Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Mary Free Bed Sub-acute Rehabilitation during CMS and state inspections, most recent first.
Failure to Supervise a Cognitively Impaired Resident Who Left the Unit Unattended: A resident with severe cognitive impairment, hemiparesis, seizures, expressive aphasia, and high fall risk left the unit and went outside without staff supervision while his wife was not with him. A CNA saw the resident go to the elevator and outside but did not intervene, and staff later found him outside and escorted him back. Interviews showed staff did not recognize he needed supervision to leave the unit safely, and the care plan did not tell CNAs that he required supervision.
Surveyors found that staff failed to properly label and date food items, did not consistently monitor or document food cooling temperatures, and did not maintain cleanliness of food-contact surfaces and equipment. Additionally, the dish machine was operated outside of manufacturer-specified pressure parameters, and staff were unaware of required monitoring procedures.
Surveyors found that the facility did not have an active plan for reducing Legionella and other waterborne pathogens, as several water fixtures were not regularly flushed or maintained, and the Director of Facilities could not provide documentation or details on flushing procedures or water testing results. The written water management plan was not fully implemented, particularly regarding the flushing of unused fixtures.
A resident with severe cognitive impairment and high elopement risk was able to leave the facility unsupervised after staff failed to properly activate and assign a replacement HUGS wander alert tag. The resident exited the building without triggering an alarm, and was later found outside by security. Staff interviews revealed confusion about the correct procedure for tag activation and inconsistent monitoring, which contributed to the deficiency.
The facility failed to discard expired food products, monitor cooling potentially hazardous foods, and properly sanitize dishware, leading to potential foodborne illness risks for all residents consuming food. Expired items were found in the freezer, and unclean equipment and storage areas were noted. The Food Service Director confirmed the deficiencies and acknowledged the need for further staff education on proper cooling log completion.
The facility failed to post required nurse staffing information daily for all 39 residents, resulting in a lack of available staffing information for residents and visitors. Observations over several days revealed no posted information, and the Interim Administrator cited a management transition as the cause.
The facility failed to annually review and update the required Facility Assessment, with the last review documented on 10/12/22. The Interim NHA, who started in April 2024, confirmed that the assessment had not been updated since then and has begun working on an updated version.
Failure to Supervise a Cognitively Impaired Resident Who Left the Unit Unattended
Penalty
Summary
The facility failed to provide adequate supervision to ensure the safety of a severely cognitively impaired resident who was at high risk for falls. The resident had diagnoses including hemiplegia and hemiparesis, seizures, and cognitive/social/emotional deficits following a cerebral infarction. The MDS described the resident as severely cognitively impaired with limited range of motion on one side, and therapy notes identified fall risk, right hemiparesis, and expressive aphasia. The care plan identified high to moderate fall risk, wheelchair use for all mobility, risk for wandering/elopement, and impaired cognitive function with a need to cue, reorient, and supervise as needed. On the day of the incident, the resident left the unit and went outside the facility without staff supervision while his wife was not with him. A CNA observed him from his room, saw him go down the hallway in his wheelchair, enter the elevator, and go outside, but did not stop him or treat the event as significant at the time. The resident remained outside for about 15 minutes before staff and security located him and returned him to the unit. The facility incident documentation stated that he was outside in the front of the facility and later in the courtyard, and that he had not signed out. Interviews showed staff did not recognize the resident as needing supervision to leave the unit safely. The CNA stated she did not think he was in danger or incompetent and did not recall being told he could not go outside. The RN stated he activated the elopement plan after learning the resident was outside and confirmed the resident had not signed out. The DON acknowledged the resident’s cognitive impairment and agreed he should not have been outside alone, but also confirmed the care plan did not tell CNAs that he needed supervision. Security reported the resident was found in the surface lot area and escorted back to the building.
Multiple Food Safety and Sanitation Deficiencies Identified
Penalty
Summary
Surveyors identified multiple failures in food safety practices within the facility's kitchen and food service areas. During observations, several food items, including milk, soy milk, grape jelly, vinaigrette dressing, artichoke hearts, and ranch dressing, were found opened and stored without proper labeling of opened or discard dates. Additionally, resident food items in the pantry were not discarded within the facility's stated 72-hour rule. These actions were inconsistent with the 2022 FDA Food Code requirements for date marking and disposition of ready-to-eat, time/temperature control for safety foods. Review of the facility's food cooling logs revealed that staff did not consistently monitor or document food temperatures during the cooling process as required by policy. Multiple entries showed that foods did not reach the required temperature of 70°F within two hours, and there was no documentation that these foods were reheated to 165°F and re-cooled, as mandated. In some cases, there were no recorded temperature checks after the initial cooking, indicating a lack of adherence to both facility policy and FDA Food Code standards for cooling potentially hazardous foods. Additional deficiencies were observed in equipment sanitation and maintenance. Sheet pans were found stacked with water trapped between them, indicating they were not air-dried as required. The juice machine spouts had visible sticky debris, and the large floor mixer had dried food residue, both of which are violations of cleanliness standards for food-contact surfaces. Furthermore, the dish machine was operating at a rinse pressure above the manufacturer's specified range, and staff were unaware of the need to monitor this parameter, contrary to FDA Food Code requirements for mechanical warewashing equipment.
