Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 The Villa At Rose City during CMS and state inspections, most recent first.
Food service practices were not maintained according to policy and Food Code standards. Chopped tomatoes were found in a refrigerator without date marking, the ice machine had calcium buildup and unclear cleaning frequency, two dirty cups were sitting in a handwashing sink basin, and cold foods including ranch and a salad were observed above the required 41 F holding temperature.
Infection Control Program Not Fully Implemented: The facility failed to operationalize its IC program by not completing process surveillance, not tracking potential infections or residents with signs/symptoms who were not on antimicrobials, and using incomplete and inconsistent surveillance data. The IC RN’s monthly line list excluded carry-over infections and did not identify whether UTIs met treatment criteria or were catheter-associated, while the IC summary contained conflicting antibiotic counts. Three facility-acquired E. coli UTIs occurred on the same wing with the same staff, but the trend was not identified. A resident with shingles was treated with Bactrim DS and placed on contact precautions, but the documentation did not specify when precautions started, and the IC RN stated she was unaware shingles required airborne precautions.
Failure to Monitor and Track Antibiotic Use: The facility did not operationalize a comprehensive antibiotic stewardship program or consistently use McGeer criteria to track antibiotic therapy. The IC RN reported that the monthly line list and summary did not show whether infections met criteria or whether treatment was appropriate, and forms were not completed for residents admitted on antimicrobial therapy. One resident received Azithromycin for a URI that the McGeer form showed did not meet treatment criteria, and the concern was not addressed with the HCP. Another resident was admitted with a UTI and received an antibiotic despite no growth on culture, with no McGeer form completed.
Unsanitary resident room and improper backflow device setup: A resident with extensive behaviors, ADL dependence, chronic lung disease, stroke, depression, and right-sided hemiplegia had a mattress on the floor, and the room floor was observed dirty with dried liquid, paper, debris, and scuff marks. Housekeeping said the room should be cleaned early and as needed, and the facility’s daily cleaning duties required resident floors to be cleaned daily. Surveyors also observed chemical feed downstream of AVBs at utility sinks in the kitchen and both nursing station janitor’s closets.
The facility failed to maintain resident dignity for multiple residents. One resident with an indwelling catheter was observed with the drainage bag uncovered and visible, another resident’s catheter bag was also left without a privacy cover and the bed sheet had dried blood on it, residents reported cold food being served, and a resident who depended on staff for ADLs had a call light placed out of reach despite a care plan directing that frequently used items remain within reach.
Missing Stop Date for PRN Ativan Order: A resident with DM, anxiety, depression, and hospice needs had a PRN Ativan order with a blank end date, resulting in no 14-day stop date being documented. The chart showed the PRN Ativan was reinstated as ordered, but there were no further notes on the order.
A resident with stroke, dementia, and major depressive disorder had a care plan that was not updated to reflect current leisure preferences. Surveyors observed the resident in bed with the blind closed and later asking for the shade to be opened to see the bird feeder, while the record showed the resident enjoyed feeding and watching birds, but the care plan instead referenced watering plants and did not mention opening the blind or bird feeding.
Inaccurate documentation of PICC and IV therapy care. A resident with a PICC line and IV antibiotics had the line removed after the antibiotic course ended, but the chart still contained an active PICC-related care plan and daily skilled nursing notes continued to list Medication Management/IV Therapy as a skilled service even though the resident was no longer receiving IV meds. The RN and DON both confirmed the documentation was inaccurate and that the resident did not currently have a PICC line.
Failure to Provide Oral Care Assistance: A resident who required help with ADLs was observed with significant buildup on the teeth and unkempt grooming, and stated they had not brushed their teeth since admission. The resident's EMR showed moderate cognitive impairment and a need for set-up and clean-up assistance with oral hygiene, while the care plan called for staff assistance with daily care needs. The DON acknowledged staff should provide oral care for residents needing assistance and that the condition observed was not standard of care.
