Cycle 1
Health 2025-06-12 · Fire 2025-06-12
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mattawan, MI
Bronson Commons
4-star overall rating with 3-star inspections with 11 recent health deficiencies
23332 Red Arrow Highway, Mattawan, MI
(269) 283-5200
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
91
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-08-15
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
1.27
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.31
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.92
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.89
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.44
CMS adjusted RN staffing hours
Adjusted total hours
4.87
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,406
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.87
Composite VBP score used to determine payment impact.
Payment multiplier
1.0120
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.12
Baseline 18.03% · Performance 19.52% · Measure score 4.12 · Achievement 4.12 · Improvement 0
Healthcare-associated infections
9.12
Baseline 4.84% · Performance 5.11% · Measure score 9.12 · Achievement 9.12 · Improvement 0
Total nurse turnover
4.01
Baseline 50.00% · Performance 47.29% · Measure score 4.01 · Achievement 4.01 · Improvement 0.58
Adjusted total nurse staffing
5.49
Baseline 3.87 hours · Performance 4.64 hours · Measure score 5.49 · Achievement 5.49 · Improvement 3.55
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.91% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 445 · Observed rate 9.44% · Lower 95% interval 8.07% |
| Discharge to community | 63.97% |
50.57%
13.4 pts better
|
Better than the National Rate · Eligible stays 418 · Observed rate 63.16% · Lower 95% interval 59.93% |
| Medicare spending per beneficiary | 0.54 |
1.02
0.5 pts better
|
|
| Drug regimen review with follow-up | 96.54% |
95.27%
1.3 pts better
|
Numerator 251 · Denominator 260 |
| Falls with major injury | 0.38% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 260 |
| Discharge self-care score | 36.68% |
53.69%
17 pts worse
|
Numerator 84 · Denominator 229 |
| Discharge mobility score | 34.06% |
50.94%
16.9 pts worse
|
Numerator 78 · Denominator 229 |
| Pressure ulcers or injuries, new or worsened | 1.16% |
2.29%
1.1 pts better
|
Numerator 3 · Denominator 259 · Adjusted rate 1.56% |
| Healthcare-associated infections requiring hospitalization | 5.11% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 239 · Observed rate 2.51% · Lower 95% interval 3.25% |
| Staff COVID-19 vaccination coverage | 14.65% |
8.2%
6.5 pts better
|
Numerator 23 · Denominator 157 |
| Staff flu vaccination coverage | 98.27% |
42%
56.3 pts better
|
Numerator 170 · Denominator 173 |
| Discharge function score | 38.43% |
56.45%
18 pts worse
|
Numerator 88 · Denominator 229 |
| Transfer of health information to provider | 73.04% |
95.95%
22.9 pts worse
|
Numerator 84 · Denominator 115 |
| Transfer of health information to patient | 42.62% |
96.28%
53.7 pts worse
|
Numerator 52 · Denominator 122 |
| Resident COVID-19 vaccinations up to date | 40.74% |
25.2%
15.5 pts better
|
Numerator 55 · Denominator 135 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.5% |
95.0%
2.5 pts worse
|
93.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 90.9% · Q3 90.6% · Q4 92.2% · 4Q avg 92.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
95.0%
1.6 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.1%
1.1 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.8% · Q3 5.7% · Q4 5.9% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
4.1%
3.1 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 2.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
5.5%
0.9 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 11.1% · Q3 5.1% · Q4 4.7% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.7% |
19.6%
2.1 pts worse
|
19.6%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 24.4% · Q3 20.0% · Q4 25.0% · 4Q avg 21.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.4% |
16.5%
0.9 pts worse
|
16.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 16.7% · Q3 17.6% · Q4 15.8% · 4Q avg 17.4% · 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 | 27.9% |
13.9%
14 pts worse
|
16.3%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.5% |
11.7%
4.8 pts worse
|
14.9%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 9.3% · Q3 25.6% · Q4 18.6% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.1% |
0.9%
2.2 pts worse
|
1.0%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 3.8% · Q3 1.3% · Q4 1.4% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
1.7%
2.5 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 1.8% · Q3 5.8% · Q4 2.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
20.4%
5.9 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 24.5% · Q3 22.7% · Q4 38.4% · 4Q avg 26.3% |
