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 Grand Village during CMS and state inspections, most recent first.
Staff preparing and serving meals did not consistently wear required beard coverings, as observed with two cooks—one in the kitchen after making lunch and another in a kitchenette serving food with long, uncovered facial hair. The dietary manager confirmed staff were instructed to wear hair and beard coverings, and facility policy required their use to prevent hair from contacting food.
A resident with a history of heart failure and respiratory issues experienced significant weight gain and edema over several days, but staff did not notify the provider as required by physician orders and facility policy. The resident showed visible swelling and reported new pain before the nurse practitioner was eventually informed, resulting in a deficiency for failure to promptly notify the physician.
A resident with moderate cognitive impairment and diagnoses of bipolar disorder and anxiety was maintained on haloperidol and Zoloft without documented evidence of a recent gradual dose reduction (GDR) or clinical justification for continued use. Staff interviews indicated that nursing relied on the pharmacy consultant for GDR recommendations, and the facility's policy requiring avoidance of unnecessary drugs was not followed in this instance.
A resident's MDS was incorrectly coded to indicate receipt of insulin injections, when the MAR showed only Trulicity, a non-insulin diabetes medication, was administered. Nursing staff confirmed the error, noting that Trulicity is not insulin and no insulin was given during the assessment period.
A resident with a history of heart failure and respiratory issues experienced significant weight gain and worsening edema, but staff did not follow physician orders to notify the provider or implement new interventions. Despite clear care plan directives and facility policy, the required monitoring and timely communication were not performed, and the nurse practitioner was not made aware of the situation until later.
A resident with moderate cognitive impairment and a history of bipolar disorder and anxiety was prescribed both an antipsychotic and an antidepressant. The consulting pharmacist did not document a gradual dose reduction (GDR) or provide a clinical justification for continued use of these medications within the past year, as required by facility policy. Monthly pharmacy reviews failed to identify this irregularity, and staff interviews confirmed the absence of necessary documentation.
A resident admitted with a recent history of C. diff infection did not have an admission note or nurse-to-nurse communication documented in the medical record. Although the admission screening was completed on paper, it was not scanned or entered into the electronic record and was destroyed, resulting in missing information about the resident's condition and required precautions. Staff interviews confirmed the lack of documentation, despite facility policy requiring complete and timely records.
A nursing assistant did not follow proper hand hygiene and glove change protocols while assisting a resident with toileting and dressing. The NA wore the same soiled gloves after cleaning the resident following a bowel movement and continued to assist with clean clothing and other items without changing gloves or performing hand hygiene, contrary to facility policy and staff expectations.
A resident with a history of MS and paraplegia experienced right arm weakness and numbness, which was reported to nursing assistants and LPNs throughout the day, but no licensed nurse assessed the resident until the next morning. The resident was later diagnosed with a stroke after being sent to the hospital. Another resident reported leg pain and swelling and requested to go to the ED multiple times, but staff delayed assessment and action until late in the evening. In both cases, staff failed to provide timely assessment and care in response to changes in condition.
A facility failed to conduct an admission care conference for a resident with renal insufficiency, diabetes, and arthritis, who was cognitively intact. The resident's EMR lacked documentation of a care conference since admission, and staff interviews revealed that care plans were often developed without initial resident input. The facility's policy required care conferences within 7-12 days of admission, but this was not followed.
A resident with severe cognitive impairment was observed using a nebulizer unsupervised, despite an assessment indicating they were not safe to self-administer medications. Nursing staff confirmed no order for self-administration was in place, and the facility's policy required an assessment and physician's order for such actions.
A resident with severe cognitive impairment and neurological conditions was observed being propelled in a wheelchair without foot pedals, contrary to their care plan. Staff interviews confirmed the necessity of foot pedals for safety, but they were not used, and the facility lacked a policy on wheelchair equipment.
A resident with moderate cognitive impairment and a history of pressure ulcers was not repositioned every two hours as required by their care plan. Despite staff entering the room multiple times, the resident remained in the same position for over two hours, contrary to the facility's policy and care plan directives.
A resident receiving continuous oxygen therapy and nebulizer treatments experienced lapses in equipment maintenance. The facility failed to change oxygen tubing weekly and did not clean nebulizer canisters after each use, contrary to policy. Staff interviews confirmed these deficiencies, and the facility's nebulizer policy required weekly changes and cleaning after each use.