The facility failed to properly assess, document, and monitor wound care for two residents and used an unordered positioning device for another resident. One resident had an old, undated dressing over a left elbow skin tear with no wound treatment order in place when the skin evaluation was completed, another had an undated right forearm dressing with no MAR/TAR treatment order after a Hoyer-pad skin tear, and a third resident had a dirty wedge in the room despite no physician order or care plan for its use. Staff interviews confirmed the device was not ordered and should not have been in the room.
Failure to prevent facility-acquired pressure injuries was identified for two residents. One resident at risk for skin breakdown was repeatedly observed in bed with heels resting on the mattress while ordered heel-protective boots were off and no heel offloading was in place; the resident later developed bilateral heel DTIs, including a blood-filled heel blister and dark DTI areas. The record also noted prior foot injury, edema, pain, and friction-related blistering associated with orthopedic boot use.
Respiratory Equipment Storage and Oxygen Safety Deficiencies: A resident with COPD had a nebulizer mask stored uncontained in a dresser drawer with visible fluid in the medication chamber, and another resident with COPD had oxygen tubing lying on the floor while the concentrator was still running when the resident was out at dialysis. The EMR showed ordered nebulizer treatments for one resident and oxygen therapy for the other, but no oxygen safety instruction was noted.
Improper Storage and Labeling of Medications in Resident Room: A resident with multiple diagnoses including a sacral wound, CKD, depression, and weakness had Dakin’s solution and an opened tube of Diclofenac found in the room during observation. The Dakin’s was sitting in an unlabeled cup with no top, name, or date, and the Diclofenac was on the bedside table despite being discontinued and having no current order or EMAR/TAR documentation. An LPN confirmed the Diclofenac should not have been in the room and that the Dakin’s should not have been left in a cup there.
Failure to provide fresh bedside fluids for a resident who usually wanted chocolate milk. The resident was observed awake in bed with a dated cup of brown liquid on the nightstand and no other fluids nearby, while CNA S identified the drink as old chocolate milk. The resident had stroke, dementia, major depressive disorder, required ADL assistance, and had severely impaired cognition.
The facility failed to maintain the correct concentration of sanitizer in the dietary department, essential for disinfecting food preparation areas. Observations revealed that the sanitizer solution used for wiping cloths was below the required concentration, and at times, registered zero ppm of quaternary ammonium sanitizer. The Certified Dietary Manager acknowledged the issue and noted the absence of a written procedure for the sanitizing process.
The facility failed to secure and properly store medications and medical supplies, with undated glucometer strips, an unlocked treatment cart with expired medications, and improper storage in the medication room. The medication refrigerator was not monitored per CDC guidelines, and the DON acknowledged these lapses.
A resident with a PICC line had an undated, loose, and peeling dressing, contrary to the facility's protocol for weekly changes. Despite hospital discharge instructions to use normal saline for flushing, the facility used heparin, as confirmed by an LPN. The DON could not explain the discrepancy between the hospital's instructions and the facility's practice, highlighting a deficiency in PICC line management.
A facility failed to discontinue a resident's PRN Melatonin despite two physicians' orders to do so. Behavioral Health Solutions recommended discontinuation as the resident had no insomnia complaints and had not used the medication. The physician signed off on these recommendations, but the medication remained active in records from December to March. Interviews with the DON and Director of Social Services confirmed the oversight.
Three residents with dementia and a history of falls experienced repeated unwitnessed falls and significant injuries due to inadequate supervision and insufficient interventions. Despite being identified as high risk for falls, the facility's measures, such as environmental adjustments and increased supervision, were not effectively implemented, resulting in injuries including hip fractures and a laceration.
