Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | ★★★★★ | 31 | 0 |
| Whitehouse Country Manor | 7.9 mi | ★★★★★ | 0 | 0 |
| Astoria Place Of Waterville | 9 mi | ★★★★★ | 39 | 1 |
| Bowling Green Manor | 10.4 mi | ★★★★★ | 0 | 0 |
| Wood Haven Health Care Senior Living & Rehab | 11.4 mi | ★★★★★ | 2 | 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 June 2026) and official state health department websites.