Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 The Villa At Rose City during CMS and state inspections, most recent first.
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.
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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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 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 | — | 0 | 0 |
| Wellspring Lutheran Services | 21.1 mi | — | 0 | 0 |
| Medilodge Of Sterling | 22.8 mi | — | 0 | 0 |
| Mission Point Nursing & Physical Rehabilitation Of | 23.3 mi | — | 9 | 0 |
| Iosco County Medical Care Facility | 31 mi | — | 30 | 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.