Grand Rapids Care Center

In the surveyor’s words

From the most serious findings on record at Grand Rapids Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 16, 2026

  Based on observation, staff interview, and review of facility policy, the facility failed to ensure food and drink items were stored in a manner to prevent spoilage. This had the potential to affect all 28 residents who received food and drink from the kitchenette. The facility identified one (#8) resident who received nothing by mouth. The facility census was 29.Findings include:Observation on 06/14/26 at 8:05 A.M. of the kitchenette refrigeration unit revealed pizza stored in an unlabeled and undated pizza box and a sandwich in an unlabeled and undated baggie. […]

• No harm, potential for more than minimal, isolatedF656Jun 16, 2026

  Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure a resident centered care plan was developed in a timely manner for a resident who smoked. This affected one (#5) of two residents reviewed for smoking. The facility census was 29.Findings included:Review of the medical record for Resident #5 revealed an admission date of 08/09/17. Diagnoses included chronic obstructive pulmonary disease (COPD), vascular dementia, and cerebral vascular accident (CVA). Review of the current physician orders for June 2026 for Resident #5 revealed the resident was admitted to hospice services on 12/05/25. […]

• No harm, potential for more than minimal, isolatedF880Jun 16, 2026

  Based on observation, staff interview, review of the medical record, review of infection control signage, and review of the facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were followed. This affected one (#1) of one resident reviewed for EBP. The facility census was 29.Findings include:Review of Resident #1's medical record revealed an admission date of 05/04/23. Diagnoses included paraplegia, non-pressure chronic ulcer of the left heel and midfoot with unspecified severity, chronic obstructive pulmonary disease, peripheral vascular disease, chronic kidney disease, and major depression. […]

• No harm, potential for more than minimal, isolatedF600Sep 30, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of a facility submitted Self-Reported Incident (SRI), review of the facility incident log, review of witness statements, staff and resident interview, and review of the facility policy, the facility failed to ensure residents were free from staff-to-resident verbal abuse. This affected one (#15) of three residents reviewed for abuse. The facility census was 30.Findings include:Review of the medical record for Resident #15 revealed an admission of 08/16/24. […]

• No harm, potential for more than minimal, isolatedF609Sep 30, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of a facility initiated Self-Reported Incident (SRI), review of the facility incident log, review of witness statements, staff interview, and review of the facility policy, the facility failed to ensure staff reported allegations of staff-to-resident verbal abuse timely. This affected one (#15) of three residents reviewed for abuse. The facility census was 30. Findings include: Review of the medical record for Resident #15 revealed an admission of 08/16/24. […]