Above average — CMS composite of the measures below.
The next survey window likely opens 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 Michigan Masonic Home during CMS and state inspections, most recent first.
Delayed call light response and toileting assistance affected three cognitively intact residents with toileting needs. One resident with cerebral palsy, one with Parkinson's Disease, and one with orthostatic hypotension reported repeated waits of about 30 minutes or more for help, with call light logs showing response times up to 61 minutes. The delays led to episodes of wetting or soiling themselves, and one resident reported feeling undignified while another said it made him feel unwanted.
A resident with chronic pain, reduced mobility, and impaired skin integrity had a care plan that included a chair cushion, but no documented interventions for the toilet or bedpan. Staff could not locate the resident’s usual pressure relief cushion, and the resident repeatedly complained of buttock pain while sitting in a wheelchair, on the toilet, and on a bedpan. During observation, the coccyx and sacral area had thick white substance and darker skin, and the resident identified the toilet seat, bedpan edges, and cup rim as painful.
Two residents were involved in a deficiency for failure to prevent falls and provide required supervision. One resident with Parkinson’s disease and unsteadiness on feet waited about 28 minutes after activating a bathroom call light before staff responded, then was found on the bathroom floor after trying to transfer to the toilet. Another resident with Parkinson’s disease, dementia, and psychotic disorders was observed ambulating with a 2-wheeled walker without staff in sight, attempting to enter another resident’s room, stepping backward so the walker tipped, and later walking without the walker to the nurse’s station despite a care plan for supervision with ambulation.
Incomplete care conference documentation was found for two residents. One resident had diagnoses including parkinsonism, bipolar disorder, anxiety disorder, and heart failure, and another had Alzheimer's disease and major depressive disorder. Several interdisciplinary conference report sheets had missing or inconsistent entries for resident and family/legal representative attendance, yet still indicated that a baseline care plan summary was completed with the resident and/or representative. Staff stated the paperwork should be completed in full and that resident/representative involvement would be expected for that section.
The facility failed to maintain an active and ongoing water management plan to reduce the risk of legionella and other OPPP. A drinking fountain in an unused wing was observed with a dry basin and appeared to be used inconsistently, and the DES was unsure of its flushing schedule or use because the area was mainly used for storage. The facility policy stated the water management team would complete an annual risk assessment.
Failure to monitor urine culture results and communicate antibiotic orders for a resident with a hx of UTI. The resident had a UA ordered, the urine specimen was sent to the lab, and the EMR later showed a positive culture for Klebsiella pneumoniae with a physician note to start Ceftin, but the facility EMR did not document monitoring of the result or the need for an ABX until much later. The IP stated there was miscommunication between the facility EMR and a separate hospital EMR where the lab results and antibiotic order were placed.
Failure to maintain cleanliness and repair in the Water room. Surveyors observed a 2-foot by 1-foot patch of black mold-like substance at eye level on the wall in the Maintenance and Laundry wing, and the DF confirmed the finding during the walk-through. The wall was dry, and there were no notable high humidity issues in the room.
The facility failed to maintain an effective infection prevention and control program, particularly in managing the risk of Legionella and other pathogens in the plumbing system. Observations revealed stagnant water fixtures in the kitchen and other areas, with no routine flushing schedule or testing protocols in place. The Water Management Plan lacked clear instructions, and staff were unsure about control measures, indicating a deficiency in the facility's infection control practices.
The facility failed to maintain a safe and sanitary environment, with issues including a dish machine lacking an AVB, improperly stored linens, and a mop sink faucet causing water spillage. Additionally, a tabletop ice machine was improperly connected to the wastewater drain, and a laundry cart had accumulated debris.
A resident with Parkinsonism and anxiety was observed in soiled clothing for two days, indicating a lack of assistance with personal hygiene. The resident expressed discomfort with female caregivers for showers, preferring male caregivers, but this preference was not documented in the care plan. Despite staff awareness, the facility did not accommodate the resident's request, leading to embarrassment and refusal to shower.
The facility failed to implement effective fall prevention interventions for three residents with severe cognitive impairments and high fall risks. One resident was observed unsupervised despite needing assistance, another did not use a provided bell for help, and a third had multiple unwitnessed falls with inadequate interventions. The facility's documentation and investigation processes were insufficient to address the root causes of the falls.