Food Storage, Ice Machine, Hand Sink, and Cold Holding Deficiencies
Penalty
Summary
Food service practices were not maintained in accordance with professional standards during the kitchen tour and meal observation. Chopped tomatoes were observed in the two-door refrigerator without a date mark, and the Certified Dietary Manager stated she did not know when they had been chopped. The facility policy required refrigerated prepared food, including leftovers, to be labeled with a discard or use-by date, with the day of preparation counted as Day 1 and a maximum of six days after preparation. The report also cited the 2022 Food Code requirement that ready-to-eat, time/temperature control for safety food held for more than 24 hours be clearly marked with the date or day by which it must be consumed or discarded. Additional food service observations showed calcium buildup on the interior walls of the kitchen ice machine, while the Certified Dietary Manager was unsure how often it was cleaned and the Maintenance Director stated it was cleaned every 3 months. The facility’s ice machine cleaning log showed the task as completed on 1/31/2026, 10/31/2025, 7/31/2025, and 4/30/2025. Two dirty cups were also observed sitting in the basin of a handwashing sink in the kitchenette. During lunch observation, ranch dressing was measured at 44 F and a salad made with lettuce, tomato, and cheese was measured at 49 F, while the Certified Dietary Manager stated cold foods should be held at 41 F. The facility policy stated cold foods should be plated at 41 F or lower, and the report cited the Food Code requirement that time/temperature control for safety food be maintained at 41 F or less.
Infection Control Program Not Fully Implemented
Penalty
Summary
The facility failed to implement and operationalize a comprehensive Infection Control (IC) program that included outcome and process surveillance, comprehensive data collection, tracking of potential infections, analysis, and trend identification. During review of the November 2025 IC records, the IC RN stated that hand hygiene was one of the most important infection prevention measures and that staff compliance was monitored by observation. However, no process surveillance documentation was provided for the month, and the IC RN stated that no IC audits or process surveillance were completed because she was pulled to the floor frequently, especially on nights. The infection line list for November 2025 only included residents treated with antimicrobial therapy and did not include carry-over infections from October 2025. It also did not indicate whether UTIs met criteria for antimicrobial treatment or whether the UTIs were associated with indwelling urinary catheters. The facility maintained a separate carry-over infection line list, but those infections were not included on the mapping tool used as a visual guide to identify possible infection trends. The IC summary also contained inconsistent data, stating both that 12 residents and 15 residents were admitted on antibiotics. The DON acknowledged that potential infections should be tracked, but the facility did not track residents with signs or symptoms of infection who were not receiving antimicrobial treatment. Review of the facility-acquired UTIs showed four infections, three of which were caused by Escherichia coli. The mapping tool showed the residents with these E. coli UTIs resided on the same wing and were cared for by the same staff, but the IC summary did not identify this as a trend. The IC RN initially stated the residents were not on the same hall, then confirmed they were on the same wing and acknowledged the pattern was an oversight. The line list also identified a resident with shingles who was treated with Bactrim DS and placed on contact precautions, but the documentation did not specify when precautions began. The IC RN stated she was unaware shingles required airborne precautions and did not explain why the resident with a viral infection was treated with an antibiotic. No IC education was completed for the month related to identified IC concerns.
Failure to Monitor and Track Antibiotic Use
Penalty
Summary
The facility failed to implement and operationalize a comprehensive antibiotic stewardship program that included a facility-wide system to monitor, track, and ensure accountability for antibiotic use. During review of the infection control program, the Unit Manager IC RN stated the facility used McGeer criteria, but the November 2025 line list and summary did not show whether infections met McGeer criteria for treatment or include information about the appropriateness of treatment. The summary also did not identify the number of infections that met criteria, and the facility did not maintain copies of the McGeer forms outside the EMR. Review of Resident #80’s records showed two infections on the line list. One was listed as a facility-acquired URI with Azithromycin given from 11/16/25 to 11/20/25, but the McGeer Infection Symptom Tracking form showed respiratory signs and symptoms were observed on 11/14/25 and that the resident did not meet criteria for treatment of an upper or lower respiratory infection. The RN confirmed the infection did not meet criteria and stated it was not addressed with the HCP. The line list also identified a community-acquired gastritis diagnosis with Micafungin given from 11/7/25 to 11/18/25, but no McGeer form was available for that resident because the facility did not complete the form for residents admitted on antimicrobial treatment. The line list also included a resident admitted with a UTI who received Zofran from 11/1/25 to 11/2/25, with the organism listed as no growth. The RN stated no McGeer form was completed because the resident arrived on antibiotic therapy, and could not explain why the resident was receiving an antibiotic when the culture and sensitivity showed no growth. The DON stated McGeer criteria should be completed for every resident who receives an antibiotic, whether treatment was initiated in the facility or not, and acknowledged concern that the monthly summary did not address residents who did not meet criteria for treatment. The facility policy provided, Infection Prevention and Control Guideline, did not address antibiotic stewardship.