A facility failed to limit PRN psychotropic medication to 14 days or have a physician-specified order for a resident with moderate cognitive impairment. The resident had an open-ended lorazepam order without a specified duration, despite no behaviors indicating its necessity. Additionally, the facility did not monitor orthostatic blood pressures for the resident on risperidone, contrary to policy requiring monthly checks to assess medication effects and fall risk.
A resident with atrial fibrillation and other conditions did not receive prescribed Slow Magnesium/Calcium tablets due to a pharmacy backorder. Facility staff failed to notify the physician or follow protocol for medication errors, resulting in missed doses. Interviews revealed a lack of communication among staff and with the pharmacy.
Failure to Ensure Staff Wore Beard Coverings During Food Preparation and Service
Penalty
Summary
The facility failed to ensure that staff preparing and serving resident meals wore beard coverings as required by professional standards and facility policy. During a kitchen tour, one cook was observed in the kitchen without a beard covering after having just finished making lunch. On a separate occasion, another cook with long, shaggy facial hair was seen serving food to residents in a kitchenette without a beard net. This cook admitted to not wearing a beard covering because he was unsure where to find them and acknowledged the risk of hair falling into food. The dietary manager confirmed that staff were instructed to always wear hair and beard coverings when working with food, including during preparation, cooking, and serving. The manager was aware that the cook was not wearing a beard covering but had not yet addressed it. Facility policy required the use of hair restraints, including beard nets for employees with beards, to prevent hair from contacting exposed food. The FDA Food Code and facility policy both emphasize the importance of hair restraints to prevent contamination.
Failure to Notify Physician of Significant Weight Gain and Edema
Penalty
Summary
The facility failed to notify the physician as required when a resident with a history of acute respiratory failure, hypertensive heart disease, and congestive heart failure experienced significant weight gain indicative of fluid retention and edema. The resident's care plan and physician orders specifically directed staff to obtain daily weights and to notify the medical provider if there was a weight gain of 3 pounds or more in 48 hours or 5 pounds in a week. Despite documented weight increases exceeding these thresholds over several consecutive days, there was no evidence that the provider was contacted prior to a nurse practitioner visit. Nursing staff acknowledged during interviews that the provider should have been notified earlier, and the director of nursing confirmed that staff were expected to follow these orders. The resident was observed with visible swelling in the face, hands, and legs, and reported new onset of pain related to leg swelling. Although the nurse practitioner was eventually informed and took action, this did not occur until after the required notification window had passed. Facility policies required immediate notification of the provider for significant changes in condition, including weight gain and edema, but these protocols were not followed in this instance, resulting in a deficiency related to timely physician notification.
Failure to Document Gradual Dose Reduction or Clinical Justification for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a gradual dose reduction (GDR) or a clinical justification for the continued use of a psychotropic medication was documented for one resident reviewed for unnecessary medication use. The resident, who had moderate cognitive impairment and diagnoses including bipolar disorder and anxiety, was receiving both an antipsychotic (haloperidol) and an antidepressant (Zoloft). The medical record indicated that the last GDR attempt for psychotropic medications was performed over a year prior, and there was no documentation that a GDR was clinically contraindicated or that the resident was on the lowest effective dose for haloperidol during the past year. Interviews with facility staff revealed that medication reviews were conducted regularly, but nursing staff relied on the pharmacy consultant to recommend GDRs rather than proactively monitoring when GDRs were due. The pharmacy consultant stated that GDRs were performed twice a year for new medications and annually for established medications, with the last attempt documented as occurring several months prior. The facility's policy required that drug regimens be free from unnecessary drugs, including those used in excessive doses or durations or without adequate indications, but this standard was not met in the resident's case.
Incorrect MDS Coding of Diabetes Medication
Penalty
Summary
The facility failed to ensure accurate coding of medications on the Minimum Data Set (MDS) for one resident with diabetes. The resident's quarterly MDS indicated that they had received both insulin injections and hypoglycemic medication. However, a review of the Medication Administration Record (MAR) for the relevant month showed that the resident only received Trulicity, a non-insulin diabetes medication, and did not receive any insulin during the assessment period. Interviews with nursing staff confirmed that the MDS was incorrectly coded, as Trulicity is not insulin and no insulin was administered. The facility's policy required staff to use information from the electronic health record to complete the MDS accurately.
