Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Corewell Health Rehabilitation & Nursing Center - during CMS and state inspections, most recent first.
A facility failed to follow infection control standards for bedside Kangaroo feeding pumps, IV poles, and an oxygen concentrator. Multiple residents with PEG or PEG J-tubes had pumps and poles visibly covered with dried tube feeding residue over repeated observations, and an LPN and DON stated the equipment should be cleaned when dirty. A resident receiving continuous oxygen also had a concentrator filter covered with dust, lint, and dried substance, with the RT and DON noting the filter should be checked and cleaned with the equipment.
A resident with TBI, dysphagia, and functional quadriplegia was dependent for eating and had a care plan for 1:1 pleasure feedings at meals. Staff did not consistently provide the assisted oral intake, with a CNA admitting the resident missed breakfast because she was busy and assumed another CNA would help, and records showed multiple meal opportunities with no documented pleasure feeding offered. The DPOA/FM reported the resident enjoyed eating and was supposed to receive help at every meal, and staff observed the resident showing clear signs of enjoyment when later assisted with pureed food.
Two residents with cognitive intactness and significant medical conditions reported being treated disrespectfully by a CNA, who used a harsh and condescending tone during care and dismissed requests for assistance, leading to feelings of humiliation and frustration. Staff interviews corroborated the residents' accounts of inappropriate interactions.
A resident, who was cognitively intact, reported being verbally abused by a CNA after a bowel accident, with the incident witnessed by an LPN and reported to multiple staff members. Despite facility policy requiring immediate reporting of alleged abuse to the State Agency, the event was handled internally without proper external notification or thorough investigation, and there was no evidence of interviews with other residents or staff to verify that abuse did not occur.
A resident with a urinary catheter was under enhanced barrier precautions, requiring staff to wear gowns and gloves during high-contact care activities. However, staff members were observed not adhering to these precautions, such as not wearing gowns or changing gloves during care tasks. Interviews revealed inconsistent understanding and application of the precautions among staff, despite facility policy requiring such measures for residents with indwelling medical devices.
The facility failed to ensure call lights were within reach for two residents, leading to their inability to call for assistance. One resident with moderate cognitive impairment repeatedly found her call light out of reach, despite expressing concerns to staff. Another resident with PTSD and TBI had his specialized call light frequently placed out of reach, with no specific placement protocol followed. The facility's policy requires call lights to be accessible, but observations and interviews revealed non-compliance, resulting in unmet care needs.
A resident with moderate cognitive impairment did not receive showers as scheduled, leading to inadequate personal hygiene and dissatisfaction. Despite being scheduled for showers twice a week, there was no documentation of showers or refusals on several dates. Staff confirmed the lack of documentation, and skin assessments did not indicate that showers were provided.
The facility failed to assess and supervise residents for self-administration of medications, leading to unsupervised administration and potential medication mismanagement. A resident with dementia was given a narcotic without supervision, another resident spilled medications and was unsure of ingestion, and a third resident was found with unsupervised medication cups. These incidents highlight deficiencies in the facility's medication management practices.
A resident with a stage 3 pressure ulcer experienced worsening of the condition due to the facility's failure to consistently assess, monitor, and treat the wound. Despite having a care plan in place, staff frequently missed daily wound care treatments, and there was confusion about documenting missed treatments in the EHR. Interviews revealed that treatments were often skipped during busy shifts, and the facility's audits failed to identify these lapses.
A facility failed to provide trauma-informed care to a resident with PTSD, as her care plan and Resident Care Summary lacked specific trauma triggers. Staff interviews revealed a lack of awareness and understanding of the resident's trauma history, contributing to the deficiency.
The facility failed to implement enhanced barrier precautions for two residents, leading to potential infection risks. A resident with wounds was assisted by a CNA wearing only gloves, not a gown, due to a lack of awareness of the precautions. Another resident with a catheter and wounds was transferred by CNAs without gowns, despite signage indicating precautions. Staff confusion and improper PPE placement contributed to the deficiency.
