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 St Ann's Home during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and dementia was admitted to hospice, but the facility did not develop a person-centered care plan reflecting hospice services or collaboration with hospice. The hospice RN said hospice had a separate care plan and the DON and SSC gave conflicting accounts about whether hospice care was incorporated into the facility care plan, while the record showed no documented hospice-related care plan.
Failure to provide appropriate pressure ulcer care and prevent a new pressure injury occurred for a resident with Alzheimer’s disease, dementia, and anxiety disorder who had moderate pressure injury risk and required substantial to dependent assistance with bed mobility. The resident developed an unstageable pressure injury on the right lateral ankle, but the care plan did not include the wound or related positioning and pressure-relief interventions. Staff observed the resident lying on her right side with the ankle wound directly on the mattress while pressure-relieving boots were left on the dresser, and a CNA, LPN, ADON, and DON confirmed the wound-related interventions were not addressed in the care plan.
A resident with a right lateral ankle pressure wound was not placed on EBP, and no signage or care plan reflected EBP use. A CNA provided incontinent care and transferred the resident without a gown, and an LPN later performed wound care without a gown; both staff reported the resident was not on EBP. The DON stated the facility only used EBP for wounds with drainage, and the ADON said there was no need for EBP because the dressing was intact.
A facility failed to identify and address PTSD triggers for a resident with multiple diagnoses, including PTSD and Takotsubo Syndrome. The resident was observed to be agitated and expressed concerns about COVID-19 and family losses. Staff interviews revealed a lack of awareness about the resident's PTSD triggers and the absence of a care plan, leading to potential re-traumatization.
The facility failed to manage PRN psychotropic medications appropriately and did not obtain informed consent for two residents. A resident received PRN Lorazepam and Haloperidol without documented behaviors to justify their use, and another resident received PRN Lorazepam for extended periods without documented rationale. The facility did not adhere to its policy requiring PRN psychotropic drugs to be used only when necessary and for a limited duration.
The facility failed to adhere to infection prevention standards, with a housekeeper not using PPE while cleaning a resident's room under enhanced barrier precautions, and multiple staff members not performing hand hygiene during meal service. Despite education and audits, these practices were inconsistently followed, posing a risk of cross-contamination.
Failure to Document Hospice Care in the Resident Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan related to hospice services for Resident #10, a male resident with diagnoses including Alzheimer's disease and dementia. Review of the admission record showed he was admitted to the facility on [DATE], and the order summary indicated an admission to hospice with a diagnosis of Alzheimer's disease and a start date of 10/31/25. Review of the care plan showed no documented care plan related to collaboration of care between the facility and hospice services. During an interview on 1/22/26, the hospice RN stated Resident #10 had been on hospice services for a few months during this stay and had previously received hospice services as well. The hospice RN reported that hospice had a separate care plan and provided it to the facility, but she did not have access to the facility care plan and could not update it. On 1/23/26, the DON stated the SSC created the initial hospice care plan and that the hospice-provided care plan was reviewed and incorporated into the facility care plan, but also stated there was no separate care plan indicating the resident received hospice services. The SSC stated she assisted with hospice start of care but did not make any changes in the care plan to reflect the start of hospice care, and that hospice care plans were kept in the resident's record.
Failure to Care Plan and Protect a Resident’s Right Ankle Pressure Injury
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent a new pressure ulcer occurred for a female resident with Alzheimer’s disease, dementia, and anxiety disorder who required substantial to dependent assistance with bed mobility. Her Braden Scale score was 13, indicating moderate risk for pressure ulcer development, and her care plan addressed fragile skin, skin cleanliness, pressure-reducing surfaces, and pillows for comfort, but did not include care plan interventions for the later ankle wound or the related positioning and pressure-relief measures. The resident was found to have an open area on her right ankle that was first documented as a 0.5 cm open area with a white base, and later assessed as a small unstageable pressure injury on the right lateral ankle measuring 0.4 x 0.4 cm with slough present. The wound care plan included cleansing with saline, applying MediHoney gel, and covering with a silicone foam border dressing. Orders also included avoiding the tight black stocking on the right lower extremity until the wound healed, using pressure-relieving boots in bed, and not positioning her on the right ankle. During observation, the resident was seen lying on her right side with the wound on her right ankle positioned directly on the mattress, while the pressure-relieving boots were on the dresser. In interviews, a CNA reported she applied the boots because she saw them in the room and assumed they were needed, but found nothing in the care plan or Kardex about them. An LPN and the ADON confirmed there was no care plan for the ankle wound, and the DON confirmed positioning and pressure-relieving boots were not addressed in the resident’s skin integrity care plan.
