Cycle 1
Health 2025-05-08 · Fire 2025-05-08
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Holland, MI
Medilodge of Holland
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1221 East 16th, Holland, MI
(616) 396-7095
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
77
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Medilodge
Operator or chain grouping
Approved since
2008-03-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
50 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 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
0.78
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.77
CMS adjusted RN staffing hours
Adjusted total hours
3.90
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,222
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9903
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
2.27
Baseline 5.78% · Performance 7.16% · Measure score 2.27 · Achievement 2.27 · Improvement 0
Total nurse turnover
4.98
Baseline 38.75% · Performance 43.33% · Measure score 4.98 · Achievement 4.98 · Improvement 0
Adjusted total nurse staffing
3.84
Baseline 4.42 hours · Performance 4.17 hours · Measure score 3.84 · Achievement 3.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.44% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 13.73% · Lower 95% interval 7.84% |
| Discharge to community | 51.55% |
50.57%
1 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 45.65% · Lower 95% interval 40.66% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.77% |
95.27%
1.5 pts better
|
Numerator 30 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 72.73% |
53.69%
19 pts better
|
Numerator 16 · Denominator 22 |
| Discharge mobility score | 59.09% |
50.94%
8.2 pts better
|
Numerator 13 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.16% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 30 · Observed rate 6.67% · Lower 95% interval 3.95% |
| Staff COVID-19 vaccination coverage | 2.65% |
8.2%
5.5 pts worse
|
Numerator 3 · Denominator 113 |
| Staff flu vaccination coverage | 16.86% |
42%
25.1 pts worse
|
Numerator 29 · Denominator 172 |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 14 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
95.0%
1.6 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 98.3% · Q3 100.0% · Q4 91.5% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
95.0%
3.5 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.1%
1.6 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 5.0% · Q3 7.0% · Q4 3.4% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.7% |
4.1%
2.6 pts worse
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 12.2% · Q4 10.3% · 4Q avg 6.7% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.5%
0.2 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 9.8% · Q3 2.4% · Q4 0.0% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.9% |
19.6%
1.3 pts worse
|
19.6%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 25.0% · Q3 16.7% · Q4 20.8% · 4Q avg 20.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
16.5%
1.9 pts worse
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 16.2% · Q3 17.1% · Q4 20.5% · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.4% |
0.1%
0.3 pts worse
|
0.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.0% |
13.9%
5.9 pts better
|
16.3%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.6% |
11.7%
7.1 pts better
|
14.9%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 2.2% · Q3 5.0% · Q4 4.4% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.7%
0.8 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.2% |
20.4%
2.8 pts worse
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 16.7% · Q3 26.5% · Q4 22.8% · 4Q avg 23.2% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.6%
1.5 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.9% · Q3 4.1% · Q4 3.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.1% |
82.8%
6.3 pts better
|
81.7%
7.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 88.0% · Q3 93.9% · Q4 82.5% · 4Q avg 89.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.5% |
11.5%
5 pts worse
|
12.0%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 17.1% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.3%
0.7 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 1.6% · Q4 3.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.2% |
79.5%
5.3 pts worse
|
79.7%
5.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.3% |
24.2%
13.1 pts worse
|
23.9%
13.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.3% · Observed 31.4% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-05 · Fire 2024-06-05
1 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-05-12 · Fire 2023-05-12
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-28
E · Potential for more than minimal harm
2025-05-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-28
E · Potential for more than minimal harm
2025-05-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-28
E · Potential for more than minimal harm
2025-05-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-28
F · Potential for more than minimal harm
2023-05-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-14
E · Potential for more than minimal harm
2023-05-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-14
D · Potential for more than minimal harm
2023-05-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-21
E · Potential for more than minimal harm
2025-12-30
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2026-01-21
E · Potential for more than minimal harm
2025-12-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-30
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 2026-01-21
F · Potential for more than minimal harm
2025-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-05-08
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 2025-05-28
C · Minimal harm
2024-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-14
F · Potential for more than minimal harm
2023-05-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-06-14
D · Potential for more than minimal harm
2023-05-12
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 2023-06-14
D · Potential for more than minimal harm
2023-05-12
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-06-14
D · Potential for more than minimal harm
2023-05-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-14
D · Potential for more than minimal harm
2023-05-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-14
D · Potential for more than minimal harm
2023-05-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-14
Penalties and ownership
What sits behind the stars
Ownership
Ark Opco Group, LLC
5% Or Greater Direct Ownership Interest · Organization
B&Y Healthcare S Corp
5% Or Greater Indirect Ownership Interest · Organization
B&Y Trust
5% Or Greater Indirect Ownership Interest · Organization
Cody Healthcare S Corp
5% Or Greater Indirect Ownership Interest · Organization
Craig Flashner 2007 Trust
5% Or Greater Indirect Ownership Interest · Organization
Flashner, Craig
Operational/Managerial Control · Individual
Flashner, Craig
Corporate Director · Individual
Kirk, Kristine
W-2 Managing Employee · Individual
Noble Healthcare Management, LLC
Operational/Managerial Control · Organization
Norcross, Robert
Contracted Managing Employee · Individual
Perlstein, Yitzchok
Operational/Managerial Control · Individual
Perlstein, Yitzchok
Corporate Director · Individual
Prestige Administrative Services, LLC
Operational/Managerial Control · Organization
Rogers, Stacey
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
The Inn at Freedom Village
Holland, MI
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Heritage Nursing and Rehabilitation Community
Zeeland, MI
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Medilodge of Zeeland
Zeeland, MI
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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