Cycle 1
Health 2025-07-09 · Fire 2025-07-09
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Grand Rapids, MI
Corewell Health Rehabilitation & Nursing Center -
5-star overall rating with 5-star inspections with 1 recent health deficiencies
1001 Leffingwell Avenue NE, Grand Rapids, MI
(616) 267-4800
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
80
Certified beds
Average residents
61
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Corewell Health
Operator or chain grouping
Approved since
2023-05-02
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
1.80
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
5.34
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.90
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.54
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
1.31
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.43
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.83
CMS adjusted RN staffing hours
Adjusted total hours
5.44
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
160
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
80.78
Composite VBP score used to determine payment impact.
Payment multiplier
1.0260
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.23
Performance 19.47% · Measure score 4.23 · Achievement 4.23 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
10
Performance 4.64% · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
10
Performance 6.68 hours · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.29% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 215 · Observed rate 10.23% · Lower 95% interval 8.05% |
| Discharge to community | 67.83% |
50.57%
17.3 pts better
|
Better than the National Rate · Eligible stays 212 · Observed rate 63.21% · Lower 95% interval 58.23% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 98.78% |
95.27%
3.5 pts better
|
Numerator 162 · Denominator 164 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 164 |
| Discharge self-care score | 63.24% |
53.69%
9.6 pts better
|
Numerator 86 · Denominator 136 |
| Discharge mobility score | 73.53% |
50.94%
22.6 pts better
|
Numerator 100 · Denominator 136 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 164 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 4.64% |
7.12%
2.5 pts better
|
No Different than the National Rate · Eligible stays 181 · Observed rate 1.66% · Lower 95% interval 2.63% |
| Staff COVID-19 vaccination coverage | 5.95% |
8.2%
2.2 pts worse
|
Numerator 10 · Denominator 168 |
| Staff flu vaccination coverage | 96.86% |
42%
54.9 pts better
|
Numerator 154 · Denominator 159 |
| Discharge function score | 74.26% |
56.45%
17.8 pts better
|
Numerator 101 · Denominator 136 |
| Transfer of health information to provider | 97.1% |
95.95%
1.1 pts better
|
Numerator 67 · Denominator 69 |
| Transfer of health information to patient | 57.3% |
96.28%
39 pts worse
|
Numerator 51 · Denominator 89 |
| Resident COVID-19 vaccinations up to date | 27.78% |
25.2%
2.6 pts better
|
Numerator 20 · Denominator 72 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
95.0%
3.2 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.1%
2.3 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.4% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 13.6% |
5.5%
8.1 pts worse
|
5.4%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
19.6%
0.4 pts better
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.0% |
16.5%
6.5 pts better
|
16.7%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.9% |
11.7%
0.8 pts better
|
14.9%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.9%
0.7 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.2% |
20.4%
3.8 pts worse
|
19.8%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.2% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
5.6%
2 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
82.8%
15.4 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 97.5% · Q3 97.7% · Q4 98.8% · 4Q avg 98.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
11.5%
0.6 pts worse
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 11.5% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.3%
0.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 1.0% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.3% |
79.5%
19.8 pts better
|
79.7%
19.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.1% |
24.2%
1.1 pts better
|
23.9%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 20.3% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-04-05 · Fire 2023-04-05
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-04-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-01
E · Potential for more than minimal harm
2023-04-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-01
E · Potential for more than minimal harm
2023-04-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-05-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-09
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-07-17
Penalties and ownership
What sits behind the stars
Ownership
Corewell Health
5% Or Greater Indirect Ownership Interest · Organization
Spectrum Health Continuing Care
5% Or Greater Direct Ownership Interest · Organization
Beg, Simin
Corporate Director · Individual
Boettcher, Iris
Operational/Managerial Control · Individual
Bragg, Talawnda
Corporate Director · Individual
Buckley, John
Corporate Director · Individual
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
Pakkala, Karen
Operational/Managerial Control · Individual
Pakkala, Karen
Corporate Officer · Individual
Pink, Bill
Corporate Director · Individual
Port, Christopher
Corporate Director · Individual
Spectrum Health Continuing Care
Operational/Managerial Control · Organization
Torres, Johannie
Corporate Director · Individual
Waalkes, Annica
Corporate Director · Individual
Watson, Sam
Corporate Director · Individual
Wilson, Mark
Corporate Director · Individual
Zank, Ryan
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Medilodge of Grand Rapids
Grand Rapids, MI
1-star overall rating with 1-star inspections with $57,658 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Optalis Health & Rehabilitation at Leonard
Grand Rapids, MI
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Porter Hills Health Center
Grand Rapids, MI
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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