Unsanitary resident room and improper backflow device setup
Penalty
Summary
The facility failed to ensure a sanitary environment for one resident reviewed for a clean environment and a safe environment for all residents currently residing in the facility. Resident #18 was 76 years old, admitted to the facility, alert but unable to make his own healthcare decisions, dependent on staff for activities of daily living, and exhibited extensive behaviors. His diagnoses included chronic lung disease, adjustment disorder, depression, stroke, and right-sided hemiplegia. His care plan noted that his mattress was kept on the floor because of a fall history, behaviors, and his preferences, and nursing notes documented that he often put himself on the floor. On observation, the resident’s mattress was sitting directly on the floor, and the room floor was very dirty with dried liquid areas by the door and head of the bed, along with several pieces of paper, dirt, debris, and scuff marks throughout the room. The Director of Housekeeping stated that housekeeping cleaned early in the morning and that the resident’s room should be cleaned early and as needed because his mattress was on the floor. The facility’s daily cleaning duties stated that residents’ floors were to be cleaned daily. In addition, surveyors observed chemical feed downstream of an atmospheric vacuum breaker at utility sinks in the kitchen janitor’s closet and both nursing station janitor’s closets, and the Michigan Cross Connection Manual states AVBs shall not be installed where they will be under continuous pressure for more than 12 hours.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure dignity for residents who had urinary catheters and for a resident who could not reach the call light. Resident #45 was observed lying in bed with an indwelling urinary catheter drainage bag on the side of the bed toward the room door, not contained in a bag and without a dignity cover. The resident’s urine was described as very dark and the color of coke. The resident’s record showed cognitive intactness, dependence for most ADLs, and an indwelling urinary catheter. The care plan directed staff to keep the draining bag covered to promote privacy, and the DON stated catheter drainage bags should be in dignity bags. Resident #5 was observed in bed with the urinary catheter bag within sight of the open door and without a concealed privacy cover. The bag was about one-quarter full of urine, and dried blood was seen on the right upper bottom sheet. The resident stated the blood was from the prior night and said she was waiting for staff to change the sheet because her IV had started bleeding. Her record showed she was alert and able to make her own healthcare decisions, dependent on staff for ADLs, and had diagnoses including low back pain, muscle wasting, osteomyelitis, a sacral wound, urinary catheter in place, adjustment disorder, major depression, and chronic kidney disease. Staff interviews confirmed the need for a privacy bag on the catheter. Resident #26 stated that food was sometimes cold and that she usually ordered cold foods because food was not served hot. During a resident group meeting, 4 of 5 attendees said the facility served cold food and they did not complain because they did not want to get anyone in trouble. Resident council minutes documented complaints about cold food being served. Resident #62 was observed in bed with the call light hanging over the wall-mounted call light system, approximately 4 to 4.5 feet away and out of reach, with the room door shut. The resident’s care plan directed staff to keep frequently used items, including the call light, within reach, and a CNA stated the resident could use the call light.
Missing Stop Date for PRN Ativan Order
Penalty
Summary
The facility failed to provide a stop date for an as-needed Ativan order for Resident #21, resulting in no 14-day stop date being documented. On 4/22/2026, review of the physician’s orders showed Ativan 0.5 mg by mouth every 6 hours as needed for anxiety with a start date of 4/4/2026, and the end date column was blank. Resident #21 was admitted with diagnoses including diabetes mellitus, adjustment disorder with anxiety and depressed mood, required assistance with ADLs, and had intact cognition. The care plan noted the resident had a terminal/end-stage prognosis and required hospice care, with interventions for symptom management coordinated between hospice and the facility. Progress notes showed that on 4/4/2026 the PRN Ativan was reinstated as ordered, and there were no further notations on the PRN Ativan order.