Infection Control Lapses With Feeding Pumps, IV Poles, and Oxygen Equipment
Penalty
Summary
The facility failed to follow infection control standards for Kangaroo feeding pumps and IV poles for residents with enteral feeding tubes. R1, R2, R25, R47, and R105 all had bedside Kangaroo pumps attached to IV poles that were observed with splatters of a dried substance resembling tube feeding on the pump, pole, and base of the pole. In several instances, the same condition was observed repeatedly over multiple days, including one pump that was completely covered with dried substance. The residents’ records showed diagnoses and orders related to PEG or PEG J-tube feeding, and care plans identified dependence on tube feeding for nutrition and hydration. During interview, an LPN stated that feeding pumps and poles should be cleaned when feedings spill on them to prevent pathogens and infection control issues, and the DON stated that tube feeding pumps and poles should be cleaned when visibly dirty and between uses. Despite these statements, the observed equipment remained visibly soiled during repeated observations. The report specifically documented dried tube feeding residue on the pumps, poles, and bases at the residents’ bedsides. The facility also failed to maintain infection control for oxygen equipment for R118. The resident had chronic respiratory failure, emphysema, restrictive lung disease, obstructive sleep apnea, and shortness of breath, and was receiving continuous oxygen via nasal cannula. The oxygen concentrator filter was observed covered with dust, lint, and a dried substance resembling applesauce, with streaks of dried substance on the concentrator itself. The same condition was observed on repeated days, and the oxygen tubing remained dated 9/3 during the observations. The RT stated that concentrator filters should be checked and cleaned at the same time as the tubing or if something is spilled on the concentrator, and the DON stated that respiratory staff audit oxygen concentrators and tubing and should check the filters at the same time for respiratory hygiene and infection control.
Failure to Consistently Provide Assisted Pleasure Feedings
Penalty
Summary
The facility failed to ensure that a resident’s right to self-determination was honored by not consistently providing the resident with assisted pleasure feedings during meals. The resident had a history of traumatic brain injury, oropharyngeal dysphagia, and functional quadriplegia, had a BIMS score of 00/15, and was dependent for eating. The care plan and resident care summary directed that the resident receive 1:1 assistance, be up in a chair for meals, and receive oral intake for pleasure with food preferences honored. The resident’s DPOA/family member reported that the resident was supposed to be helped with pleasure feeding at every meal and stated that on one occasion she arrived in the morning and assisted the resident with a snack, after which the resident ate the entire snack and appeared hungry. She then learned from a CNA that the resident had not been assisted with breakfast. The CNA acknowledged that she had cared for the resident that morning, became busy assisting other residents, assumed another CNA would help, and did not feel comfortable assisting because of the resident’s swallowing issues. She also stated she had seen other staff skip assisting the resident because it was “just a pleasure feeding.” Additional staff confirmed the resident was supposed to receive pleasure feedings at every meal and that the resident was not assisted with breakfast on that occasion. A review of the oral intake flowsheet showed 11 of 90 meal opportunities with no record of a pleasure feeding being offered. During an observation, the resident was later seen in the dining room being assisted with small amounts of pureed food, and the resident responded with visible signs of enjoyment, including lifting his right leg when asked if he liked the food and wanting more. The DON stated she was not aware the resident was supposed to be assisted with pleasure feedings at every meal or that it was not always being offered.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that two cognitively intact male residents were treated with dignity and respect by a Certified Nurse Aide (CNA). One resident, who had diagnoses including diarrhea, anxiety, and cerebral palsy, reported feeling humiliated and disrespected after experiencing a bowel movement accident. The CNA entered his room and, according to the resident and corroborating staff interviews, spoke to him in a loud, condescending, and harsh tone, projecting frustration about having to clean him. The resident expressed that this interaction made him feel even worse about his accident. Multiple staff members, including a Licensed Practical Nurse (LPN) and two social workers, confirmed the resident's account of the CNA's inappropriate tone and demeanor during the incident. Another resident, with a history of major depressive disorder and hemiplegia following a stroke, reported that the same CNA had previously treated him in a rude manner, making him feel insignificant when he requested assistance. The resident stated that the CNA dismissed his need to use the restroom, telling him he did not need to go because he had just gone, which led to him having accidents while waiting for toileting assistance. These actions by the CNA resulted in both residents feeling diminished self-worth and frustration.
