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 Grand Rapids Care Center during CMS and state inspections, most recent first.
Improper Storage of Food and Drinks in Kitchenette Refrigerator: Surveyors found multiple food and drink items in the kitchenette refrigerator that were unlabeled, undated, outdated, or expired, including pizza, a sandwich, yogurt, juices, spaghetti, soda, seltzer water, pretzels, and an onion. An aide verified the items, and the DM confirmed the refrigerator was for resident use only and that food should be properly labeled and dated per facility policy.
Smoking Care Plan Not Timely Developed: A resident with COPD, vascular dementia, CVA, and hospice services was identified as a current smoker, but the record did not show a smoking care plan or interventions at the time of review. The resident was observed smoking outdoors under staff supervision, and an LPN could not locate a smoking care plan. The SSD later stated the resident was care planned for smoking, and the care plan was shown as created/updated during the survey.
A resident with paraplegia, a chronic heel and foot ulcer, COPD, PVD, CKD, and depression was on IV antibiotics for osteomyelitis and was care planned for EBP with close contact care. During PICC/IV care, an RN wore gloves but did not use the correct PPE required by the facility’s EBP policy and posted signage, which called for gown and gloves during high-contact device care.
A resident with dementia and significant care needs was subjected to verbal abuse by a CNA, who used explicit and derogatory language, called the resident 'stupid,' and made the resident apologize to others in the dining room. Multiple witnesses, including staff and residents, confirmed the CNA's inappropriate and demeaning behavior, which violated the facility's abuse policy.
A resident with cognitive impairment and complex behavioral needs was subjected to verbal abuse by a CNA, who used explicit and demeaning language in front of others and forced the resident to apologize publicly. Multiple witnesses, including staff and residents, confirmed the incident, but it was not reported to management until a visitor brought it to attention two days later, contrary to facility policy requiring immediate reporting of abuse allegations.
The facility failed to revise a resident's care plan to include supports and interventions for depression and related antidepressant use. Despite physician orders for mirtazapine and Zoloft, the care plan did not address the resident's depression. The DON confirmed the absence of care plan supports, contrary to the facility's policy requiring comprehensive care plans to be updated at least every 90 days.
A resident with multiple health conditions reported her dentures missing to the Social Services Designee months ago, but no timely action was taken. Despite staff awareness, the facility failed to follow its policy requiring prompt dental referrals within three days, leading to a significant delay in obtaining necessary dental services.
The facility failed to submit accurate PBJ data for the first quarter of 2024, indicating a lack of 24-hour nursing coverage on specific dates. However, a review of staffing schedules and time cards confirmed that 24-hour coverage was provided. The DON verified that the data was incorrectly entered by corporate staff.
Improper Storage of Food and Drinks in Kitchenette Refrigerator
Penalty
Summary
Food and drink items were found stored improperly in the kitchenette refrigeration unit, with multiple items left unlabeled, undated, outdated, or expired. During observation, surveyors found pizza in an unlabeled and undated pizza box, a sandwich in an unlabeled and undated baggie, outdated yogurt cups, expired juices, a large container of spaghetti that was unlabeled and not dated, leftover food containers without a name or date, two half-full 20-ounce soda pops that were not labeled or dated, an open bottle of seltzer water that expired in December 2025, pretzels in individual snack bags that were not dated, and an onion wrapped in foil and not dated. Dietary Aide #317 verified the improperly labeled, dated, outdated, and expired food and drink items during interview. Dietary Manager #316 confirmed the kitchenette refrigerator was intended only for residents of the facility and stated that all food items should be properly dated and labeled, with only resident food stored in that refrigerator. The facility policy titled, Food Brought in From Outside the Facility Policy, required refrigerated outside food to be labeled with the food item name, resident name, and date, and stated that food dated by facility staff would be discarded within seven days from the date mark, except condiments.
Smoking Care Plan Not Timely Developed
Penalty
Summary
The facility failed to ensure a resident-centered care plan was developed in a timely manner for a resident who smoked. Resident #5 was admitted on 08/09/17 and had diagnoses including COPD, vascular dementia, and CVA. The resident was admitted to hospice services on 12/05/25, and a smoking assessment dated [DATE] identified the resident as a current smoker who was anticipated to continue smoking. However, the medical record did not show a care plan addressing the resident’s smoking status or related interventions at the time of review. On 06/15/26 at 3:17 P.M., two residents, including Resident #5, were observed smoking outside on the patio under staff supervision. During interview at 3:24 P.M., an LPN verified Resident #5 was a supervised smoker and could not locate a care plan addressing smoking. The LPN directed the surveyor to the SSD. During interview at 3:31 P.M., the SSD stated Resident #5 had just started smoking after admission to hospice services and said the resident was care planned for smoking. Review of the care plan with the SSD showed a smoking care plan was created on 06/15/26, and the SSD stated it had been updated, while the facility policy on Comprehensive Care Planning required a comprehensive person-centered care plan with measurable goals and timetables to address the resident’s medical, nursing, mental, and psychosocial needs.
Failure to Follow EBP During PICC Line Care
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were followed for one resident reviewed for EBP. Resident #1 was admitted on 05/04/23 and had diagnoses including paraplegia, a non-pressure chronic ulcer of the left heel and midfoot, COPD, peripheral vascular disease, CKD, and major depression. The resident’s June 2026 physician orders included IV daptomycin and IV meropenem for acute hematogenous osteomyelitis of the left ankle and foot, and the care plan was revised in June 2026 to include EBP with all close contact care. During observation, a sign outside the room indicated EBP and PPE supplies were available inside the room. Resident #1 was resting in bed with an IV infusing into a PICC line when RN #385 entered, put on gloves, and stopped the antibiotic infusion, cleaned the IV end cap, and dismantled the IV medication. The RN later verified that he did not put on the correct PPE while completing tasks for the resident’s IV antibiotics and PICC line. The facility policy stated that EBP requires gown and gloves for high-contact care, including device care or use such as central line care, and the posted signage also indicated gown and gloves must be worn for this type of care.
