Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around January 2027
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 The Gilbert Residence during CMS and state inspections, most recent first.
The facility failed to maintain proper food safety and sanitization standards, as observed during a survey. Milk containers lacked discard dates, a commercial toaster was heavily soiled, and the sanitizer concentration in the three-compartment sink exceeded recommended levels. These deficiencies increased the likelihood of cross-contamination and foodborne illness.
A resident with severe cognitive impairment and a history of falls was observed using bed bolsters as a restraint without ongoing re-evaluation. The facility failed to conduct quarterly restraint assessments as required by the care plan, relying only on an initial assessment and consent obtained at admission. The facility's policy required ongoing re-evaluation and documentation of medical symptoms warranting restraint use, which was not adhered to.
A facility reported a medication error rate of 15.38% due to errors involving three residents. An LPN crushed medications that should not have been crushed and inaccurately measured a liquid medication. The facility's list of medications that should not be crushed was incomplete, contributing to the errors.
A resident with Parkinson's Disease, depression, and hypertension was not offered an updated pneumococcal vaccine as per CDC guidelines. The resident had received a PCV13 vaccine in 2016, but there was no documentation of further vaccinations. The DON confirmed the absence of consent or declination for additional pneumococcal vaccines.
Food Safety and Sanitization Deficiencies
Penalty
Summary
The facility failed to maintain proper food safety standards, as observed during a survey. The surveyors noted that a gallon of Country Fresh 2% milk in the 2-door reach-in cooler lacked an effective discard date, despite the manufacturer's best-by-date being 10-26-24. This oversight was acknowledged by the Dietary Manager, who confirmed that staff should have marked a discard date on the container. Additionally, another gallon of the same milk in the General Electric refrigerator also lacked an effective open or discard date, contrary to the facility's policy of marking dairy products with a day of plus 3 days for a total of 4 days. The survey also revealed that the commercial toaster in the Nursing Kitchenette was heavily soiled with accumulated and encrusted food residue on both its interior and exterior surfaces. This condition was contrary to the 2017 FDA Model Food Code, which requires equipment food-contact surfaces and utensils to be clean to sight and touch. The Dietary Manager acknowledged the issue and stated that they would have someone clean the toaster. Furthermore, the facility failed to ensure proper sanitizer concentration within the three-compartment sink. The sanitizer concentration was observed to be greater than 500 parts-per-million, exceeding the manufacturer's recommended range of 200-400 parts-per-million for the Diversey J-512 sanitizer. This discrepancy was noted during a routine check, and the Dietary Manager indicated that they would contact the Diversey technician for adjustments. These deficiencies collectively increased the likelihood of cross-contamination, bacterial harborage, and resident foodborne illness.
Failure to Re-evaluate Restraint Use for Resident
Penalty
Summary
The facility failed to perform ongoing re-evaluation of the need for a restraint for a resident who was admitted with diagnoses including major depressive disorder, epilepsy, Parkinson's Disease, and dementia. The resident was observed using a Broda chair and bed bolsters, which were considered restraints. The resident's care plan required a new restraint assessment and signed consent before applying restraints, but the facility only had an admission restraint consent on file and did not conduct the required quarterly assessments. The resident experienced a fall from bed, which led to the implementation of roll control bolsters as a restraint. Despite the facility's policy requiring ongoing re-evaluation of restraints, the resident's medical record lacked documentation of such assessments. The Director of Nursing confirmed that restraint assessments were performed yearly, but no additional assessments were provided to meet the quarterly requirement stated in the care plan. The facility's Restraint Free Environment policy emphasized that a physician's order alone is insufficient for restraint use and required documentation of medical symptoms warranting restraints, as well as attempts of less restrictive alternatives. The facility did not adhere to these guidelines, as evidenced by the lack of re-evaluation and documentation of the bolsters as a restraint, despite the resident's history of falls and the use of an air mattress increasing fall risk.
Medication Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 15.38% due to four observed medication errors among three residents. Resident #3, who was severely cognitively impaired, received crushed topiramate tablets, which should not have been crushed, and an inaccurately measured dose of levetiracetam oral solution. The LPN administering the medication used a medication cup without a 12.5 mL mark, leading to an incorrect dosage. Resident #7, who was cognitively intact, received only sennosides instead of the prescribed combination of sennosides and docusate sodium. Resident #2, diagnosed with depression and Parkinson's Disease, was given crushed paroxetine tablets, which should not have been crushed. The facility's list of medications that should not be crushed did not include topiramate and paroxetine, contributing to the errors. The DON acknowledged that nurses had access to a list of medications that should not be crushed and expected accurate measurement of liquid medications.
Failure to Offer Updated Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer an updated pneumococcal vaccine to one resident, identified as Resident #2, among the five reviewed. Resident #2 was admitted with diagnoses including Parkinson's Disease, depression, and hypertension, and was cognitively intact as per the Minimum Data Set assessment. The resident's vaccine history showed they received a PCV13 pneumococcal vaccine in 2016, but there was no documentation of any further pneumococcal vaccines. According to CDC guidelines, Resident #2 should have been offered a dose of PCV20 or PPSV23 at least one year after the PCV13 vaccine. However, the Director of Nursing reported that there was no consent or declination for any further pneumococcal vaccines for this resident.
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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.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ypsilanti
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villa At Parkridge | 0.6 mi | — | 15 | 0 |
| Villa At Willow Place | 2.7 mi | — | 19 | 0 |
| Optalis Health And Rehabilitation Of Ann Arbor | 3.4 mi | — | 1 | 0 |
| Glacier Hills | 4.9 mi | — | 0 | 0 |
| Regency At Canton | 6.8 mi | — | 1 | 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 August 2026) and official state health department websites.