Failure to Immediately Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to implement its policies and procedures for the immediate reporting of alleged abuse to the State Agency for one resident. A cognitively intact resident reported that a certified nurse aide (CNA) verbally abused him by yelling after he had a bowel movement accident. The resident stated he reported the incident to facility staff, including a nurse who witnessed the event and encouraged him to report it, as well as to the social worker and facility leadership. The resident also indicated he had previously reported similar concerns about the same CNA, and management had stated they would address it. Interviews with staff confirmed that the resident's complaint was discussed among the nursing home administrator, social workers, and nursing supervisor. The staff acknowledged that the resident expressed feeling unsafe with the CNA and that other residents had also complained about the same CNA in the past. The nurse who witnessed the incident described the CNA's tone as condescending and reported intervening to deescalate the situation. However, documentation of the investigation was limited, and there was no evidence that interviews with other residents or staff were conducted to verify that abuse did not occur. Review of facility policy revealed that alleged violations involving abuse must be reported immediately to the State Agency within two hours. Despite this requirement, the incident was not reported as mandated. Instead, the facility handled the complaint internally, documenting it in a clinical note and making changes to the resident's care assignment, but failed to follow the required external reporting procedures.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices, specifically in the use of enhanced barrier precautions for a resident with a traumatic brain injury, dysphagia, and neurogenic bladder. The resident was under enhanced barrier precautions due to the presence of a urinary catheter, which required staff to wear gowns and gloves during high-contact care activities. However, observations revealed that staff members did not consistently adhere to these precautions. For instance, a Rehab Tech/Certified Nurse Assistant (RT/CNA) was observed performing various care tasks, such as emptying a urinary catheter bag and providing a bed bath, without changing gloves or wearing a gown as required. Further observations showed that another RT/CNA also failed to wear a gown while applying hand splints and positioning the resident in bed, despite being in close proximity to the resident. Interviews with staff members, including CNAs and the Infection Preventionist, confirmed a lack of understanding and inconsistent application of the enhanced barrier precautions. Some staff members believed that the precautions were only necessary for nurses working with G-tubes, while others acknowledged the need for gowns and gloves but did not follow through with the practice. The facility's policy on isolation precautions clearly stated the requirement for gown and glove use during specific high-contact activities for residents with indwelling medical devices, such as urinary catheters. Despite this, the staff did not consistently follow the policy, as evidenced by multiple instances of non-compliance observed by the surveyor. Interviews with the Director of Nursing and other supervisory staff highlighted the expectation that staff should adhere to the posted signage and facility policy, yet this was not reflected in the observed practices.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, resulting in their inability to call for staff assistance. Resident #101, a female with moderate cognitive impairment, expressed concerns about her call light not being accessible while she was in her wheelchair. Despite voicing these concerns to several staff members, the issue persisted, as observed on multiple occasions when the call light was found out of reach. Staff members, including a CNA and a nursing supervisor, acknowledged the oversight but did not conduct follow-up audits to ensure compliance with the facility's policy. Resident #102, a male with PTSD, TBI, and other conditions, also experienced issues with his specialized call light being out of reach. Observations revealed that the call light was often clipped to the wall behind his wheelchair, making it inaccessible. Although a CNA placed the call light near Resident #102's shoulder when he was in bed, there was no specific placement protocol followed for his specialized call light. A family member expressed concerns about staff not checking the resident care summary for individualized care needs. The facility's policy requires that call lights be accessible and within reach during each interaction with residents. However, the observations and interviews indicated a failure to adhere to this policy, leading to the deficiency. The lack of consistent placement of call lights within reach for these residents highlights a gap in ensuring their needs and preferences are reasonably accommodated, as required by the facility's standards.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that showers were provided according to the resident's preference and care plan, resulting in inadequate personal hygiene and dissatisfaction with care for one resident. The resident, who had moderate cognitive impairment, was scheduled to receive showers twice a week, but there was no documentation of showers or refusals on several scheduled dates. The resident expressed concerns about not receiving showers consistently, which was confirmed by the review of the electronic health record and interviews with staff. The nursing supervisor and director of nursing confirmed the lack of documentation for the resident's showers on the specified dates. Although skin assessments were completed by nurses on the resident's scheduled shower days, these assessments did not indicate that a shower had been provided. Interviews with registered nurses revealed that skin assessments were conducted regardless of whether a shower was given, and documentation did not confirm the completion of showers unless specifically noted.
Failure to Assess and Supervise Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for self-administration of medications, leading to unsupervised administration and potential medication mismanagement. Resident #84, who was diagnosed with vascular dementia, was observed receiving a narcotic pain medication from an LPN without supervision. The LPN allowed the resident to take the medication to her room without confirming ingestion, despite the resident's known forgetfulness and risk for aspiration. The nurse supervisor confirmed that Resident #84 had not been assessed for self-administration and was not eligible due to her high risk for aspiration. Resident #44, with diagnoses including chronic back pain and type 2 diabetes, was found picking up medications from the floor after spilling them. The resident, who was cognitively intact, reported difficulty seeing the medications and was unsure of what she had taken. This incident occurred without staff supervision, indicating a lapse in ensuring safe medication administration practices. Resident #74, also cognitively intact, was observed with multiple medication cups containing pills on the bedside table, with no staff present. This situation further exemplifies the facility's failure to monitor and validate self-administration of medications, as required by their medication management policy. The lack of staff presence during medication administration for these residents highlights a significant deficiency in the facility's adherence to safe medication practices.
