Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure
resident care plans were revised to included supports and interventions for depression and related
antidepressant use. This affected one resident (#3) of five residents reviewed for unnecessary medications.
The facility census was 30.
Findings Include:
Review of Resident #3's medical record revealed an admission date of 10/02/23. Diagnoses included type II
diabetes, heart disease, peripheral vascular disease, depression, osteomyelitis, pain, kidney cancer,
prostate cancer, and lymphedema.
Review of Resident #3's Minimum Data Set (MDS) assessment, 04/07/24, revealed Resident #3 was
cognitively intact. Resident #3 displayed no behaviors during the review period.
Review of Resident #3's physician orders revealed an order dated 12/18/23 for mirtazapine tablet 7.5
milligrams (mg), administer one tablet at bedtime for depression. An order dated 01/22/24 included Zoloft
25 mg and 50 mg for a total of 75 mg once a day for diagnosis of depression.
Review of Resident #3's care plan revised 03/04/24 revealed no care plan support or intervention was
found related to Resident #3's depression or antidepressant use.
Interview on 04/11/24 at 10:53 A.M. with the Director of Nursing (DON) verified there were no care plan
supports for Resident #3's depression.
Review of the facility policy titled,Comprehensive Care Planning Policy revised 03/02/21 revealed the facility
must develop a comprehensive person centered care plan for each resident which included measurable
objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs. The
comprehensive care plan was to be reviewed and updated at least every 90 days.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
366181
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366181
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Grand Rapids Care Center
24201 W 3rd St
Grand Rapids, OH 43522
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0791
Provide or obtain dental services for each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the medical record, observation, interview, and policy review, the facility failed to ensure a resident
was timely referred for dental services for missing dentures. This affected one (#5) of one resident reviewed
for dental services. The facility census was 30.
Residents Affected - Few
Findings include
Review of the medical record revealed Resident #5 had an admission date of 03/17/23. Diagnoses included
chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease stage three, atrial
fibrillation, vascular dementia, hypertension, osteoarthritis, and fibromyalgia.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had
intact cognition.
Review of the plan of care initiated 01/24/24 revealed the resident had impaired dental/oral hygiene related
to no natural teeth and the resident wore full dentures. Interventions included to encourage the resident to
remove dentures at bedtime and store dentures in proper container to soak, obtain dental consult as
needed, and provide assistance for oral hygiene as needed.
Review of an oral cavity observation assessment dated [DATE] at 11:39 A.M. revealed the resident's
dentures were described as having a good fit.
Observation on 04/09/24 at 11:08 A.M. revealed the resident was edentulous (no teeth) and was not
wearing dentures.
Interview on 04/09/24 at 11:08 A.M., Resident #5 revealed her dentures were lost and she had not seen the
dentist. Resident #5 revealed she lost her dentures a couple of months ago. Resident #5 revealed she
reported the lost dentures to Social Services Designee (SSD) #536. Resident #5 revealed she was able to
put in her own dentures and take them out but staff assisted her by getting the storage container.
Interview on 04/10/24 at 11:41 A.M., SSD #536 revealed he was not aware the resident was missing her
dentures. SSD #536 revealed he would get the resident a dental consult.
Interview on 04/10/24 at 2:33 P.M. State Tested Nursing Assistant (STNA) #530 revealed Resident #5
required set up for oral care. STNA #530 revealed staff provided the resident her dentures and the resident
was able to apply them. STNA #530 revealed the last time she cared for the resident a couple of weeks ago
the resident's dentures were missing. STNA #530 was unaware how long the resident's dentures were
missing. STNA #530 revealed she reported the missing dentures to the Director of Nursing (DON).
Interview on 04/11/24 at 9:37 A.M., the DON revealed staff had not reported the resident's missing
dentures recently. The DON revealed the resident had lost her dentures a couple of times but they had
been found.
Interview of 04/11/24 at 3:38 P.M., STNA #522 revealed the resident's dentures had been missing since the
end of February or the beginning of March. STNA #522 revealed she notified the DON about the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366181
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366181
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Grand Rapids Care Center
24201 W 3rd St
Grand Rapids, OH 43522
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0791
missing dentures.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 04/12/24 7:35 A.M., Licensed Practical Nurse (LPN) #512 revealed she completed the
resident's oral cavity assessment on 03/20/24. LPN #512 verified the assessment documentation was
incorrect. LPN #512 verified she never saw the resident's dentures during the assessment.
Residents Affected - Few
Review of the policy titled Dental Services Policy, last revised 04/02/24, revealed the would make prompt
referrals for residents with lost or damaged dentures. Further review of the policy revealed the Director of
Nursing Services or designee or any clinical staff member was responsible for notifying Social Services of a
resident's need for dental services. The facility would promptly, within three days, refer residents with lost or
damaged dentures for dental services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366181
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366181
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Grand Rapids Care Center
24201 W 3rd St
Grand Rapids, OH 43522
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0851
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and
other verifiable and auditable data.
Based on the review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report, staffing schedule,
posted daily staffing sheets, staff time sheets, and staff interview, the facility failed to submit accurate
information in the PBJ for the first quarter of 2024. This had the potential to affect all residents. The facility
census was 30.
Findings Include:
Review of the Payroll-Based Journal (PBJ) Staffing Data Report revealed the facility triggered for not having
licensed nursing coverage 24 hours a day in the first quarter of 2024. The specific days identified were
10/05/24, 12/24/23, 12/25/23, 12/26/23, 12/27/23, 12/28/23, 12/29/23, 12/30/23, and 12/31/23.
Review of the Staffing Schedule, Posted Daily Staffing sheets, and corresponding time cards for nursing
staff for 10/05/24, 12/24/23, 12/25/23, 12/26/23, 12/27/23, 12/28/23, 12/29/23, 12/30/23, and 12/31/23
revealed there was 24 hour nursing coverage for all the specified days indicated in the PBJ staffing data
report.
Interview on 04/10/24 at 8:13 A.M. with the Director of Nursing (DON) verified there was 24 hour nursing
coverage for the days indicated in the PBJ as not having coverage. The DON reported it was corporate who
entered the PBJ data and verified the data was not entered correctly.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366181
If continuation sheet
Page 4 of 4
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F791 - Dental Services
Provide or obtain dental services for each resident.
F851 - Mandatory submission of staffing information based on payroll data in a
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
FAQ · About this visit
Common questions about this visit
What happened during the April 12, 2024 survey of GRAND RAPIDS CARE CENTER?
This was a inspection survey of GRAND RAPIDS CARE CENTER on April 12, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GRAND RAPIDS CARE CENTER on April 12, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a t..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.