Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Michigan Veteran Homes At Grand Rapids during CMS and state inspections, most recent first.
Kitchen equipment and utensil storage were found soiled and in poor condition. A meat/deli slicer had dried brown food debris between the blade and surrounding metal plate, and multiple utensil storage bins near the grill contained debris on the inside surfaces with scoops, lids, tongs, and other food-contact items in direct contact with the debris. Several plastic food storage lids were also burned or melted and no longer smooth, and the NSD and NSS acknowledged the conditions.
Care plans were not revised after falls for several residents with significant fall risk factors, including dementia, Parkinson’s disease, muscle weakness, and prior falls. One resident fell when a wheelchair rolled out from under him, another had multiple incidents involving a recliner, bed transfer, and walker wheel entrapment, and a third was assisted to the floor during a self-transfer attempt. Staff stated that fall-related interventions and care plan updates were expected after incidents.
A resident with dementia, visual agnosia, impaired memory, and high fall risk had repeated falls after staff did not consistently follow the care plan for hand-in-hand guidance and supervision when walking or sitting. She fell while trying to sit on a couch and chair, and later fell in her bedroom after standing suddenly and tripping, resulting in head redness and bruising and an ED transfer. The care plan was not reviewed or revised after the falls, and the RNCM stated staff overlooked the resident’s cognitive and visual deficits.
Staff did not follow enhanced barrier precautions for two residents with wounds and medical devices, including not posting required signage, not providing PPE outside rooms, and not wearing gowns and gloves during high-contact care activities. Staff were observed providing care and handling resident belongings without full PPE, and documentation inaccurately indicated that precautions were in place. Communication breakdowns led to delayed implementation of required infection control measures.
Kitchen Equipment and Utensil Storage Not Kept Clean
Penalty
Summary
The facility failed to ensure kitchen food-contact and nonfood-contact surfaces were consistently maintained in a clean and sanitary manner or in good repair. During an observation in the main kitchen, the meat/deli slicer had dried brown food debris in several areas between the blade and the metal plate surrounding it, and the Nutrition Services Director confirmed it was soiled. The Nutrition Services Supervisor stated the slicer was newer, that a slicer training had been held the prior month with some staff not present, and that the cleaning instructions were posted near the slicer. The facility’s cleaning instructions stated that food particles can accumulate in and around parts of the slicer and allow bacteria to breed, and the cook’s cleaning list showed the slicer machine was last cleaned several days earlier, with cleaning scheduled after use. During another observation in the main kitchen, all 13 storage bins on the shelving rack near the grill had debris of various colors and sizes accumulated on the inside surfaces. These bins contained food storage lids, scoops, tongs, and other food-contact items that were in direct contact with the debris, and 5 scoops had debris stuck to their scooping surfaces. There were also 13 light brown plastic food storage container lids with burned or melted edges and areas that were no longer smooth and had lost their original form. The Nutrition Services Director reported the facility would clean the storage bins and items, and the Nutrition Services Supervisor stated he had recently been addressing with staff the need to keep the utensil storage bins clean. The report also cited Food Code requirements that food-contact surfaces be smooth and clean to sight and touch, and that equipment and utensils be kept free of accumulated debris.
Care plans not revised after resident falls
Penalty
Summary
The facility failed to review and revise comprehensive, individualized care plans after falls for residents identified as high fall risk. For Resident #13, who had diagnoses including difficulty talking and limitation of activities due to disability, the care plan identified fall risk related to psychoactive drug use and diabetes, but it was not revised after a witnessed fall in the dining room when the resident attempted to stand from a wheelchair with the locks not engaged and the wheelchair rolled out from under him, causing him to go to the ground on his bottom. For Resident #86, whose diagnoses included Alzheimer’s disease, dementia, abnormalities of gait and mobility, Parkinson’s disease, hearing loss, and muscle weakness, the care plan addressed fall risk, use of a walker, recliner safety, and other interventions. However, the record showed multiple fall-related incidents and the care plan was not revised to reflect them, including an incident where the resident attempted to climb out of a recliner with the footrest up and slid to the floor, another where he slipped down to the floor while being assisted with changing his shirt, and another where his foot became trapped in a walker wheel and he fell backward in the bistro area. For Resident #111, who had dementia, anxiety, and a history of falls, the care plan identified fall risk related to urinary dribbling, occasional bowel incontinence, psychoactive drug use, and prior falls. The record showed an incident in which the resident attempted to self-transfer from a wheelchair to a recliner in a common area and was assisted to the floor by a CNA, but the care plan was not revised to reflect the event. Staff interviews confirmed that nurses and the interdisciplinary team were responsible for updating care plans after falls and incidents, and that immediate interventions were expected following such events.
