Cycle 1
Health 2025-03-19 · Fire 2025-03-19
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Hastings, MI
Thornapple Manor
5-star overall rating with 3-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2700 Nashville Rd, Hastings, MI
(269) 945-2407
Overall
5 / 5
CMS overall stars
Health inspections
3 / 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
161
Certified beds
Average residents
153
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
0.87
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.45
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.92
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.05
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.44
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
0.97
CMS adjusted RN staffing hours
Adjusted total hours
5.51
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
14%
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
482
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.09
Composite VBP score used to determine payment impact.
Payment multiplier
1.0219
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.48
Baseline 17.63% · Performance 19.36% · Measure score 4.48 · Achievement 4.48 · Improvement 0
Healthcare-associated infections
8.76
Baseline 6.49% · Performance 5.22% · Measure score 8.76 · Achievement 8.76 · Improvement 8.01
Total nurse turnover
8.32
Baseline 36.42% · Performance 29.68% · Measure score 8.32 · Achievement 8.32 · Improvement 5.33
Adjusted total nurse staffing
6.08
Baseline 4.97 hours · Performance 4.81 hours · Measure score 6.08 · Achievement 6.08 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.38% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 132 · Observed rate 8.33% · Lower 95% interval 7.34% |
| Discharge to community | 67.62% |
50.57%
17.1 pts better
|
Better than the National Rate · Eligible stays 136 · Observed rate 66.18% · Lower 95% interval 58.62% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 96.67% |
95.27%
1.4 pts better
|
Numerator 58 · Denominator 60 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 60 |
| Discharge self-care score | 64.71% |
53.69%
11 pts better
|
Numerator 33 · Denominator 51 |
| Discharge mobility score | 56.86% |
50.94%
5.9 pts better
|
Numerator 29 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 1.67% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 60 · Adjusted rate 2.06% |
| Healthcare-associated infections requiring hospitalization | 5.22% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 0% · Lower 95% interval 2.65% |
| Staff COVID-19 vaccination coverage | 3.15% |
8.2%
5 pts worse
|
Numerator 10 · Denominator 317 |
| Staff flu vaccination coverage | 46.02% |
42%
4 pts better
|
Numerator 185 · Denominator 402 |
| Discharge function score | 70.59% |
56.45%
14.1 pts better
|
Numerator 36 · Denominator 51 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 52 · Denominator 52 |
| Resident COVID-19 vaccinations up to date | 36.67% |
25.2%
11.5 pts better
|
Numerator 11 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.5
1 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.0%
5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.3% |
95.0%
4.3 pts better
|
95.5%
3.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.1%
2 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 5.8% · Q3 5.1% · Q4 3.6% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
4.1%
0.3 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.6% · Q3 4.0% · Q4 3.3% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.5%
2.1 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 3.9% · Q3 2.5% · Q4 3.3% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.9% |
19.6%
5.3 pts worse
|
19.6%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 24.2% · Q3 22.5% · Q4 24.8% · 4Q avg 24.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
16.5%
0.9 pts better
|
16.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 15.7% · Q3 14.4% · Q4 14.7% · 4Q avg 15.6% · 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 | 11.1% |
13.9%
2.8 pts better
|
16.3%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 6.8% · Q3 7.0% · Q4 9.9% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
11.7%
3.2 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 7.8% · Q3 7.1% · Q4 7.1% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.6% |
1.7%
3.9 pts worse
|
1.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.5% · Q3 5.1% · Q4 5.1% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.4% |
20.4%
4 pts worse
|
19.8%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 23.2% · Q3 25.9% · Q4 22.1% · 4Q avg 24.4% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
5.6%
1.6 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.4% · Q3 3.6% · Q4 3.6% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
82.8%
13.8 pts better
|
81.7%
14.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.4% · Q2 94.7% · Q3 97.2% · Q4 99.3% · 4Q avg 96.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.3% |
11.5%
3.8 pts worse
|
12.0%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 13.4% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
79.5%
16.3 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.4% |
24.2%
5.8 pts better
|
23.9%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 14.9% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-02 · Fire 2024-02-02
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-12-08 · Fire 2022-12-08
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-19
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-04-15
F · Potential for more than minimal harm
2025-03-19
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-04-16
F · Potential for more than minimal harm
2025-03-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-15
E · Potential for more than minimal harm
2025-03-19
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 2025-04-15
E · Potential for more than minimal harm
2025-03-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-15
E · Potential for more than minimal harm
2025-03-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-15
E · Potential for more than minimal harm
2025-03-19
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-15
F · Potential for more than minimal harm
2024-02-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-23
E · Potential for more than minimal harm
2024-02-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-23
E · Potential for more than minimal harm
2024-02-02
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2024-02-23
F · Potential for more than minimal harm
2022-12-08
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-08
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-01-06
F · Potential for more than minimal harm
2022-12-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-12-08
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 2023-01-06
E · Potential for more than minimal harm
2022-12-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-12-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-06
Inspection history
Recent health citations
G · Actual harm
2025-09-04
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 2025-09-02
D · Potential for more than minimal harm
2025-09-04
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-03-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-03-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-03-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-15
D · Potential for more than minimal harm
2024-11-15
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 2024-12-09
F · Potential for more than minimal harm
2024-02-02
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 2024-03-04
E · Potential for more than minimal harm
2024-02-02
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 2024-03-04
E · Potential for more than minimal harm
2024-02-02
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-04
E · Potential for more than minimal harm
2024-02-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-02
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 2024-03-04
D · Potential for more than minimal harm
2024-02-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-02
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-03-04
G · Actual harm
2023-12-07
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 2023-12-26
D · Potential for more than minimal harm
2023-12-07
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 2023-12-22
D · Potential for more than minimal harm
2023-10-11
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 2023-10-24
D · Potential for more than minimal harm
2023-10-11
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 2022-12-23
F · Potential for more than minimal harm
2022-12-08
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 2023-01-06
D · Potential for more than minimal harm
2022-12-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-12-08
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 2023-01-06
Penalties and ownership
What sits behind the stars
Ownership
County Of Barry
5% Or Greater Direct Ownership Interest · Organization
Behrendt, June
Corporate Director · Individual
Bishop, Elizabeth
W-2 Managing Employee · Individual
Dehaan, Rebecca
Corporate Officer · Individual
Johnson, Bradley
Corporate Director · Individual
Price, Sarah
W-2 Managing Employee · Individual
Sabo, Rebekah
Corporate Director · Individual
Nearby options
Other facilities in reach
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Clearstream Rehabilitation and Nursing Center
Hastings, MI
2-star overall rating with 1-star inspections with abuse icon flag with $35,416 in total fines with 16 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
The Laurels of Bedford
Battle Creek, MI
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
The Oaks at Battle Creek
Battle Creek, MI
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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