Plan Of Correction
Element 1: All residents/patients can be affected by deficient practice of food procurement, storing/labeling/preparing/sanitizing. 2% milk, organic soy milk, grape jelly, artichokes, container of ranch dressing and vinaigrette and patient food from home were discarded immediately. All wet nested pans were rewashed and air dried thoroughly. Drink machine spouts and mixer were cleaned and sanitized immediately. All open and prepped food in coolers and dry storage areas and in pantry refrigerators were checked for proper labeling and dating and were addressed appropriately. All food on cooling logs that were still in use but not cooled properly were discarded immediately. All clean dishes were inspected to ensure there was no water or food debris left on them. All small equipment was also inspected for signs of food debris. Element 2: All residents/patients have the potential to be affected by deficient practice of food procurement, storing/labeling/preparing/sanitizing. Element 3: Staff will be educated on labeling/dating food in kitchen and in pantries and on proper method to air dry dishes. Staff will be trained. Chefs and cooks will be educated on properly filling out cooling logs and how to cool food properly and in proper cleaning of small equipment. Trayline staff and supervisors will be educated on proper cleaning of juice machine and all its parts. Maintenance ticket submitted to identify and fix root cause of dish machine pressure. Element 4: The dining services manager or designee(s) will complete an audit 5 times a week for 12 weeks to check for properly labeled, stored and dated foods in coolers in kitchen and in pantry refrigerators. Food will be discarded after 72 hours of initial date. The cooling log and food cooling procedure to proper temperatures will be audited 5 times a week for 12 weeks. Small equipment, including mixer and juice machines will be audited for cleanliness and to ensure no wet nesting of clean dishes 5 times a week for 12 weeks. The dishwasher pressure will be audited 5 times a week for 12 weeks to ensure pressure is in recommended range. All audit findings will be submitted to Quality Assurance Process Improvement committee monthly and the Administrator is responsible for compliance.
Deficient Water Management and Legionella Control
Penalty
Summary
The facility failed to maintain an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens in its plumbing system. During a facility tour, surveyors observed that several water fixtures, including hoppers in soiled utility rooms and capped water lines in a spa room, were not being regularly flushed or maintained. Some fixtures had missing handles, were zip-tied shut, or were otherwise inaccessible for flushing, and discolored water was observed from one faucet. The Director of Facilities was unable to provide documentation or a list of fixtures being regularly flushed, and was unsure about the control limits for free chlorine in the domestic hot water supply. Although the facility had a written Legionella Control/Water Management Plan, it was not being fully implemented as described, particularly regarding the flushing of minimally used or unused fixtures. Interviews revealed that while housekeeping staff flushed water in vacant rooms weekly, there was no comprehensive system in place for ensuring all low-use or unused fixtures were included. The Director of Facilities also stated that quarterly Legionella testing and some free chlorine sampling were being performed, but no results were available for review. The facility's policy assigned responsibility for standard operating procedures to the Facility Director, but the lack of documentation and uncertainty about procedures contributed to the deficiency.
Plan Of Correction
Element 1: All residents/patients can be affected by the deficient practice of failing to reduce risk of Legionella and other opportunistic pathogens of premise plumbing. Element 2: The water management team initiated facility-wide water sampling for free chlorine and Legionella. Free chlorine meter was purchased to monitor levels when needed. All hopper faucet handles were replaced or reinstalled by plumber. The zip ties restricting hopper spray hose were removed. Water lines in spa room were assessed for flushing function and fixture accessibility. The Environmental Services team was retrained on flushing protocols. Element 3: All residents/patients can be affected by failing to reduce the risk of Legionella and other opportunistic pathogens of premise plumbing. All unused or low-use fixtures, including hoppers and spa room lines, will be flushed weekly. Vacant or unoccupied rooms will have showers, faucets flushed for at least one minute on a weekly basis. Testing for free chlorine will be monthly. Water testing policy reviewed and updated as necessary. Element 4: Audits for flushing will be performed weekly by EVS Manager or designee(s). Audits for hopper functionality checks will be completed monthly. Free chlorine levels and flushing compliance data will be reviewed, and findings of all audits will be reported to the Quality Assurance and Process Improvement committee monthly for 3 months. Administrator is responsible for compliance.