Failure to Implement Edema Interventions and Notify Provider for Significant Weight Gain
Penalty
Summary
The facility failed to implement physician-ordered interventions for edema management for a resident with a history of acute respiratory failure, hypertensive heart disease, and congestive heart failure. The resident's care plan required staff to monitor for signs of increased edema and weight gain, document findings, and notify the medical provider as necessary. Physician orders specified that the nurse practitioner should be updated if the resident gained 3 pounds or more in 48 hours or 5 pounds in a week. Despite documented weight increases exceeding these thresholds over several days, there was no evidence that staff identified or reported the significant weight gain or associated edema to the provider in a timely manner. Nursing documentation did not reflect a comprehensive assessment or implementation of new interventions in response to the resident's worsening edema and new onset of pain. Observations confirmed the resident exhibited visible swelling in the face, hands, and legs, and interviews with nursing staff and administration revealed that the required monitoring and notification procedures were not followed. The nurse practitioner was unaware of the specific physician order to be notified of significant weight gain and indicated that earlier intervention would have been expected. Facility policy required standardized assessment and provider notification for untoward results related to edema, but this was not carried out as directed.
Failure to Document Gradual Dose Reduction or Justification for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the consulting pharmacist (CP) identified the need for a gradual dose reduction (GDR) or provided medical justification for the continued use of psychotropic medications for one resident reviewed. The resident in question had moderate cognitive impairment, exhibited verbal behaviors, and had diagnoses including bipolar disorder and anxiety. The resident was prescribed both an antipsychotic (haloperidol) and an antidepressant (Zoloft), with the last documented GDR attempt occurring over a year prior. There was no documentation in the medical record of a GDR attempt or a clinical justification for the ongoing use of these medications within the past year. Monthly pharmacy reviews conducted from June 2024 to May 2025 did not identify any irregularities with the resident's psychotropic medications. Interviews with facility staff, including a registered nurse and the CP, confirmed that the resident's record lacked evidence of a recent GDR or a documented contraindication. The facility's policy required monthly reviews and recommendations for dosage reductions or modifications as appropriate, but this process was not followed for the resident in question.
Failure to Maintain Accurate Admission Documentation for Resident with C. diff History
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident who was admitted with a recent history of Clostridium difficile (C. diff) infection. Although the resident had completed a course of oral vancomycin and their diarrhea had resolved prior to admission, the medical record lacked an admission note and documentation of nurse-to-nurse communication regarding the resident's condition at the time of transfer from the hospital. The admission screening was completed on a handwritten form, but this form was not scanned into the electronic medical record and was instead destroyed. As a result, there was no documentation in the resident's record to clarify the resident's status or the transmission-based precautions needed upon admission. Interviews with nursing staff revealed that the admission nurse was responsible for entering an admission note or scanning handwritten notes, but this was not done. Staff acknowledged that the information was not documented in the electronic record, and the director of nursing confirmed that facility policy required such documentation to ensure a complete medical record. The administrator also stated that staff were expected to maintain complete records to support quality care. The facility's own policy emphasized the need for timely and accurate documentation reflecting the resident's condition and care provided.
Failure to Follow Hand Hygiene and Glove Change Protocols During Personal Care
Penalty
Summary
A nursing assistant (NA) failed to follow proper hand hygiene and glove use protocols while assisting a resident who required help with toileting, dressing, and grooming. During personal care, the NA did not use hand sanitizer or don gloves before assisting the resident to the toilet. After cleaning the resident following a bowel movement, the NA continued to wear the same soiled gloves while helping the resident with clean clothing, flushing the toilet, and handling other items in the resident's room, without performing hand hygiene or changing gloves between tasks. Interviews with facility staff, including an LPN, RN, DON, and the administrator, confirmed that the expectation was for staff to change gloves and perform hand hygiene after contact with feces and before touching clean items to prevent cross-contamination. The facility's hand hygiene policy also directed staff to change gloves and perform hand hygiene when moving from a contaminated to a clean body site. The NA's actions were inconsistent with both facility policy and staff expectations, resulting in a failure to prevent potential cross-contamination during resident care.