Staff-to-Resident Verbal Abuse in Dining Room
Penalty
Summary
A deficiency occurred when a staff member failed to protect a resident from verbal abuse. The resident involved had vascular dementia, generalized anxiety disorder, and a history of stroke, with moderate cognitive impairment and a need for total assistance with activities of daily living. The resident exhibited challenging behaviors, including throwing incontinence briefs, smearing stool, unplugging his feeding tube, and attempting to leave the dining room without assistance. On the date of the incident, a certified nursing assistant (CNA) directed explicit and derogatory language toward the resident in the presence of other residents and staff. Multiple witnesses, including another staff member, a dietary aide, and residents, reported that the CNA called the resident 'stupid,' told him he was acting like a toddler, and stated that if he wanted to act like a child, he would be treated as one. The CNA also made the resident apologize to everyone in the dining room for his behavior. Witnesses described the CNA as frustrated and making fun of the resident, with some stating the CNA spoke to the resident as if he were an animal. The incident was reported by a visitor and corroborated by several interviews with staff and residents. The facility's policy defined verbal abuse as the use of disparaging or derogatory language toward residents, regardless of their ability to comprehend. The actions of the CNA were found to be in violation of this policy, constituting staff-to-resident verbal abuse.
Failure to Timely Report Staff-to-Resident Verbal Abuse
Penalty
Summary
Staff failed to timely report an allegation of staff-to-resident verbal abuse involving a resident with vascular dementia, generalized anxiety disorder, and a history of stroke. The resident, who had moderate cognitive impairment and required total assistance with activities of daily living, exhibited a range of challenging behaviors, including throwing objects, smearing stool, and moving between rooms without assistance. During a dining room incident, a certified nursing assistant (CNA) became frustrated with the resident's behaviors and directed inappropriate, explicit, and demeaning language toward the resident in front of others. Multiple witnesses, including another staff member and residents, confirmed that the CNA called the resident derogatory names, made fun of him, and forced him to apologize to the dining room. Despite the presence of staff and witnesses, the incident was not immediately reported to facility management as required by facility policy. The administrator only became aware of the incident two days later when a visitor who witnessed the event reported it. Interviews with staff and review of witness statements revealed that at least one staff member present felt uncomfortable with the CNA's conduct but did not report the incident. The facility's policy required immediate reporting of all allegations or suspicions of abuse to the administrator or abuse coordinator, but this protocol was not followed in this case, resulting in a delay in addressing the alleged abuse.
Failure to Revise Care Plan for Depression and Antidepressant Use
Penalty
Summary
The facility failed to ensure that the care plan for a resident was revised to include supports and interventions for depression and related antidepressant use. This deficiency was identified during a review of the medical record, staff interviews, and facility policy. The resident, who was cognitively intact, had multiple diagnoses including type II diabetes, heart disease, peripheral vascular disease, depression, osteomyelitis, pain, kidney cancer, prostate cancer, and lymphedema. Despite physician orders for mirtazapine and Zoloft to treat depression, the care plan revised on 03/04/24 did not include any supports or interventions for depression. The Director of Nursing confirmed the absence of care plan supports for the resident's depression. The facility's policy required comprehensive person-centered care plans to be developed, reviewed, and updated at least every 90 days to meet the resident's needs, which was not adhered to in this case.
Failure to Timely Refer Resident for Dental Services After Losing Dentures
Penalty
Summary
The facility failed to ensure a resident was timely referred for dental services after losing her dentures. Resident #5, who had multiple diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and vascular dementia, reported her dentures missing to the Social Services Designee (SSD) a couple of months prior. Despite this, the SSD was unaware of the missing dentures until interviewed by surveyors. The resident's care plan included interventions for dental hygiene and obtaining dental consults as needed, but these were not followed through in a timely manner. Observations and interviews revealed that the resident had been without dentures for an extended period, and staff members, including the State Tested Nursing Assistant (STNA) and Director of Nursing (DON), were aware of the issue but did not take prompt action to address it. Further interviews indicated that the resident's dentures had been missing since the end of February or the beginning of March, and multiple staff members, including STNAs and the DON, were aware of the situation. However, the facility's policy, which required prompt referrals for lost or damaged dentures within three days, was not adhered to. Additionally, an oral cavity assessment conducted in March incorrectly documented the presence of dentures, further highlighting the lack of proper follow-up and communication among the staff. The facility's failure to act promptly on the resident's missing dentures led to a significant delay in obtaining necessary dental services for the resident.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to submit accurate information in the Payroll-Based Journal (PBJ) for the first quarter of 2024, which had the potential to affect all residents. The review of the PBJ Staffing Data Report indicated that the facility did not have licensed nursing coverage 24 hours a day on specific dates. However, a review of the staffing schedule, posted daily staffing sheets, and corresponding time cards for the specified dates revealed that there was indeed 24-hour nursing coverage. An interview with the Director of Nursing (DON) confirmed that the data was entered incorrectly by corporate staff.
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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) |
|---|---|---|---|---|
| Ayden Healthcare Of Waterville | 7.4 mi | ★★★★★ | 33 | 0 |
| Whitehouse Country Manor | 7.9 mi | ★★★★★ | 0 | 0 |
| Astoria Place Of Waterville | 9 mi | ★★★★★ | 2 | 0 |
| Bowling Green Manor | 10.4 mi | ★★★★★ | 0 | 0 |
| Wood Haven Health Care Senior Living & Rehab | 11.4 mi | ★★★★★ | 11 | 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.