Failure to Ensure Proper Functioning of Wander Management System Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision, monitoring, and safety precautions for a resident with severe cognitive impairment and a high risk for elopement. The resident, who had diagnoses including dementia with behavioral disturbance, anxiety, and a history of falls, was assessed as being at risk for elopement and had a care plan in place that included the use of a HUGS wander alert bracelet. Documentation indicated that the resident exhibited frequent exit-seeking behaviors, required constant supervision, and had a history of attempting to leave the unit. On the day of the incident, the resident's HUGS tag was replaced due to a low battery. During the replacement process, staff failed to properly activate and assign the new tag in the monitoring system. As a result, the resident was not protected by the wander management system, and no alarm was triggered when the resident left the unit. The resident was able to exit the building without staff being alerted, and was later found outside by security personnel. Interviews with staff revealed confusion and lack of clarity regarding the proper procedure for activating and assigning the HUGS tag, as well as inconsistent documentation and verification of the tag's functionality. The failure to ensure the HUGS tag was correctly activated and assigned, combined with the lack of effective supervision and monitoring, directly led to the resident's elopement. The system did not alert staff when the resident left the unit, and the resident was able to leave the building unobserved. The deficiency was further compounded by staff not immediately realizing the resident was missing and only discovering the elopement after a period of time had passed.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to discard expired food products, monitor cooling potentially hazardous foods, and properly sanitize dishware, leading to potential foodborne illness risks for all residents consuming food. During an inspection, it was observed that the dish machine's final rinse temperature was below the required 160 degrees F, and staff were improperly rinsing dishware after sanitization in the three-compartment sink. Additionally, the cooling logs for potentially hazardous foods were incomplete, with missing entries for critical temperature checks, indicating improper monitoring of the cooling process. Expired food items were found in the walk-in freezer, including whipped topping, ciabatta bread, and popsicles, which should have been discarded. The inspection also revealed unclean equipment and storage areas, such as a powdered sugar shaker with dried food on the handle, an opened container of soy milk past its discard date, and a cooler with an unidentified jelly-like substance. Multiple containers of yogurt with varied expiration dates were also noted, along with a speed rack containing pre-cut desserts that had dried food and debris on the racks. The Food Service Director (FSD) confirmed the deficiencies and acknowledged the need for further staff education on proper cooling log completion. The FSD also took immediate actions to address some of the issues, such as discarding expired items and instructing staff to clean and sanitize affected areas. However, the report highlights significant lapses in food safety practices that could potentially impact the health of the residents.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post required nurse staffing information on a daily basis for all 39 residents, resulting in a lack of available staffing information for residents and visitors. Multiple observations from 5/14/24 to 5/16/24 revealed no posted nurse staffing information in the hallways and common areas. In an interview on 5/16/24, the Interim Administrator reported that the daily nurse staffing information was not posted due to a transition in management staff, and the responsibility was not passed onto the appropriate staff member. The facility's policy, dated 11/1/19, requires the posting of direct care daily staffing numbers at the beginning of each shift in a prominent location accessible to residents and visitors.
Failure to Annually Review and Update Facility Assessment
Penalty
Summary
The facility failed to annually review and update the required Facility Assessment, which is essential for determining the necessary resources to care for residents competently during both day-to-day operations and emergencies. The last documented review of the Facility Assessment was on 10/12/22. During an interview on 5/16/24, the Interim Nursing Home Administrator (NHA) reported that he had only been at the facility since April 2024 and confirmed with the former NHA that the Facility Assessment had not been updated or reviewed since 10/12/22. The Interim NHA has since started working on an updated Facility Assessment and plans to review it with the quality team upon completion.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Corewell Health Grand Rapids Hospitals Rehabilitat | 1.6 mi | ★★★★★ | 10 | 0 |
| Clark Retirement Community | 1.8 mi | ★★★★★ | 0 | 0 |
| Optalis Health & Rehabilitation At Leonard | 2.2 mi | ★★★★★ | 14 | 0 |
| Medilodge Of Grand Rapids | 2.5 mi | ★★★★★ | 2 | 1 |
| Beacon Hill At Eastgate | 2.7 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.