Failure to Provide Consistent Pressure Ulcer Care
Penalty
Summary
The facility failed to accurately assess, monitor, and treat a resident with a stage 3 pressure ulcer, leading to the worsening of the condition. Resident #27, who was cognitively intact, was admitted with a pressure injury on the left buttock. The care plan included daily monitoring for signs of infection and specific wound care treatments. However, the facility did not consistently document or complete the required wound care treatments on several occasions, as evidenced by missing documentation on specific dates in July and August 2024. The resident reported that staff frequently skipped his daily wound care treatments, and the wound had increased in size during the last assessment. Interviews with staff revealed that wound care treatments were often missed due to busy shifts, and there was confusion about how to document missed treatments in the electronic health record (EHR). Wound Care Nurse PP confirmed that treatments were signed off as completed without proper documentation of wound assessments. Nurse Supervisor C acknowledged the lack of documentation and that the facility's audits had failed to identify the missed treatments. Despite being informed of the issue, the facility staff continued to miss multiple wound care treatments for the resident, contributing to the deficiency.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident with a history of PTSD, resulting in the potential for exposure to trauma triggers and re-traumatization. Resident #99, who was admitted with a diagnosis of PTSD, had experienced multiple traumatic events, including a car accident and physical abuse by her father. Despite this, the resident's care plan did not specify her trauma triggers, and the Resident Care Summary (RCS) lacked any information related to her PTSD or past trauma. Interviews with facility staff revealed a lack of awareness and understanding of Resident #99's trauma history and triggers. The Nurse Manager acknowledged that the care plan and RCS did not include the resident's trauma triggers, which are essential for providing appropriate care. The Social Worker confirmed that the care plan should have included specific details about the resident's traumatic events and triggers, but it only referred to the trauma assessment without listing them. Furthermore, the Certified Nursing Assistant (CNA) reported being unaware of Resident #99's trauma history, as the RCS did not contain relevant information. The CNA also expressed difficulty accessing the resident's diagnoses, care plan, and trauma assessments in the electronic health record. This lack of accessible information and communication among staff members contributed to the deficiency in providing trauma-informed care to Resident #99.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to properly implement enhanced barrier precautions for two residents, resulting in potential cross-contamination and spread of infection. Resident #35, who was admitted with conditions including chronic diastolic heart failure, cellulitis, and venous stasis dermatitis, was observed to have enhanced barrier precautions signage outside her room. However, a Certified Nursing Assistant (CNA) assisted her with grooming and other personal care activities while wearing only gloves, not a gown, as required by the facility's policy for residents with wounds. The CNA was unaware of the enhanced barrier precautions in place for Resident #35. Resident #72, admitted with bladder obstruction and multiple skin wounds, also had enhanced barrier precautions ordered due to having a catheter and wounds. Despite signage indicating these precautions, CNAs were observed transferring Resident #72 using a mechanical lift without wearing gowns, only gloves. One CNA reported confusion about the need for enhanced barrier precautions, mistakenly believing they were only necessary for residents with active infections, and noted that the personal protective equipment (PPE) bin was located on the other side of the hallway. Interviews with staff, including a Nurse Supervisor and the Director of Nursing, confirmed that both residents had orders for enhanced barrier precautions due to their medical conditions. However, the lack of proper implementation and awareness among the staff led to the deficiency in infection control practices, as evidenced by the observations and interviews conducted during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Grand Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health And Rehabilitation Of Grand Rapids | 1.2 mi | ★★★★★ | 34 | 2 |
| Holland Home Breton Rehabilitation & Living Centre | 1.3 mi | ★★★★★ | 0 | 0 |
| Optalis Health & Rehabilitation Of Wyoming | 2.9 mi | ★★★★★ | 41 | 0 |
| Optalis Health & Rehabilitation At Kent-crossing | 3.1 mi | ★★★★★ | 33 | 0 |
| Holland Home - Raybrook Manor | 3.1 mi | ★★★★★ | 11 | 0 |
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