Failure to Provide Adequate Supervision and Follow Fall Care Plan
Penalty
Summary
The facility failed to provide adequate supervision and implement care planned interventions for a resident identified as high risk for falls due to being unaware of safety needs, visual agnosia, and use of psychotropic medications. The resident also had diagnoses including anxiety disorder, diabetes, Alzheimer's disease, wandering, dementia, lack of coordination, adjustment disorder, cognitive communication deficit, and need for assistance with personal care. Her care plan directed staff to anticipate and meet her needs and to provide hand-in-hand guidance with locations and directions, including walking side by side with her if she wanted to go to the bathroom or sit in a chair because she was unable to recognize familiar objects, shapes, or people. The resident experienced multiple falls in the living room and bedroom. One incident occurred when she got up from a couch, took a couple of steps, and then attempted to sit back down but misjudged the location and fell onto her bottom. Another fall occurred when she was going to sit in a chair and missed the seat. A later fall occurred in her bedroom when she stood up suddenly from bed, tripped by the blanket she was carrying, fell to the floor, and hit her head, resulting in redness and bruising to the forehead and a transfer to the emergency department. The incident documentation described her as confused, with impaired memory, gait imbalance, and impaired vision related to brain issues. Review of the care plan showed it was not noted as reviewed or revised after the falls. The RN case manager stated staff were expected to implement immediate interventions after an incident and reported that the documented hand-in-hand assistance was not reflected as being implemented when the falls occurred. The RN case manager also stated staff appeared to focus on the resident's mobility status and overlooked her documented cognitive and visual deficits, and that the pattern of repeated falls should have prompted recognition of increased fall risk.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Medical Devices
Penalty
Summary
The facility failed to implement and follow enhanced barrier precautions (EBP) for two residents with wounds and/or indwelling medical devices, as required by facility policy and physician orders. For one male resident with a cholecystectomy drain, pressure ulcer on the right heel, and a deep tissue injury to the left medial bunion, staff did not post EBP signage outside the room, nor did they wear gowns during high-contact care activities such as transferring, bed making, and adjusting the resident. Although gloves were used for some tasks, gowns were not worn, and staff were observed handling the resident and his belongings without full PPE as required. Interviews revealed that staff believed gowns were only necessary when wounds were exposed, contrary to the facility's EBP policy, which mandates gown and glove use for all high-contact care activities for residents under EBP. For another resident with an unstageable pressure ulcer on the right heel and a dialysis access site, EBP orders were in place, but there was no signage or PPE cart outside the room, and staff did not use PPE during care activities. Nursing staff documented that EBP was in place and completed each shift, but observations and interviews confirmed that EBP was not actually implemented until several days after the order was written. Staff, including an LPN and CNAs, provided care such as medication administration, wound dressing changes, and transfers without wearing gowns or gloves as required. Interviews with nursing staff, the infection preventionist, and the nursing supervisor confirmed a breakdown in communication regarding the initiation and implementation of EBP. Staff were unaware of the EBP orders or did not follow them, and documentation inaccurately reflected that precautions were in place when they were not. The failure to implement EBP as ordered and per facility policy resulted in a deficiency related to infection prevention and control.
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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 | 2.7 mi | ★★★★★ | 10 | 0 |
| Optalis Health & Rehabilitation At Leonard | 2.8 mi | ★★★★★ | 14 | 0 |
| Medilodge Of Grand Rapids | 3.1 mi | ★★★★★ | 3 | 1 |
| Edison Christian Health Center | 3.4 mi | ★★★★★ | 0 | 0 |
| St Ann's Home | 3.5 mi | ★★★★★ | 6 | 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 October 2026) and official state health department websites.