Failure to Timely Assess and Respond to Change in Condition
Penalty
Summary
The facility failed to provide timely assessment and care for a resident who experienced a significant change in condition. The resident, who had a history of multiple sclerosis, paraplegia, and was cognitively intact, began experiencing right arm and hand weakness, numbness, and loss of motor skills. These symptoms were first reported to nursing assistants in the morning and throughout the day, but no licensed nurse assessed the resident until the following morning. Despite multiple reports from nursing assistants and a family member, the licensed practical nurses did not assess the resident or escalate the concern appropriately. The resident was eventually assessed by the charge nurse after further decline and was sent to the hospital, where a stroke was diagnosed. Interviews with staff and review of documentation revealed that nursing assistants reported the resident's symptoms to several LPNs, but these concerns were not acted upon in a timely manner. The LPNs either did not recognize the urgency of the symptoms or believed that assessment for a stroke was outside their scope of practice. As a result, the resident did not receive a nursing assessment or medical evaluation for over 18 hours after the initial onset of symptoms. The facility's policy required staff to assess and report changes in condition, but this was not followed in this case. A second resident also experienced a delay in assessment and care after reporting leg pain and swelling. The resident requested to go to the emergency department multiple times throughout the day, but staff did not act on these requests until late in the evening. Documentation and interviews indicated that the resident's concerns were not promptly communicated to the nurse practitioner, and there was a lack of timely assessment and documentation by the nursing staff. Both cases demonstrate failures in timely assessment and response to changes in condition, as well as inadequate communication among staff.
Failure to Conduct Admission Care Conference
Penalty
Summary
The facility failed to provide an opportunity for an admission care conference for a resident identified as R49, who was cognitively intact and had diagnoses including renal insufficiency, diabetes, and arthritis. The resident's electronic medical record lacked documentation of a care conference since admission. During an interview, the resident stated he had not been invited to or attended any care conference to discuss his plan of care since his admission. Interviews with facility staff revealed that the facility rarely conducted admission care conferences. A registered nurse mentioned that care plans were typically built without initial resident input and were only reviewed with residents closer to discharge. The social services designee confirmed the absence of a care conference for the resident and stated that care conferences were supposed to be scheduled by her department. The director of nursing stated that the facility's policy and resident handbook expected care conferences to occur within 7-12 days of admission, but this was not adhered to in the case of R49.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a comprehensive assessment for self-administration of medications for a resident with severe cognitive impairment. The resident, identified as R2, was observed using a nebulizer without staff supervision, despite an assessment indicating that R2 required frequent prompting and was not safe to self-administer medications. The assessment also noted that R2 did not wish to self-administer any medications. Interviews with nursing staff and the director of nursing confirmed that no order for self-administration of medications was in place for R2, and that an assessment should have been completed to ensure the resident's safety during nebulizer treatments. The facility's policy required a self-administration assessment and a physician's order for any resident to self-administer medications, including nebulizer treatments, without direct supervision.
Failure to Use Proper Wheelchair Equipment for Resident
Penalty
Summary
The facility failed to ensure proper wheelchair equipment was used for a resident with severe cognitive impairment and multiple neurological conditions. The resident required assistance with all activities of daily living and had a care plan indicating the need for bilateral foot pedals on the wheelchair due to limited physical mobility. However, during observations, the resident was seen being propelled in a wheelchair without foot pedals, causing difficulty in holding their feet up, which resulted in the feet dropping and bouncing on the floor. The foot pedals were found on top of the dresser in the resident's room. Interviews with staff, including a licensed practical nurse, a nursing assistant, a registered nurse manager, and the director of nursing, confirmed the resident's need for foot pedals when being propelled for longer distances. The staff acknowledged the importance of using foot pedals to prevent the resident from falling forward or sustaining injuries. Despite this, the facility did not provide a wheelchair/foot pedal policy when requested, indicating a lack of adherence to the resident's care plan and safety protocols.
