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.
Corrected 2024-05-27
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-05-27
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-27
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-05-27
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-27
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 2024-05-27
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-05-27
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-05-27
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-16
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-01-16
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-16
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-16
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-16
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-16
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-16
Health
Provide appropriate foot care.
Corrected 2024-01-16
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-08
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-08
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-08
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 2023-05-08
Penalties and ownership
Payment Denial · denial start 2025-10-16 · 34 days
34 day denial
Fine · fine $18,274
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Organization
Corporate Officer · Individual
W-2 Managing Employee · Individual
Contracted Managing Employee · Individual
Nearby options
Plainwell, MI
1-star overall rating with 1-star inspections with abuse icon flag with $171,837 in total fines with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Kalamazoo, MI
1-star overall rating with 1-star inspections with $157,270 in total fines with 20 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Kalamazoo, MI
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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