Kalamazoo, MI

Medilodge of Kalamazoo

4-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

1701 S 11th Street, Kalamazoo, MI

(269) 375-2020

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

39

Certified beds

Average residents

37

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Medilodge

Operator or chain grouping

Approved since

1976-04-05

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

0.90

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.79

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

2.07

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

3.77

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.69

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

3.22

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.66

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

0.95

CMS adjusted RN staffing hours

Adjusted total hours

3.99

CMS adjusted total nurse staffing hours

Case-mix index

1.29

Higher values indicate more complex resident acuity

RN turnover

56%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

43%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,511

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

26.50

Composite VBP score used to determine payment impact.

Payment multiplier

0.9842

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.79

Baseline 18.18% · Performance 20.60% · Measure score 1.79 · Achievement 1.79 · Improvement 0

Healthcare-associated infections

0

Baseline 5.65% · Performance 8.22% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

4.16

Baseline 34.29% · Performance 46.67% · Measure score 4.16 · Achievement 4.16 · Improvement 0

Adjusted total nurse staffing

4.65

Baseline 4.29 hours · Performance 4.4 hours · Measure score 4.65 · Achievement 4.65 · Improvement 0.24

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.88%	10.72% 0.8 pts better	No Different than the National Rate · Eligible stays 54 · Observed rate 7.41% · Lower 95% interval 5.97%
Discharge to community	56.66%	50.57% 6.1 pts better	No Different than the National Rate · Eligible stays 52 · Observed rate 48.08% · Lower 95% interval 39.21%
Medicare spending per beneficiary	0.78	1.02 0.2 pts better
Drug regimen review with follow-up	29.17%	95.27% 66.1 pts worse	Numerator 7 · Denominator 24
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 24
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 24 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	8.22%	7.12% 1.1 pts worse	No Different than the National Rate · Eligible stays 28 · Observed rate 14.29% · Lower 95% interval 4.48%
Staff COVID-19 vaccination coverage	6.45%	8.2% 1.7 pts worse	Numerator 4 · Denominator 62
Staff flu vaccination coverage	40.54%	42% 1.5 pts worse	Numerator 30 · Denominator 74
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 10 · 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	86.2%	95.0% 8.8 pts worse	93.4% 7.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 86.2% · Q2 75.9% · Q3 90.0% · Q4 92.9% · 4Q avg 86.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	96.9%	95.0% 1.9 pts better	95.5% 1.4 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9%
Percentage of long-stay residents experiencing one or more falls with major injury	8.6%	3.1% 5.5 pts worse	3.3% 5.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 10.3% · Q3 3.3% · Q4 10.7% · 4Q avg 8.6% · 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	4.3%	5.5% 1.2 pts better	5.4% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 8.3% · Q4 9.5% · 4Q avg 4.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	45.3%	19.6% 25.7 pts worse	19.6% 25.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 52.2% · Q3 41.7% · Q4 36.4% · 4Q avg 45.3%
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 · 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	13.6%	13.9% 0.3 pts better	16.3% 2.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 13.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	16.5%	11.7% 4.8 pts worse	14.9% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 20.0% · Q3 13.6% · 4Q avg 16.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	0.9% About the same	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.7% · 4Q avg 0.9% · 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 · 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 new or worsened bowel or bladder incontinence	32.6%	20.4% 12.2 pts worse	19.8% 12.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 44.7% · Q2 26.1% · Q3 24.0% · Q4 35.9% · 4Q avg 32.6%
Percentage of long-stay residents with pressure ulcers	8.0%	5.6% 2.4 pts worse	5.1% 2.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 10.4% · Q3 7.3% · Q4 10.0% · 4Q avg 8.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	85.8%	82.8% 3 pts better	81.7% 4.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 83.5% · Q2 85.7% · Q3 90.5% · Q4 84.4% · 4Q avg 85.8%
Percentage of short-stay residents who had an outpatient emergency department visit	5.0%	11.5% 6.5 pts better	12.0% 7 pts better	Short Stay · 20240701-20250630 · Adjusted 5.0% · Observed 5.0% · Expected 11.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.6%	1.3% 0.7 pts better	1.6% 1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	90.1%	79.5% 10.6 pts better	79.7% 10.4 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 90.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	10.6%	24.2% 13.6 pts better	23.9% 13.3 pts better	Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 10.0% · Expected 22.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-09 · Fire 2025-07-09

7 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-08-01 · Fire 2024-08-01

6 health deficiencies

Top issue: Resident Rights (2 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2023-06-14 · Fire 2023-06-14

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-07-09

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 2025-07-25

E · Potential for more than minimal harm 2025-07-09

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-07-17

E · Potential for more than minimal harm 2025-07-09

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2025-07-17

E · Potential for more than minimal harm 2024-08-01

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 2024-08-20

E · Potential for more than minimal harm 2024-08-01

K925 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that sources of ignition are removed from patients receiving respiratory therapy.

Corrected 2024-08-20

F · Potential for more than minimal harm 2023-06-14

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2023-07-06

F · Potential for more than minimal harm 2023-06-14

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-07-06

F · Potential for more than minimal harm 2023-06-14

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-07-06

F · Potential for more than minimal harm 2023-06-14

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-07-06

Inspection history

Recent health citations

G · Actual harm 2025-07-09

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-07-29

E · Potential for more than minimal harm 2025-07-09

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-07-29

D · Potential for more than minimal harm 2025-07-09

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-08-21

D · Potential for more than minimal harm 2025-07-09

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2025-07-29

D · Potential for more than minimal harm 2025-07-09

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 2025-07-29

D · Potential for more than minimal harm 2025-07-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-21

D · Potential for more than minimal harm 2025-05-14

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 2025-04-22

F · Potential for more than minimal harm 2024-08-01

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 2024-08-20

D · Potential for more than minimal harm 2024-08-01

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-08-20

D · Potential for more than minimal harm 2024-08-01

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2024-08-20

D · Potential for more than minimal harm 2024-08-01

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2024-08-20

D · Potential for more than minimal harm 2024-08-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-20

G · Actual harm 2024-05-23

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-02-12

E · Potential for more than minimal harm 2023-06-14

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2023-07-11