Cycle 1
Health 2024-11-22 · Fire 2024-11-22
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Grand Rapids, MI
St Ann's Home
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2161 Leonard NW, Grand Rapids, MI
(616) 453-7715
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
55
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-12-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.62
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
3.01
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.71
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.12
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
5.31
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
50%
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
2,055
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.03
Composite VBP score used to determine payment impact.
Payment multiplier
1.0065
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.38
Baseline 41.67% · Performance 53.95% · Measure score 2.38 · Achievement 2.38 · Improvement 0
Adjusted total nurse staffing
8.03
Baseline 5.19 hours · Performance 5.36 hours · Measure score 8.03 · Achievement 8.03 · Improvement 2.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.92% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 4.26% · Lower 95% interval 6.52% |
| Discharge to community | 59.57% |
50.57%
9 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 65.63% · Lower 95% interval 48.29% |
| Medicare spending per beneficiary | 0.59 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| 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 | Not Available |
2.29%
|
Numerator Not Available · Denominator 17 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 9.66% |
8.2%
1.5 pts better
|
Numerator 14 · Denominator 145 |
| Staff flu vaccination coverage | 41.97% |
42%
About the same
|
Numerator 81 · Denominator 193 |
| 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 Not Available · Newly certified or not enough cases to report. |
| 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · 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 | 82.9% |
95.0%
12.1 pts worse
|
93.4%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.0% · Q2 80.4% · Q3 85.0% · Q4 83.3% · 4Q avg 82.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.1%
1.4 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.5% · Q4 2.4% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.0% |
4.1%
0.1 pts better
|
11.4%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.7% · Q3 2.9% · Q4 5.7% · 4Q avg 4.0% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
5.5%
3.4 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 2.7% · Q4 2.5% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
19.6%
4.2 pts better
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 15.8% · Q3 18.9% · Q4 12.5% · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.7% |
16.5%
0.2 pts worse
|
16.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 13.8% · Q3 18.8% · Q4 17.1% · 4Q avg 16.7% · 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 | 13.4% |
13.9%
0.5 pts better
|
16.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 11.7% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.1% |
11.7%
0.6 pts better
|
14.9%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 17.6% · Q3 2.9% · Q4 5.4% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
0.9%
2.3 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.2% · Q3 4.4% · Q4 2.1% · 4Q avg 3.2% · 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 | 27.1% |
20.4%
6.7 pts worse
|
19.8%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 19.6% · Q3 29.4% · Q4 38.0% · 4Q avg 27.1% |
| Percentage of long-stay residents with pressure ulcers | 11.5% |
5.6%
5.9 pts worse
|
5.1%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 12.8% · Q3 9.0% · Q4 10.2% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.0% |
82.8%
8.8 pts worse
|
81.7%
7.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.7% · Q2 56.2% · Q3 76.7% · Q4 90.2% · 4Q avg 74.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
1.3%
2.1 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 3.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.8% |
79.5%
2.3 pts better
|
79.7%
2.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.8% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2023-01-25 · Fire 2023-01-25
4 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-08
F · Potential for more than minimal harm
2024-11-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-08
F · Potential for more than minimal harm
2024-11-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-08
F · Potential for more than minimal harm
2024-01-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-08
F · Potential for more than minimal harm
2024-01-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-08
F · Potential for more than minimal harm
2024-01-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-01-11
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-06-30
E · Potential for more than minimal harm
2024-01-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-01-11
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 2024-06-30
E · Potential for more than minimal harm
2024-01-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-01-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-06-30
E · Potential for more than minimal harm
2024-01-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-30
E · Potential for more than minimal harm
2024-01-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-01-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-01-11
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-03-08
F · Potential for more than minimal harm
2023-01-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-01-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-01-25
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-03-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-22
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-22
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-01-11
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
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 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
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 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-21
F · Potential for more than minimal harm
2023-01-25
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 2023-02-22
E · Potential for more than minimal harm
2023-01-25
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-02-22
D · Potential for more than minimal harm
2023-01-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-22
C · Minimal harm
2023-01-25
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-02-22
Penalties and ownership
What sits behind the stars
Ownership
Carmelite Sisters Of The Divine Heart Of Jesus
5% Or Greater Direct Ownership Interest · Organization
Freimark, Shelley
Operational/Managerial Control · Individual
Fryling, Kimberly
Corporate Director · Individual
Hall, Jennifer
Operational/Managerial Control · Individual
Prince, Dana
Operational/Managerial Control · Individual
Prince, Dana
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Edison Christian Health Center
Grand Rapids, MI
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Covenant Village of the Great Lakes
Grand Rapids, MI
4-star overall rating with 4-star inspections with 7 recent health deficiencies
#3
Valley View Care Center
Grand Rapids, MI
1-star overall rating with 1-star inspections with abuse icon flag with $43,876 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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