Cycle 1
Health 2025-09-10 · Fire 2025-09-10
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Grand Rapids, MI
Corewell Health Rehabilitation & Nursing Center -
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
4118 Kalamazoo Ave SE, Grand Rapids, MI
(616) 486-7002
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
165
Certified beds
Average residents
141
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Corewell Health
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.39
Registered nurse staffing
LPN hours / resident day
1.08
Licensed practical nurse staffing
Aide hours / resident day
2.82
Nurse aide staffing
Weekend hours
4.58
Weekend nurse staffing
RN turnover
17%
Annual RN turnover
Total nurse turnover
47%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 74.9% |
95.0%
20.1 pts worse
|
93.4%
18.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.9% |
95.0%
7.1 pts worse
|
95.5%
7.6 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.1%
2.2 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 4.4% |
5.5%
1.1 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
19.6%
1.6 pts worse
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
16.5%
1 pts better
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.0% |
13.9%
3.9 pts better
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.3% |
11.7%
0.4 pts better
|
14.9%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
1.7%
1.3 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.6% |
20.4%
4.2 pts worse
|
19.8%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
5.6%
1.4 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.1% |
82.8%
7.3 pts better
|
81.7%
8.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.0% |
11.5%
2.5 pts worse
|
12.0%
2 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
79.5%
15.1 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
24.2%
5.7 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-07-12 · Fire 2023-07-12
9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 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
2025-09-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-09-10
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 2025-11-21
E · Potential for more than minimal harm
2025-09-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-09-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-09-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-11-21
E · Potential for more than minimal harm
2024-08-15
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 2024-09-19
E · Potential for more than minimal harm
2024-08-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-08-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-19
E · Potential for more than minimal harm
2023-07-12
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 2023-08-07
D · Potential for more than minimal harm
2023-07-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-09-10
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 2025-10-10
D · Potential for more than minimal harm
2025-04-29
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 2025-05-30
D · Potential for more than minimal harm
2025-04-29
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 2025-05-30
D · Potential for more than minimal harm
2025-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-11
D · Potential for more than minimal harm
2024-12-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-08-15
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-09-19
D · Potential for more than minimal harm
2024-08-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-19
D · Potential for more than minimal harm
2024-08-15
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-09-19
D · Potential for more than minimal harm
2024-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-19
D · Potential for more than minimal harm
2024-03-12
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 2024-04-02
D · Potential for more than minimal harm
2023-11-07
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 2023-11-30
F · Potential for more than minimal harm
2023-07-12
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 2023-08-07
E · Potential for more than minimal harm
2023-07-12
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 2023-08-07
D · Potential for more than minimal harm
2023-07-12
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 2023-08-07
D · Potential for more than minimal harm
2023-07-12
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 2023-08-07
D · Potential for more than minimal harm
2023-07-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-07
D · Potential for more than minimal harm
2023-07-12
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 2023-08-07
D · Potential for more than minimal harm
2023-07-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-08-07
C · Minimal harm
2023-07-12
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 2023-08-07
Penalties and ownership
What sits behind the stars
Ownership
Corewell Health
5% Or Greater Direct Ownership Interest · Organization
Beg, Simin
Corporate Director · Individual
Boettcher, Iris
Operational/Managerial Control · Individual
Boss, Michelle
Operational/Managerial Control · Individual
Bragg, Talawnda
Corporate Director · Individual
Buckley, John
Corporate Director · Individual
Corewell Health
Operational/Managerial Control · Organization
Cox, Matthew
Corporate Officer · Individual
Doornbos, Mary
Corporate Director · Individual
Ferrell-Robinson, Lynnette
Corporate Director · Individual
Freese Decker, Christina
Corporate Officer · Individual
Hofman, Ronald
Corporate Director · Individual
Marlow, Tamila
Operational/Managerial Control · Individual
Pakkala, Karen
Corporate Officer · Individual
Pink, Bill
Corporate Director · Individual
Port, Christopher
Corporate Director · Individual
Torres, Johannie
Corporate Director · Individual
Waalkes, Annica
Corporate Director · Individual
Watson, Sam
Corporate Director · Individual
Wilson, Mark
Corporate Director · Individual
Nearby options
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1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $134,605 in total fines with 44 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
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5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Optalis Health & Rehabilitation of Wyoming
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3-star overall rating with 3-star inspections with 16 recent health deficiencies
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