Failure to Use EBP During Wound Care and High-Contact Resident Care
Penalty
Summary
The facility failed to maintain infection control practices and implement enhanced barrier precautions (EBP) for Resident #9, a female admitted with diagnoses including Alzheimer's disease, dementia, and anxiety disorder. Review of the resident's record showed a right lateral ankle pressure wound with scant serous drainage and a dressing in place, but no order for EBP, no EBP signage outside the room, and no care plan addressing the wound or EBP. The facility's policy stated that EBP should be used for residents with wounds, including chronic pressure wounds, and that gown and gloves are required during high-contact care activities such as transferring, providing hygiene, changing briefs, and wound care. On 1/23/26, a CNA provided incontinent care, changed the resident's brief, and transferred her from bed to wheelchair without wearing a gown, and reported the resident did not have a wound and was not on EBP. Later that day, an LPN provided wound care to the resident's right lateral ankle wound without wearing a gown and also reported the resident was not on EBP. The DON stated EBP were only implemented for a resident with a wound if the wound had drainage and acknowledged the resident had not been placed on EBP when the wound was noted. The ADON also stated there was no need for EBP because the wound had no drainage and the dressing remained intact.
Failure to Address PTSD Triggers in Resident Care
Penalty
Summary
The facility failed to identify and address post-traumatic stress disorder (PTSD) triggers for a resident, resulting in a deficiency in providing trauma-informed care. The resident, who was admitted with diagnoses including PTSD, depression, bipolar disorder, chronic respiratory failure, and Takotsubo Syndrome, was observed to be agitated after exercising, expressing concerns about COVID-19 due to her respiratory issues and discussing the loss of family members. Despite these indicators, the resident's chart lacked an assessment for PTSD triggers or a care plan addressing trauma or mood/behavior interventions. Interviews with facility staff, including a CNA, LPN, and the Assistant Director of Nursing, revealed a lack of awareness regarding the resident's PTSD triggers and the absence of a care plan. The Nursing Home Administrator confirmed that the Social Worker acknowledged the missing PTSD care plan. This oversight resulted in the potential for re-traumatization, as staff were not informed or knowledgeable about the resident's past trauma and specific triggers.
Failure to Manage PRN Psychotropic Medications and Obtain Informed Consent
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications did not extend beyond 14 days, that there was a continued indication for the use of psychotropic and antipsychotic medications, and that informed consents for medications were obtained for two residents. This resulted in the risk of serious side effects and adverse reactions from potentially unnecessary medications. The report highlights that the facility did not document behaviors or agitation that would justify the administration of PRN medications for the residents involved. Resident #23 was admitted with diagnoses including dementia, depression, and anxiety. The resident received PRN Lorazepam and Haloperidol without documented behaviors or agitation to justify their use. The facility's records lacked documentation of informed consent for these medications. Additionally, the facility's policy required PRN psychotropic drugs to be used only when necessary to treat a diagnosed condition and for a limited duration, which was not adhered to in this case. Resident #27, who was moderately cognitively impaired and on hospice care, also received PRN Lorazepam for extended periods without documented rationale for continued use beyond 14 days. The facility did not provide documentation for the rationale for the extended use of PRN Lorazepam, and there was no evidence of informed consent for the medication. Interviews with facility staff and hospice personnel revealed a lack of communication and documentation regarding the necessity and consent for the continued use of these medications.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to professional standards of infection prevention, specifically in the use of personal protective equipment (PPE) for enhanced barrier precautions and hand hygiene during dining and meal service. The report highlights two main deficiencies. Firstly, a housekeeper did not don the required PPE, such as a gown and gloves, while cleaning the room of a resident under enhanced barrier precautions due to leg wounds and pressure ulcers. This was observed despite the facility's signage indicating the necessity of PPE for high-contact activities like changing linens. Interviews with the Director of Environmental Services and the Director of Nursing revealed that while education and audits on enhanced barrier precautions were conducted, the facility struggled with consistent implementation. Secondly, multiple instances of inadequate hand hygiene were observed during meal service. A Certified Nursing Assistant (CNA) was seen passing out lunch trays and assisting residents with meals without performing hand hygiene between tasks. This included handling utensils and cups for different residents without sanitizing hands in between. Similar observations were made with another CNA and a Registered Nurse (RN) in the memory care area, where they assisted multiple residents with eating without completing hand hygiene between each resident. Interviews with staff indicated an understanding of the hand hygiene protocol, but it was not consistently followed due to being busy or understaffed. The report also notes that hand sanitizer was available on meal delivery carts, and other staff members were observed using it. However, the failure to perform hand hygiene between resident interactions during meal service was a recurring issue. Staff interviews confirmed that hand hygiene should be performed between each resident interaction, but this was not always feasible due to workload and staffing levels. The facility conducted audits and provided education on hand hygiene, but the observations indicate a gap in adherence to these protocols.
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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) |
|---|---|---|---|---|
| Edison Christian Health Center | 0.4 mi | ★★★★★ | 16 | 0 |
| Covenant Village Of The Great Lakes | 1.1 mi | ★★★★★ | 5 | 0 |
| Valley View Care Center | 1.6 mi | ★★★★★ | 13 | 2 |
| Mary Free Bed Sub-acute Rehabilitation | 3.4 mi | ★★★★★ | 2 | 0 |
| Michigan Veteran Homes At Grand Rapids | 3.5 mi | ★★★★★ | 0 | 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.