Care Plan Did Not Reflect Resident’s Bird-Feeding Preference
Penalty
Summary
The facility failed to update Resident #49’s care plan in a timely manner and the care plan did not reflect the resident’s current preferences. Resident #49 was admitted with diagnoses including cerebral infarction (stroke), dementia, and major depressive disorder, required assistance with ADLs, and had severely impaired cognition. Survey observations found the resident lying in bed awake with the room dark and the blind pulled closed on 4/20/2026 and again on 4/21/2026, when the resident asked the surveyor to pull back the shade so they could look out the window and see the bird feeder. The resident stated they filled the feeder every other day or every other month. Record review showed the resident’s leisure preferences included choosing how to spend the day, enjoying visits from friends and family, and enjoying feeding and watching birds out the window. The recreational services record also stated the resident enjoyed watching out the window and spending time with a longevity companion, and noted the resident liked to feed and watch the birds, but the care plan did not mention feeding the birds or ensuring the blind was open. On 4/22/2026, the longevity companion said they visited three times a week and helped fill the bird feeder, and the Activities Director and DON were informed that the care plan stated the resident liked to water plants and did not reflect that the resident fed the birds. The DON told the Activities Director to provide a plant in the resident’s room, but when the room was checked there was no plant present.
Inaccurate Documentation of PICC and IV Therapy Care
Penalty
Summary
The facility failed to ensure accurate documentation of care for one resident with a PICC line and IV antibiotic therapy. The resident was admitted with diagnoses including heart disease, CHF, diabetes mellitus, COPD, and lymphedema, and was cognitively intact but required moderate to total assistance with ADLs. The resident stated they had been admitted with a PICC line and IV antibiotics and that the PICC had been removed at the facility; no PICC was observed in either upper extremity during the surveyor’s observation. Record review showed the resident had an active care plan for infection risk related to a PICC line, including dressing changes, flushing the PICC, and monitoring the site, even though an order to remove the PICC had been received and the last IV antibiotic dose and final PICC flush had already occurred. Daily skilled nursing notes continued to document the resident as receiving skilled services for Medication Management/IV Therapy on multiple dates after IV therapy had ended, and a care management note still listed IV antibiotics as a discharge barrier. The Unit Manager/Infection Control RN and the DON both acknowledged the documentation was inaccurate, and the DON confirmed the resident was not currently receiving IV antibiotics and did not have a PICC line.
Failure to Provide Oral Care Assistance
Penalty
Summary
The facility failed to ensure oral care was provided for one resident who required assistance with activities of daily living. On observation, the resident was in bed with unkempt, uncombed hair, and while speaking, the resident's teeth were noted to have a significant, visible amount of build up. When asked whether they could brush their own teeth, the resident stated they needed help and said they had not brushed their teeth since being admitted to the facility. With the resident's permission, the bathroom and room were toured, and one unopened toothbrush was found in the top drawer of the dresser. Record review showed the resident was moderately cognitively impaired and required set-up and clean-up assistance for oral hygiene. The care plan identified the resident as needing assistance with daily care needs related to altered mobility and pain, with an intervention to assist with ADLs. During interview, the DON stated staff should provide oral care for residents who require assistance and acknowledged that the resident's report of not having brushed their teeth since admission, along with the unopened toothbrush and visible buildup on the teeth, was not standard of care.
