The Gilbert Residence

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Staffing

How full it usually is: this home is certified for 32 beds and averages 30.0 residents a day — about 94% occupied, or roughly 2 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.86 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.39 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.45 hrs/resident/day on weekends vs 3.82 on weekdays — 10% thinner on weekends. RN hours go from 0.95 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.

• Potential for harm · Fcited before2025-10-07 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: On 10/06/2025 at 09:00 a.m. during an initial tour of food services was conducted with Certified Dietary Manager (CDM) “E”, the following items were observed: Cooler was observed to have red substance on the back wall and on the floor-CDM “E” explained that it was possibly spilt Jello from the weekend. Freezer was observed to have two individual containers of ice cream on the floor. Dry storage was observed to have particles on the floor which CDM “E' explained that it was possibly spilt oatmeal. The top of the enclosed stove appeared to be soiled with food particles and dust. Inside of the same stove appeared soiled with multiple layers of burn on food. End of the dish counter appeared soiled with multiple layers of old food and the back of the splash wall was observed to have black…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-10-07 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor 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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure accurate advance directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for two residents (#7 and 33) of two residents reviewed for advance directives from a total sample of 9 residents. Resident #7 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident #7 (R7) was admitted to the facility on [DATE] with diagnosis that included vascular dementia and hypertension. The MDS revealed R7 had long and short-term memory impairment and severely impaired decision-making skills. A statement of decision-making capacity, signed by the Physician on 7/30/25 and signed by a psychologist on 7/22/25 revealed R7 was unable to fully participate in medical treatment decisions due to vascular dementia. Further review of R7's medical record reflected R7's Durable Power of Attorney (DPOA) signed an advanced directive for Do Not resuscitate (DNR),…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-10-07 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure that residents were free from significant medication errors for one resident (#28) of four residents reviewed during medication administration. Findings Included:Resident #28 (R38)Review of the medical record revealed R28 was admitted to the facility 09/23/2025 with diagnoses that included atrial fibrillation, hyperlipidemia, sleep apnea, congestive heart failure (CHF), hypertension, muscle wasting, ischemic cardiomyopathy (damage of heart muscle), gastro-esophageal reflux disease, anxiety, and cerebral infarction (CVA). The most recent Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 09/23/2025, revealed R28 had Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. On 10/07/2025 at 08:56 a.m. Registered Nurse (RN) D was observed preparing medication to provide to R28. R28 was observed sitting at a dining room table. RN D provided six medications to R28 who then was observed to orally consume the six medications. One of the medications observed to be provided…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-10-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean food service equipment (toaster), (2) ensure proper sanitizer concentration within the 3-compartment sink, and (3) effectively date mark all potentially hazardous ready-to-eat food products effecting 30 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, improper three-compartment sink sanitization, and resident foodborne illness. Findings include: On 10/22/24 at 09:45 A.M., An initial tour of the food service was conducted with Dietary Manager E. The following items were noted: One gallon of Country Fresh 2% milk (3/4 full) was observed within the 2-door reach-in cooler, without an effective discard date. The manufacturer's best-by-date was also observed to read 10-26-24. Dietary Manager E stated: Staff should have placed a discard date on the container. The 2017 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E)…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-24 · tag F0604 — failed to not use physical restraints improperly — isolated
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform ongoing re-evaluation of the need for a restraint for one (Resident #25) of one reviewed. Findings include: Review of the medical record revealed Resident #25 (R25) admitted to the facility on [DATE] with diagnoses that included major depressive disorder, epilepsy, Parkinson's Disease, and dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/28/24 revealed R25 was severely cognitively impaired and had a restraint that was used daily. An observation on 10/23/24 at 10:37 AM revealed R25 was asleep, seated in a Broda chair (a wheelchair that provides supportive positioning through a combination of tilt, recline, adjustable leg rest angle, wings with shoulder bolsters and height adjustable arms) in their room. R25 had an air mattress on their bed. The right side of the bed was against the wall. Bolsters, approximately six inches high, were observed on both sides of the bed and ran the full length of the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-24 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure their medication error rate was below 5% when four medication errors were observed from a total of 26 opportunities for three residents (Resident #2, Resident #3, and Resident #7) of six reviewed resulting in a medication error rate of 15.38%. Resident #3 (R3) Review of the medical record revealed R3 admitted to the facility on [DATE] with diagnoses that included dementia and seizures. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/24 revealed R3 was severely cognitively impaired. Review of the Physician's Order dated 5/7/18 revealed an order for topiramate 25 milligrams (mg) two tablets twice a day. The order did not specify that the medication could be crushed. Review of the Physician's Order dated 7/13/22 revealed an order for levetiracetam solution 100 milligrams/milliliters (mg/mL); administer 1250 mg/12.5 mL twice a day. On 10/22/24 at 10:18 AM, Licensed Practical Nurse (LPN) D was observed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-24 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer an updated pneumococcal vaccine for one (Resident #2) of five reviewed. Findings include: Review of the medical record revealed Resident #2 (R2) admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, depression, and hypertension. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/30/24 revealed R2 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was up to date on the pneumococcal vaccine. Review of R2's vaccine history revealed R2 received a PCV13 pneumococcal vaccine on 7/22/16. R2 did not have documentation of any further pneumococcal vaccines. According to the Centers for Disease Control and Prevention (CDC) PneumoRecs VaxAdviser application, the recommendation for R2 was give one dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of which vaccine is used (PCV20 or PPSV23), their pneumococcal vaccinations are…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2023-09-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 29 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 09/25/23 at 02:30 P.M., An initial tour of the food service was conducted with Director of Food Services C. The following items were noted: The interior and exterior surfaces of the South Bend convection ovens were observed soiled with accumulated and encrusted food residue. The exterior surfaces of the South Bend stove/ovens were observed soiled with accumulated and encrusted food residue. The Proctor Silex commercial toaster was observed soiled with accumulated and encrusted food residue. The General Electric microwave oven interior and exterior surfaces were observed soiled with accumulated and encrusted food residue. The meat slicer was observed soiled with accumulated and encrusted food residue. The can opener assembly was observed soiled with accumulated and encrusted food residue. The spice rack shelves were observed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-09-28 · tag F0756 — failed to review each resident's drug regimen — pattern
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician reviewed and acted upon identified medication regimen irregularities for four (Residents #'s 8, 13, 15 and 16) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions. Findings include: Resident #15 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] resident 15 (R15) was admitted to the facility with diagnoses that included diabetes, heart failure , and depression. R15 scored 14 out of 15 (cognitively intact) on Brief Interview Mental Status (BIMS). Further review of both the facility's electronic medical record and hard copy medical record for R15 did not reflect any monthly reviews by a pharmacist. On 09/27/28 at 11:00 am evidence that R15 had a monthly medication management review was completed by a Pharmacist, along with any indication of irregularities and physician recommendation reports were requested. What was received was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-09-28 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor 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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure accurate completion of advance directive information for one (Resident #24) of one resident reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) resulting in the potential for a resident's preferences for medical care to not be followed by the facility. Findings include: Review of the medical record reflected that Resident #24 (R24) was admitted to facility 9/7/2023 with diagnoses including unspecified dementia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/8/23 reflected that R24 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 00 (severe cognitive impairment). In an observation and interview on 9/25/23 at 3:36 PM, R24 was observed sitting in wheelchair, in front yard of building, with daughter sitting at side. R24 was noted to be alert, watching passing by traffic, nodded head yes when questioned if he was enjoying the day, but otherwise did not respond to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in MI