Delayed Call Light Response and Toileting Assistance
Penalty
Summary
The facility failed to provide dignified care to residents who needed timely assistance with toileting and call light response. R5, who was cognitively intact with a BIMS score of 15 and had diagnoses including cerebral palsy and periodic limb movement disorder, had a toileting care plan directing staff to toilet him on request and offer a urinal every two hours around the clock. He reported that he routinely waited about 30 minutes for his call light to be answered and that the delay was not always fast enough to prevent episodes of incontinence. Call light records for R5 showed multiple prolonged response times, including waits of 18 to 59 minutes over the review period. R5 stated that on one morning he waited 59 minutes after pressing the call light, was unable to hold his urine, and wet himself, which he said made him feel undignified. R11, who had diagnoses including Parkinson's Disease and unsteadiness on feet, had a toileting care plan directing staff to toilet him every 2 hours while awake and upon request. He reported often waiting about 30 minutes for his call light to be answered and often urinating on himself because he could not hold his urine that long, which he said made him feel like he was not wanted. R11's call light report documented repeated delays, including response times of 17 to 61 minutes. R87, who had diagnoses including orthostatic hypotension, syncope, and collapse and was cognitively intact with a BIMS score of 15, reported that staff sometimes did not respond timely to her call light when she needed to use the bathroom. She stated she had previously fallen after self-transferring when staff did not respond, and that since then slow call light response had resulted in wetting or soiling herself. Her call light report also showed multiple waits of 22 to 37 minutes, and she reported that staff sometimes turned off the call light and returned later to provide assistance, leaving her unable to hold her urine until they came back.
Failure to Implement Pressure Relief Measures
Penalty
Summary
The facility failed to implement a pressure relieving care plan for R28, a female resident admitted with chronic pain, dysuria, reduced mobility, and chronic kidney disease. Her BIMS score was 15 out of 15, indicating normal mental status. Her skin integrity care plan, revised on 11/06/25, documented actual impairment to skin integrity related to hemiplegia/hemiparesis and included a cushion for chair dated 10/25/25, but no interventions were noted for the toilet or bedpan. On 1/27/26, R28 was observed sitting in her wheelchair and complained of buttock pain, including pain when sitting on the toilet and bed pan for extended periods. A CNA assisted her to stand, and R28 pointed to her coccyx area as the source of pain. The coccyx and sacral area were coated with a thick white substance, and some skin in the sacral area appeared darker than the rest of the buttock; the coccyx was not visible. The CNA stated R28 was supposed to be sitting on a pressure relief cushion but could not locate the cushion normally used in her wheelchair and obtained a different seat cushion. R28 also described the outside edge of her drink cup as similar to the bed pan and said the edge hurt her buttock when she sat on it. On 1/29/26, R28 was observed sitting on the toilet with her feet several inches off the floor and complained that the toilet seat hurt her buttock. The charge nurse asked her to shift her weight, but R28 said she could not. When the nurse handed her the bed pan and asked where it hurt, R28 pointed to the narrow sides.
Failure to Prevent Falls and Provide Required Ambulation Supervision
Penalty
Summary
The facility failed to implement interventions to prevent falls for two residents who were reviewed for falls. One resident had Parkinson’s disease and unsteadiness on feet and had a toileting care plan directing staff to toilet him every 2 hours while awake and upon request. He reported that he often waited about 30 minutes for his call light to be answered and said he could not hold his urine that long, often urinating on himself while waiting for assistance. After a fall event, the resident was found sitting on the bathroom floor after trying to get onto the toilet and being unable to make it, then sitting down on the floor. The post-fall huddle and root-cause analysis documented that he had his call light on before self-transferring and that he was not patient and tried to transfer without being strong enough to do so safely, but the report did not identify how long the call light had been activated before staff found him. The call light record showed the bathroom pull station was activated at 12:25 PM and remained on for 28 minutes before staff turned it off. Another resident had Parkinson’s disease, dementia, psychotic disorder with hallucinations, delusional disorder, and major depressive disorder. During observation, he ambulated in the hallway with a two-wheeled walker but was without staff presence, attempted to enter another resident’s room, stepped backward in the common area causing his walker’s front legs to tip off the floor, and later ambulated back down the hallway without his walker and leaned against the nurse’s station. His care plan directed staff to provide supervision with ambulation using a two-wheeled walker, and multiple staff members described supervision as keeping the resident in visual sight or line of sight, yet staff were not present or within sight during the observed ambulation.
