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
Chain footprint
8 facilities
Chain averages 4 overall / 4 health / 5 staffing / 5 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
1.39
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.82
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
5.29
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.47
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.58
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.92
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.40
CMS adjusted RN staffing hours
Adjusted total hours
5.32
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,767
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9888
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.75
Performance 20.62% · Measure score 1.75 · Achievement 1.75 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.04
Baseline 5.55% · Performance 6.93% · Measure score 3.04 · Achievement 3.04 · Improvement 0
Total nurse turnover
2.91
Baseline 54.40% · Performance 51.80% · Measure score 2.91 · Achievement 2.91 · Improvement 0.38
Adjusted total nurse staffing
6.34
Baseline 4.98 hours · Performance 4.88 hours · Measure score 6.34 · Achievement 6.34 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.37% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 14.12% · Lower 95% interval 7.78% |
| Discharge to community | 59.26% |
50.57%
8.7 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 52.33% · Lower 95% interval 48.6% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 75 · Denominator 75 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 75 |
| Discharge self-care score | 57.38% |
53.69%
3.7 pts better
|
Numerator 35 · Denominator 61 |
| Discharge mobility score | 40.98% |
50.94%
10 pts worse
|
Numerator 25 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 1.33% |
2.29%
1 pts better
|
Numerator 1 · Denominator 75 · Adjusted rate 1.63% |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 6.25% · Lower 95% interval 4.1% |
| Staff COVID-19 vaccination coverage | 5.34% |
8.2%
2.9 pts worse
|
Numerator 14 · Denominator 262 |
| Staff flu vaccination coverage | 95.11% |
42%
53.1 pts better
|
Numerator 253 · Denominator 266 |
| Discharge function score | 55.74% |
56.45%
0.7 pts worse
|
Numerator 34 · Denominator 61 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 59 · Denominator 59 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 24.44% |
25.2%
0.8 pts worse
|
Numerator 11 · Denominator 45 |
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 · Adjusted 1.8 · Observed 1.6 · 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 1.2 · Expected 1.5 · Used in QM five-star |
| 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 · Q1 95.7% · Q2 72.3% · Q3 63.0% · Q4 68.8% · 4Q avg 74.9% |
| 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 · 4Q avg 87.9% |
| 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 · Q1 0.9% · Q2 1.7% · Q3 0.8% · Q4 0.0% · 4Q avg 0.9% · 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 | 4.4% |
5.5%
1.1 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.3% · Q3 5.5% · Q4 3.8% · 4Q avg 4.4% |
| 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 · Q1 21.1% · Q2 20.4% · Q3 20.7% · Q4 22.6% · 4Q avg 21.2% |
| 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 · Q1 20.5% · Q2 15.0% · Q3 13.4% · Q4 13.6% · 4Q avg 15.5% · 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 | 10.0% |
13.9%
3.9 pts better
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q3 13.2% · Q4 4.2% · 4Q avg 10.0% · Used in QM five-star |
| 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 · Q1 11.9% · Q2 12.1% · Q3 11.1% · Q4 10.1% · 4Q avg 11.3% · Used in QM five-star |
| 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 · Q1 0.9% · Q2 0.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| 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 · Q1 3.4% · Q2 5.0% · Q3 0.0% · Q4 3.6% · 4Q avg 3.0% · Used in QM five-star |
| 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 · Q1 26.8% · Q2 26.5% · Q3 23.1% · Q4 21.8% · 4Q avg 24.6% |
| 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 · Q1 3.8% · Q2 3.8% · Q3 4.5% · Q4 4.6% · 4Q avg 4.2% · Used in QM five-star |
| 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 · Q1 96.0% · Q2 88.6% · Q3 86.6% · Q4 90.9% · 4Q avg 90.1% |
| 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 · Adjusted 14.0% · Observed 15.1% · Expected 12.0% · Used in QM five-star |
| 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 · Q1 2.5% · Q2 0.9% · Q3 0.8% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| 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 · 4Q avg 94.6% |
| 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 · Adjusted 18.5% · Observed 17.8% · Expected 23.0% · Used in QM five-star |
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
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#3
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3-star overall rating with 3-star inspections with 16 recent health deficiencies
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