Wound Care Documentation and Unordered Positioning Device
Penalty
Summary
The facility failed to assess, monitor, and document wound care for two residents and improperly used a positioning device for another resident. For Resident #75, who had diabetes mellitus, pneumonia, COVID positive status, required assistance with ADLs, and had intact cognition, staff observed an occlusive dressing on the left elbow/forearm dated 4/17 while the resident reported bumping the area after a fall the day before. When the dressing was removed, the wound measured about 1 cm by 1 cm, the wound bed was red and shiny, and a small amount of bloody drainage was noted. Nurse U stated the doctor would be called and treatment ordered after the dressing was removed. Record review for Resident #75 showed a readmission after a two-day hospital stay and a nursing admission/re-admission skin evaluation started on 4/19 and completed on 4/20 that documented a skin tear to the left elbow measuring 1 cm x 1 cm x 0 cm, with bruising noted throughout the arms, legs, and left buttock. The skin evaluation also indicated there was an order for all wounds requiring treatment, yet the physician orders did not include a skin treatment order for the left elbow until after Nurse U assessed the skin tear on 4/20. The DON stated that if the documentation was incorrect, it would have to be struck out. For Resident #5, who was alert, able to make healthcare decisions, and dependent on staff for ADLs, staff observed a dirty dark blue positional device/wedge on the floor at the bottom of the bed. The resident stated staff used it to get her off her hip and for her butt. Review of physician orders and care plans found no order or care plan for the device, and OT, the unit manager, the charge nurse, and the DON all stated there should not be a wedge/device in the room and that it was not ordered. For Resident #12, a right forearm dressing was observed with no date or initials, and the resident could not recall when it was applied. The next day the same dressing remained in place without date or initials, and the resident stated nobody changed it. Record review showed a skin tear from a Hoyer pad during transfer, but there was no order for a dressing to the right forearm and no treatment on the MAR or TAR, despite the facility wound care policy requiring dressings to be labeled with initials, time, and date.
Failure to Prevent Facility-Acquired Heel DTIs
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for two residents. Resident #6 was documented as being at risk for pressure ulcers/injuries on the significant change MDS, with no unhealed pressure ulcers at that time. However, observations showed the resident repeatedly in bed with heels resting on the mattress, regular socks on, and the gray Prafo boots not on the feet despite being present in the room or wheelchair. No extra pillows were noted for heel elevation or offloading. The record also showed a prior fall with left foot fracture, bruising, edema, pain, limited range of motion, and later skin findings including a blister thought to be caused by friction from an orthopedic boot and gripper socks, abrasions to the lower back and left buttocks, and a fluid-filled blister to the right heel. By 4/21/2026, the resident had bilateral heel injuries described as deep tissue injuries, including a blood-filled right heel blister and dark areas on the left heel. The RN stated the right heel deep tissue injury was new and that it had not been present the prior week. The facility’s prevention policy required daily skin inspection, inspection of pressure points, repositioning as indicated, and regular monitoring of medical devices for pressure-related injury. The report also identified Resident #29 as part of the deficiency, but no additional details for that resident were included in the provided text.
Respiratory Equipment Storage and Oxygen Safety Deficiencies
Penalty
Summary
Sanitary nebulizer storage was not provided for Resident #2, who was admitted with diagnoses including heart disease, CHF, diabetes mellitus, COPD, and lymphedema and was cognitively intact per the MDS. On 04/20/26, the resident was observed in bed with a nebulizer machine on the dresser, tubing going into the top dresser drawer, and a nebulizer mask sitting in the drawer. The mask was uncontained and connected with visible fluid present in the medication administration chamber. The resident confirmed they were receiving nebulizer treatments. The MAR showed DuoNeb breathing treatments ordered every six hours from 4/12/26 to 4/19/26, and on 4/21/26 the nebulizer mask was again observed in the top drawer with visible fluid in the chamber. Safe oxygen administration was not provided for Resident #77, who was readmitted with diagnoses including diabetes mellitus, COPD, and dependence on renal dialysis and required assistance with daily care needs with intact cognition. On 4/20/26, the resident was observed in a wheelchair in their room with oxygen via nasal cannula. Later that morning, the resident was out of the room, and the oxygen cannula was lying on the floor with the concentrator running. A nurse was asked about the resident's whereabouts and stated the resident was out of the building at dialysis. When the running oxygen tubing on the floor was shown to the nurse, the nurse stated, "oh, I will take care of that," donned PPE, discarded the tubing, and shut off the concentrator. The EMR showed oxygen therapy related to COPD with O2 via nasal cannula at 2-4 LPM, and there was no intervention noted regarding oxygen safety instructions.