Failure to Reposition Resident as Per Care Plan
Penalty
Summary
The facility failed to provide timely assistance with repositioning to minimize the risk of pressure ulcer development for a resident identified as R50. R50 had moderate cognitive impairment and required assistance with all activities of daily living. The resident's care plan indicated a need for repositioning every two hours due to fragile skin and a history of pressure ulcers. However, observations on a specific day revealed that R50 was left in the same position for over two hours, despite staff entering the room multiple times for other tasks. Interviews with nursing staff confirmed that R50 was unable to reposition himself and required assistance every two hours, as per the care plan. The facility's policy on repositioning residents emphasized the importance of relieving pressure to prevent skin breakdown. Despite this, the staff did not adhere to the care plan directives for R50, who had a protective bandage on his spine due to thin skin and a history of pressure ulcers. Interviews with the nursing assistant, LPNs, and the director of nursing highlighted the importance of repositioning to prevent skin breakdown, yet the observations indicated a lapse in following the care plan, leading to the deficiency.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to adhere to its policy regarding the maintenance of oxygen and nebulizer equipment for a resident receiving continuous oxygen therapy. The resident, who was cognitively intact, had been on continuous oxygen therapy since admission and was also prescribed budesonide inhalation suspension via nebulizer twice daily. Observations revealed that the oxygen tubing and nasal cannula had not been changed according to the facility's schedule, with the last documented change occurring on 8/18/24, despite the policy requiring changes every 7 days. Additionally, the nebulizer canister and tubing were not cleaned and allowed to air dry after each use, as evidenced by visible liquid and condensation inside the canister. Interviews with the resident and staff confirmed these lapses in protocol. The resident reported that staff rarely changed the oxygen tubing as required and never cleaned the nebulizer canister after treatments. Both an LPN and an RN acknowledged that the oxygen and nebulizer equipment should be changed weekly and cleaned after each use to prevent bacterial growth. The facility's policy on nebulizer treatment, revised in 12/23, specified that nebulizer pieces should be changed weekly and cleaned after each use, but no policy for oxygen tubing changes was provided upon request.
Failure to Limit PRN Psychotropic Medication and Monitor Orthostatic Blood Pressure
Penalty
Summary
The facility failed to ensure that the use of PRN psychotropic medications was limited to 14 days or had a physician-specified, time-limited order. This deficiency was identified in the case of a resident with moderate cognitive impairment and multiple diagnoses, including non-Alzheimer's dementia and anxiety disorder. The resident had an open-ended order for lorazepam, initiated on March 8, 2024, without an end date, despite the absence of behaviors indicating its necessity. Interviews with the registered nurse case manager and the director of nursing confirmed that the lorazepam order lacked a specified duration and that the resident did not exhibit behaviors warranting its continued use. Additionally, the facility did not monitor orthostatic blood pressures for the resident who was prescribed risperidone, an antipsychotic medication. The facility's policy required monthly orthostatic blood pressure checks to monitor for adverse effects such as postural hypotension, which could increase the risk of falls. However, the resident's medical record showed no evidence of such monitoring. Interviews with the registered nurse case manager, director of nursing, and consultant pharmacist highlighted the importance of monitoring orthostatic blood pressures to assess the effectiveness and potential side effects of antipsychotic medications.
Failure to Administer Prescribed Medication and Notify Physician
Penalty
Summary
The facility failed to ensure that a resident received physician-ordered medications, specifically Slow Magnesium/Calcium oral tablets, as prescribed for hypomagnesemia. The resident, who had a history of atrial fibrillation, chronic kidney disease, and hypertension, was admitted to the facility with a care plan directing staff to administer medications per physician's orders. However, the Medication Administration Record indicated that the resident only received the medication on three occasions throughout July, despite the order for daily administration. The facility also failed to notify the physician of the missed doses. Interviews revealed that the medication was not available due to a backorder from the pharmacy's supplier, and the facility staff did not follow the protocol for notifying the nursing supervisor, DON, or the resident's physician about the medication error. The LPN stated that they would typically notify the charge nurse if a medication was unavailable, while the RN and DON were unaware of the issue. The pharmacy technician confirmed the backorder and stated that the facility should have been informed. The nurse practitioner, who wrote the order, was not notified of the missed doses, which could have addressed the resident's low magnesium levels and potential electrolyte imbalance.
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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) |
|---|---|---|---|---|
| The Emeralds At Grand Rapids Llc | 3.2 mi | — | 1 | 0 |
| Essentia Health Homestead | 12.7 mi | — | 7 | 1 |
| Guardian Angels Health & Rehab Center | 32.1 mi | — | 0 | 0 |
| Bigfork Valley Communities | 34.9 mi | — | 8 | 0 |
| Heritage Manor | 36.7 mi | — | 0 | 0 |
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