Cycle 1
Health 2025-04-16 · Fire 2025-04-16
4 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Grand Rapids, MI
Mary Free Bed Sub-Acute Rehabilitation
4-star overall rating with 3-star inspections with 4 recent health deficiencies
235 Wealthy Street SE, 5th Floor, Grand Rapids, MI
(616) 840-8931
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trinity Health
Operator or chain grouping
Approved since
2015-09-30
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
20 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.40
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.27
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.79
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
5.46
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.67
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.78
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.68
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.41
CMS adjusted RN staffing hours
Adjusted total hours
5.51
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
421
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
70.28
Composite VBP score used to determine payment impact.
Payment multiplier
1.0225
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.60
Baseline 22.06% · Performance 20.00% · Measure score 3.60 · Achievement 3.10 · Improvement 3.60
Healthcare-associated infections
10
Baseline 5.10% · Performance 4.57% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
4.51
Baseline 48.05% · Performance 45.24% · Measure score 4.51 · Achievement 4.51 · Improvement 0.71
Adjusted total nurse staffing
10
Baseline 5.71 hours · Performance 6.07 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.13% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 639 · Observed rate 9.23% · Lower 95% interval 8.13% |
| Discharge to community | 78.17% |
50.57%
27.6 pts better
|
Better than the National Rate · Eligible stays 651 · Observed rate 74.96% · Lower 95% interval 75.34% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 99.45% |
95.27%
4.2 pts better
|
Numerator 361 · Denominator 363 |
| Falls with major injury | 0.55% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 363 |
| Discharge self-care score | 51.29% |
53.69%
2.4 pts worse
|
Numerator 159 · Denominator 310 |
| Discharge mobility score | 55.16% |
50.94%
4.2 pts better
|
Numerator 171 · Denominator 310 |
| Pressure ulcers or injuries, new or worsened | 2.2% |
2.29%
0.1 pts better
|
Numerator 8 · Denominator 363 · Adjusted rate 3.22% |
| Healthcare-associated infections requiring hospitalization | 4.57% |
7.12%
2.5 pts better
|
Better than the National Rate · Eligible stays 331 · Observed rate 2.42% · Lower 95% interval 2.93% |
| Staff COVID-19 vaccination coverage | 3.48% |
8.2%
4.7 pts worse
|
Numerator 4 · Denominator 115 |
| Staff flu vaccination coverage | 98.26% |
42%
56.3 pts better
|
Numerator 113 · Denominator 115 |
| Discharge function score | 51.61% |
56.45%
4.8 pts worse
|
Numerator 160 · Denominator 310 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 354 · Denominator 354 |
| 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 | 39.5% |
25.2%
14.3 pts better
|
Numerator 79 · Denominator 200 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
82.8%
15.1 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.7% · Q2 99.5% · Q3 99.4% · Q4 92.5% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
11.5%
2.3 pts worse
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 12.7% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.3%
1 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.3% · Q3 0.0% · Q4 0.3% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
79.5%
20 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
24.2%
4.1 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 17.5% · Expected 20.7% · 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: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-22 · Fire 2023-03-22
5 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
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
2023-03-22
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-28
Inspection history
Recent health citations
G · Actual harm
2025-10-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-17
F · Potential for more than minimal harm
2025-04-16
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 2025-05-26
F · Potential for more than minimal harm
2025-04-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-26
D · Potential for more than minimal harm
2025-04-16
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 2025-03-27
F · Potential for more than minimal harm
2024-05-16
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 2024-06-10
C · Minimal harm
2024-05-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-06-10
C · Minimal harm
2024-05-16
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-06-10
F · Potential for more than minimal harm
2023-03-22
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 2023-04-28
D · Potential for more than minimal harm
2023-03-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-22
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 2022-05-12
D · Potential for more than minimal harm
2023-03-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-04-28
B · Minimal harm
2023-03-22
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-04-28
Penalties and ownership
What sits behind the stars
Ownership
Bowens, Marcus
Corporate Director · Individual
Brasser, Bruce
Corporate Director · Individual
Cheslek, Ingrid
Corporate Director · Individual
Cudney, Kiersten
Operational/Managerial Control · Individual
Guzman, Nathaniel
Corporate Director · Individual
Johnson, Stacey
Corporate Director · Individual
Johnson, Stacey
Corporate Officer · Individual
Latovick, Pamela
Corporate Director · Individual
Mary Free Bed Rehabilitation Hospital
5% Or Greater Indirect Ownership Interest · Organization
Pennington, Leeann
Corporate Director · Individual
Treat, Meg
Corporate Director · Individual
Trinity Continuing Care Services
5% Or Greater Indirect Ownership Interest · Organization
Trinity Health Corporation
5% Or Greater Indirect Ownership Interest · Organization
Wang, Ralph
Corporate Director · Individual
Wang, Ralph
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Corewell Health Grand Rapids Hospitals Rehabilitat
Grand Rapids, MI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Clark Retirement Community
Grand Rapids, MI
1-star overall rating with 2-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
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
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