Improper Storage and Labeling of Medications in Resident Room
Penalty
Summary
The facility failed to ensure that drugs and biologicals used in the facility were labeled and stored in accordance with accepted professional principles for one resident reviewed for medication storage. Resident #5 was 61 years old, admitted to the facility, alert and able to make her own healthcare decisions, and dependent on staff for activities of daily living. Her diagnoses included low back pain, muscle wasting, muscle weakness, osteomyelitis, a sacral wound, urinary catheter in place, adjustment disorder, major depression, and chronic kidney disease. Her mood problem care plan directed staff to administer medications as ordered and monitor for side effects, and the facility policy stated medications were to be given per the 5 Rights and not left at the bedside or unattended in the resident’s room. During observation, a small cup of liquid identified as Dakin’s solution for wound care was found sitting next to the sink on the counter in the resident’s room, with no top, no resident name, and no dates on the cup. During a second observation, an opened and partly used tube of Diclofenac Sodium Topical 1% was found sitting on the resident’s bedside table, also with no name and no dates. Record review showed the Diclofenac topical cream had been ordered on 11/11/24 and discontinued on 1/6/25, and there was no order or documentation on the EMAR/TAR for the resident receiving Diclofenac topical cream. The resident’s orders also showed Dakin’s solution was ordered for the sacral wound, and the EMAR showed staff were using it as ordered. An interview with the East Unit Manager, LPN, confirmed the Diclofenac had been discontinued and should not have been in the room, and that the Dakin’s solution should not have been in a cup in the room.
Failure to Provide Fresh Bedside Fluids
Penalty
Summary
The facility failed to provide fresh fluids at bedside for Resident #49, who was reviewed as one of six residents for bedside fluids. On 4/20/2026 at 11:06 AM, the resident was observed lying awake in bed with one Styrofoam cup on the nightstand containing brown liquid and dated 4/18, along with an empty Coke bottle on the overbed table; no other fluids were present at bedside. When asked later that morning, CNA S stated the resident usually only wants chocolate milk. During a follow-up observation, CNA S identified the dated cup as chocolate milk and acknowledged it was old, telling the resident a new cup would be brought. The resident stated they had just been given the drink and that it was half full. Record review on 4/21/2026 showed the resident had diagnoses including cerebral infarction (stroke), dementia, and major depressive disorder, required assistance with ADLs, and had severely impaired cognition.
Sanitizer Concentration Deficiency in Dietary Department
Penalty
Summary
The facility failed to maintain the correct concentration of sanitizer in the dietary department, which is essential for disinfecting food preparation areas. During a tour, it was observed that the sanitizer solution in the red bucket, used for wiping cloths, measured only 50-100 ppm, whereas the required concentration is 200-400 ppm. On a subsequent visit, the sanitizer solution did not register any quaternary ammonium sanitizer, indicating a complete lack of disinfectant. The Certified Dietary Manager (CDM) acknowledged the discrepancy and noted the absence of a written procedure for the sanitizing process. Further inspection revealed that the sanitizer bucket continued to show zero ppm of quaternary ammonium sanitizer, despite containing a wiping cloth ready for use. The CDM provided an undated guide titled 'Sanitizer Sink Procedure,' which specified the required concentration levels. The FDA Food Code 2017 mandates that wiping cloths used for counters and equipment surfaces must be held in a chemical sanitizer solution at specified concentrations, which the facility failed to meet. This deficiency was identified through observation, interview, and record review, highlighting a lapse in maintaining professional standards for food safety.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications and medical supplies were secured, stored, and disposed of according to professional standards. During a tour of the medication cart on the C and D hall, undated glucometer testing strips were found, and the LPN confirmed they should have been dated. Additionally, a treatment cart near the C hall entrance was found unlocked and unattended, containing both prescription and OTC medications. The RN confirmed the cart was unlocked and contained open, undated, and expired wound care dressings, as well as expired prescription creams that were still being used on residents. In the medication room, items were improperly stored under the sink, and multiple expired items, including laboratory blood tubes and syringes, were found. The medication refrigerator, which contained vaccines, was only monitored once a day, contrary to CDC guidelines that recommend twice-daily checks. The Director of Nursing acknowledged that supplies should not be stored under the sink and that expired items should be disposed of. The facility's policy on medication storage was not followed, as it requires medications and biologicals to be stored securely and outdated items to be immediately removed.
