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The Gilbert Residence Inspection Report, Violations & Safety Grade (Ypsilanti, Michigan)

203 S Huron Street, Ypsilanti, Michigan 48197

Phone: 7344829498

CMS Overall:4/5

Overview & Bed Count

Certified Beds
32
Avg Residents/Day
30.5
Ownership
Non profit - Corporation
Provider Type
Medicaid
County
Washtenaw
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall4/5
Health4/5
Staffing4/5
Quality2/5

Nurse Staffing Check

MetricThis FacilityMichigan AvgDifference
RN Hours per Resident per Day0.760.78-0.02
Total Nurse Hours per Resident per Day3.804.03-0.23
CMS Staffing Rating4/53.6/5-
Nursing Staff Turnover50.0%44.6%-

Health Citation History

21 health citations on record

DateCategoryDescriptionSeverity
2026-08-28Resident Rights DeficienciesHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.E – Moderate Harm Potential
2026-08-28Resident Assessment and Care Planning DeficienciesEnsure services provided by the nursing facility meet professional standards of quality.D – Moderate Harm Potential
2026-08-28Nutrition and Dietary DeficienciesEnsure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.D – Moderate Harm Potential
2025-10-07Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2025-10-07Resident Rights DeficienciesHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.D – Moderate Harm Potential
2025-10-07Pharmacy Service DeficienciesEnsure that residents are free from significant medication errors.D – Moderate Harm Potential
2024-10-24Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2024-10-24Freedom from Abuse, Neglect, and Exploitation DeficienciesEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.D – Moderate Harm Potential
2024-10-24Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.D – Moderate Harm Potential
2024-10-24Infection Control DeficienciesDevelop and implement policies and procedures for flu and pneumonia vaccinations.D – Moderate Harm Potential
2023-09-28Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2023-09-28Pharmacy Service DeficienciesEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.E – Moderate Harm Potential
2023-09-28Resident Rights DeficienciesHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.D – Moderate Harm Potential
2023-09-28Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D – Moderate Harm Potential
2023-09-28Resident Assessment and Care Planning DeficienciesAssess the resident when there is a significant change in conditionD – Moderate Harm Potential
2023-09-28Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2023-09-28Quality of Life and Care DeficienciesProvide appropriate pressure ulcer care and prevent new ulcers from developing.D – Moderate Harm Potential
2023-09-28Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2023-09-28Nursing and Physician Services DeficienciesObserve each nurse aide's job performance and give regular training.D – Moderate Harm Potential
2023-09-28Administration DeficienciesArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.D – Moderate Harm Potential
2023-09-28Resident Rights DeficienciesAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.C – Minimal Harm Potential

Fire Safety Citation History

16 fire safety citations on record

DateCategoryDescriptionSeverity
2025-10-07Smoke DeficienciesProvide properly protected cooking facilities.F – Moderate Harm Potential
2025-10-07Smoke DeficienciesInstall a fire alarm system that can be heard throughout the facility.F – Moderate Harm Potential
2025-10-07Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.F – Moderate Harm Potential
2025-10-07Smoke DeficienciesProperly select, install, inspect, or maintain portable fire extinguishes.F – Moderate Harm Potential
2025-10-07Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.F – Moderate Harm Potential
2025-10-07Egress DeficienciesProvide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.E – Moderate Harm Potential
2025-10-07Services DeficienciesHave properly installed electrical wiring and gas equipment.D – Moderate Harm Potential
2024-10-24Services DeficienciesHave properly installed electrical wiring and gas equipment.E – Moderate Harm Potential
2024-10-24Egress DeficienciesHave properly located and lighted "Exit" signs.D – Moderate Harm Potential
2023-09-28Emergency Preparedness DeficienciesCreate arrangements with other facilities to receive patients.F – Moderate Harm Potential
2023-09-28Emergency Preparedness DeficienciesConduct testing and exercise requirements.F – Moderate Harm Potential
2023-09-28Egress DeficienciesInstall emergency lighting that can last at least 1 1/2 hours.F – Moderate Harm Potential
2023-09-28Smoke DeficienciesInstall a fire alarm system that can be heard throughout the facility.F – Moderate Harm Potential
2023-09-28Smoke DeficienciesInstall an approved automatic sprinkler system.F – Moderate Harm Potential
2023-09-28Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.F – Moderate Harm Potential
2023-09-28Gas, Vacuum, and Electrical Systems DeficienciesHave proper medical gas storage and administration areas.D – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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