| 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 0.0% · Q2 8.8% · Q3 7.3% · Q4 9.2% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
82.8%
8.4 pts better
|
81.7%
9.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 91.2% · Q3 91.2% · Q4 89.4% · 4Q avg 91.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.9% |
11.5%
4.4 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 14.7% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.5% · Q4 0.4% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
79.5%
17.4 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
24.2%
0.7 pts worse
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 21.1% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-04-19 · Fire 2023-04-19
5 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-13
E · Potential for more than minimal harm
2024-05-16
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 2024-07-13
E · Potential for more than minimal harm
2024-05-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-13
E · Potential for more than minimal harm
2024-05-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-13
E · Potential for more than minimal harm
2023-04-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-26
Inspection history
Recent health citations
G · Actual harm
2025-06-12
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 2025-07-22
E · Potential for more than minimal harm
2025-06-12
F585 · Resident Rights Deficiencies
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 2025-07-22
D · Potential for more than minimal harm
2025-06-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-06-12
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-06-12
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-06-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-06-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-06-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-06-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-06-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-29
C · Minimal harm
2025-06-12
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-07-22
D · Potential for more than minimal harm
2024-05-16
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-25
F · Potential for more than minimal harm
2023-04-19
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 2023-05-26
D · Potential for more than minimal harm
2023-04-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-19
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 2023-05-26
D · Potential for more than minimal harm
2023-04-19
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-26
Penalties and ownership
What sits behind the stars
$0
2025-06-12
Payment Denial
Payment Denial · denial start 2025-07-08 · 21 days
21 day denial
Ownership
Bronson Health Care Group Inc
5% Or Greater Direct Ownership Interest · Organization
Allen, Richard
Corporate Director · Individual
Arnan, Martinson
Corporate Officer · Individual
Chen-Zhang, Lynn
Corporate Director · Individual
Colegrove, Leigh
Operational/Managerial Control · Individual
Coleman, Genevieve
Corporate Director · Individual
East, Rebecca
Corporate Officer · Individual
Eaton, Patricia
Operational/Managerial Control · Individual
Eberts, Randall
Corporate Director · Individual
Ewbank, Jodee
Operational/Managerial Control · Individual
Falahee, James
Corporate Officer · Individual
Gibson, Scott
Corporate Director · Individual
Goel, Ashutosh
Operational/Managerial Control · Individual
Gonzalez, Jorge
Corporate Director · Individual
Hermsen, Katharine
Corporate Director · Individual
Hoffman, Kellie
Corporate Director · Individual
Hunt, Brenda
Corporate Director · Individual
Johnson, Cheryl
Corporate Officer · Individual
Karre, Nelson
Corporate Director · Individual
Liggins, James
Corporate Director · Individual
Lins, Steven
Corporate Director · Individual
Lubwama, Grace
Corporate Director · Individual
Manns, Bill
Corporate Officer · Individual
Nicholson, Robert
Corporate Director · Individual
Nyberg, Neil
Corporate Director · Individual
Odar, Michael
Corporate Director · Individual
Parfet, Donald
Corporate Director · Individual
Reinoehl, Susan
Corporate Officer · Individual
Sanchez, Hugh
Operational/Managerial Control · Individual
Sangali, Christine
Operational/Managerial Control · Individual
Sharma, Namita
Corporate Director · Individual
Stewart, Erick
Corporate Director · Individual
Washington, Luther Marshall
Corporate Director · Individual
Way, Mike
Corporate Officer · Individual
Worgess, Rachel
Corporate Director · Individual
Workman, William
Corporate Director · Individual
Nearby options
Other facilities in reach
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Kalamazoo, MI
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Friendship Village
Kalamazoo, MI
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Medilodge of Westwood
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
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