Deficiency in PICC Line Management and Care
Penalty
Summary
The facility failed to implement and operationalize policies and procedures for the management and care of a Peripherally Inserted Central Catheter (PICC) for a resident. The resident, who had undergone spinal fusion surgery and was wearing a neck immobilizer brace, was observed with an undated, loose, and peeling transparent dressing over the PICC line insertion site. The resident was unsure of the last dressing change date, and the facility records indicated the dressing was last changed on 2/26/25, despite the requirement for weekly changes. The resident's hospital discharge instructions specified the use of normal saline for flushing the PICC line, but the facility was using heparin as per their protocol and Health Care Provider (HCP) order. The Director of Nursing (DON) was unable to provide an explanation for the discrepancy between the hospital's discharge instructions and the facility's practice. Additionally, the Licensed Practical Nurse (LPN) confirmed using a 5 mL syringe of heparin for flushing, contrary to the recommendation of using a syringe barrel size of 10 mL or greater. The facility's failure to adhere to evidence-based best practices for PICC line care was further highlighted by a study recommending the discontinuation of heparin use in favor of normal saline. The facility's policy did not align with this recommendation, and the DON was unable to clarify the rationale behind the current practice. This deficiency in care and management of the PICC line was observed over multiple days, indicating a systemic issue in the facility's adherence to proper protocols.
Failure to Discontinue Unnecessary Medication
Penalty
Summary
The facility failed to follow two physicians' orders to discontinue a medication for a resident, leading to a deficiency in the management of unnecessary medications. The resident had an active order for Melatonin, prescribed as needed for insomnia, despite recommendations from Behavioral Health Solutions (BCS) to discontinue the medication. The BCS recommendations, dated 12/29/2024 and 2/25/2025, indicated that the resident had no complaints of insomnia and had not used the PRN Melatonin. Both recommendations were signed by the physician, agreeing to discontinue the medication. Despite the physician's agreement to discontinue the Melatonin, the medication administration records for December 2024 through March 2025 showed that the order remained active. Interviews with the Director of Nursing (DON) and the Director of Social Services confirmed that the Melatonin order was not discontinued until 3/5/2025, contrary to the physician's signed recommendations. The facility's policy stated that medications should only be administered upon the written order of a licensed prescriber, highlighting a failure to adhere to this policy.
Inadequate Supervision Leads to Repeated Falls and Injuries
Penalty
Summary
The facility failed to provide adequate supervision and timely interventions for three residents, resulting in repeated unwitnessed falls and significant injuries. Resident #1, who had a history of falls and was diagnosed with dementia, experienced multiple falls, including one that resulted in a laceration to the left eyebrow and another that led to a right hip fracture. Despite being identified as high risk for falls, the interventions in place were insufficient to prevent these incidents. The care plan included supervision during ambulation and environmental adjustments, but these measures did not prevent the falls. Resident #2, also diagnosed with dementia and a history of falls, suffered a hip fracture after multiple unwitnessed falls. The resident was found on the floor on several occasions, indicating a lack of adequate supervision and fall prevention measures. The care plan for Resident #2 included environmental modifications and supervision, but these interventions were not effectively implemented, leading to the resident's injury. Resident #3, with a history of dementia and a recent subdural hematoma, experienced several falls, both witnessed and unwitnessed. Despite being identified as high risk for falls, the resident continued to fall, indicating that the interventions in place were not sufficient. The care plan included the use of non-slip materials and increased supervision, but these measures were not adequately enforced, resulting in repeated falls. The facility's failure to provide appropriate supervision and timely interventions for these residents highlights a significant deficiency in fall prevention and resident safety.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 19 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rose City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villa At West Branch | 11.7 mi | ★★★★★ | 1 | 0 |
| Wellspring Lutheran Services | 21.1 mi | ★★★★★ | 3 | 0 |
| Medilodge Of Sterling | 22.8 mi | ★★★★★ | 6 | 0 |
| Mission Point Nursing & Physical Rehabilitation Of | 23.3 mi | ★★★★★ | 9 | 0 |
| Iosco County Medical Care Facility | 31 mi | ★★★★★ | 30 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.