Incomplete Care Conference Documentation
Penalty
Summary
The facility failed to consistently provide clear and concise medical records for 2 residents, R9 and R12, during review of interdisciplinary conference report sheets. For R9, the record showed admission with diagnoses including parkinsonism, bipolar disorder, anxiety disorder, and heart failure. Multiple conference report sheets dated 02/11/25, 5/13/25, and 8/12/25 were marked as quarterly, with resident attendance marked No and family/legal representative attendance also marked No, yet the form still indicated that a baseline care plan summary encompassing updates to goals, medications, dietary information, and treatments since the last care plan summary had been completed with the resident and/or resident family/legal representative. On the 10/21/25 sheet, resident attendance was marked No, family/legal representative attendance was left blank, and the same completion statement was checked. For R12, the record showed admission with diagnoses including Alzheimer's disease and major depressive disorder. The 10/16/25 quarterly conference report sheet had both resident and family/legal representative attendance sections left blank, while the same baseline care plan summary completion statement was checked. A later annual conference report sheet dated 01/13/2026 again showed resident attendance marked No and family/legal representative attendance blank, with the same completion statement checked. During interview, the Social Service Designee stated the care conference paperwork should be filled out in its entirety to assist with family involvement, and the RN Charge Nurse stated that resident/representative involvement would be expected for the section indicating the baseline care plan summary was completed with the resident/representative.
Water Management Program Lacked Ongoing Legionella Risk Plan
Penalty
Summary
The facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing, resulting in the potential for increased risk of respiratory infection among all residents in the facility. On 01/27 at 9:13 AM, a drinking fountain in the unused Boardroom wing on the Ground Level was observed and appeared to be used inconsistently; the basin was dry at the time of observation. The Director of Environmental Services was asked about the drinking fountain’s use and flushing schedule and stated they were unsure about the flushing schedule or use of the fountain because the area was mainly used for storage and that restroom facilities were sometimes used by facility personnel. Record review of the facility’s Water Management Program Policy MN-D 153 Procedure 2 stated that a risk assessment would be conducted annually by the water management team, indicating the drinking fountain would have been assessed annually and its flushing schedule known.
Failure to Monitor Urine Culture Results and Communicate Antibiotic Orders
Penalty
Summary
The facility failed to monitor lab results and promote communication between health care providers to maintain an effective antibiotic stewardship program for one resident with a history of urinary tract infections. R103 was admitted with pertinent diagnoses including a history of UTI. A urinalysis was ordered by a physician, the urine specimen was obtained and sent to the laboratory, and the EMR showed abnormal urine lab results with a culture and sensitivity to be completed. The EMR also documented a physician note stating the urinalysis was positive for Klebsiella pneumoniae and that a 7-day course of Ceftin would be started, with an extended course due to hematuria. The EMR showed the culture and sensitivity result was finalized as >100000 col/ml Klebsiella pneumoniae, but there was no documentation in the facility EMR of monitoring for the urine specimen results submitted on 1/4/26. The positive lab result for the UTI and the need for an antibiotic were not documented until 1/16/26, when an antibiotic was ordered, and the January 2026 MAR showed antibiotic therapy began that evening. During interview, the Infection Preventionist stated charge nurses were expected to inform her of suspected infections, urine samples sent to the lab, or physician plans to start antibiotics, and that she would follow up to ensure a note was entered into the medical record. She also stated the lab results and antibiotic order were placed in a separate hospital EMR and there was miscommunication despite documentation in the facility EMR that the urine sample had been sent to the lab.
Failure to Maintain Cleanliness and Repair in Water Room
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises. On 01/27/2026 at 8:30 AM, surveyors observed a patch of black mold-like substance measuring 2 feet long by 1 foot wide on the wall at eye level in the Water room in the Maintenance and Laundry wing on the Ground Level. The Director of Facilities confirmed the observation during the walk-through. At the time of observation, the wall was dry and there were no notable high humidity issues in the room.
Inadequate Water Management and Infection Control
Penalty
Summary
The facility failed to maintain an active and ongoing infection prevention and control program specifically targeting the risk of Legionella and other opportunistic pathogens in the plumbing system. During a tour of the main dry storage area for the kitchen, it was observed that multiple water fixtures, including a preparation sink, hand sink, steam table fill, and pot fill fixture, were stagnant and not under any routine flushing schedule. The hot and cold water lines for the kitchenette hand sink emitted brown water initially, indicating a lack of regular use and maintenance. Additionally, the first-floor kitchenette's back dish room was not on a regular flushing schedule, and the staff were unsure about any testing or control measures in place to mitigate the risk of waterborne pathogens. Further observations revealed that a janitor's closet on the second floor had a faucet that was not routinely flushed, and a water line in the Ventilation Unit was potentially stagnant, with crusted debris indicating it was still servicing water. The facility's Water Management Plan lacked a facility layout or instructions on water flow, and staff were uncertain about control measures or testing protocols. The Michigan Masonic Home Water Management Program Procedure and Policy outlined the need for risk assessments and control measures, but these were not effectively implemented, as evidenced by the lack of routine flushing and testing for pathogens.
Environmental Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment, as observed during a series of inspections. In the kitchen, the dish machine area had a rinse stream with multiple submerged inlets lacking an atmospheric vacuum breaker (AVB), posing a risk of back siphonage. The Director of Facilities was unaware of the AVB's presence. Additionally, a mop sink faucet in the first floor North clean holding room was left on and connected to a chemical pre-dispense without a device to relieve back pressure, as noted by the Director of Environmental Services. Further observations revealed that towels and washcloths were improperly stored open and exposed next to showers in the second floor North spa room and the Ventilation Unit spa room. The Life Safety Emergency Manager confirmed that linens should not be stored in this manner. On the second floor North, a tabletop ice machine was directly connected to the wastewater drain without an air gap, increasing contamination risk. In the Ventilation Unit soiled utility room, a mop sink faucet was installed over a non-functional hopper area, causing water to spill onto the floor. Lastly, the laundry room had a clean laundry cart with accumulated paper trash and debris under its false bottom.
Failure to Honor Resident's Preference for Male Caregivers
Penalty
Summary
The facility failed to maintain the dignity and self-esteem of a resident diagnosed with Parkinsonism, mood disorder, anxiety, and agoraphobia. The resident was observed wearing soiled clothing for two consecutive days, with food spills and an unclean crucifix, indicating a lack of assistance in maintaining personal hygiene. The resident reported that his breakfast had spilled the previous day, and no staff had helped him clean up. Additionally, the resident expressed discomfort with female caregivers assisting with showers, preferring male caregivers instead. However, this preference was not documented in the care plan, and the facility did not accommodate his request, leading to the resident's embarrassment and refusal to shower. The care plan for the resident, initiated in 2021, required assistance with activities of daily living, including bathing, but did not specify the resident's preference for male caregivers. The Task Monitor for showering showed limited showering activity, with refusals noted on two occasions and no applicable entries on others. Interviews with nursing staff confirmed awareness of the resident's preference for male caregivers, yet this was not reflected in the care plan. The Assistant Director of Nursing acknowledged the need for better documentation of the resident's shower refusals and attempts to reapproach, as well as the availability of a male CNA to accommodate the resident's preference.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to prevent falls for three residents, all of whom were severely cognitively impaired and at high risk for falls. Resident #87 was observed unsupervised in his room, despite requiring a walker and assistance for ambulation. He had a history of falls, including a witnessed fall while attempting to go to the bathroom and an unwitnessed fall in the hallway. The interventions listed in his care plan, such as keeping him in a supervised area while awake, were not implemented, and there was no indication of supervision when he was awake. Resident #12, who was also a fall risk, experienced multiple falls, including a witnessed fall in the day room and an unwitnessed fall in the sunroom. Despite being provided with a bell to ring for help, she did not use it, and the intervention was deemed ineffective for her cognitive impairment. The facility's interventions, such as placing Dycem in her chair and assisting her to common areas, did not adequately address her tendency to self-transfer and her need for assistance with toileting. Resident #38 had several unwitnessed falls, including in the dining room, hallway, and her room. The facility's interventions, such as gripper strips and moving her closer to the nurse's station, did not address the root causes of her falls, such as her refusal to use the bathroom and her tendency to self-transfer. The facility's documentation lacked details on her behaviors, sleep patterns, and toileting needs, and there was no clear process for determining effective interventions. The Unit Manager and ADON were unable to locate new interventions or explain how they were determined, indicating a lack of thorough investigation and appropriate response to the residents' fall risks.
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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 Alma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Healthcare Center | 2.2 mi | ★★★★★ | 3 | 0 |
| Schnepp Senior Care And Rehabilitation Center | 3.5 mi | ★★★★★ | 4 | 0 |
| Isabella County Medical Care Facility | 15.3 mi | ★★★★★ | 8 | 0 |
| The Laurels Of Mt. Pleasant | 15.3 mi | ★★★★★ | 2 | 0 |
| Medilodge Of Mt. Pleasant | 15.8 mi | ★★★★★ | 6 | 0 |
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