Inspection Reports for Glacier Hills, a CCRC
1200 Earhart Rd, Ann Arbor, MI 48105, United States, MI, 48105
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
3.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% better than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
29% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 34
Capacity: 116
Deficiencies: 3
Date: Mar 25, 2025
Visit Reason
The inspection was conducted as a Renewal Licensing Study to assess compliance with state regulations and determine eligibility for license renewal.
Findings
The facility was found non-compliant with medication management and kitchen sanitation rules, including incomplete narcotic count logs and improper medication administration, as well as incomplete sanitization temperature logs. Violations were established for these deficiencies.
Deficiencies (3)
Incomplete narcotic count logs for medication carts on multiple dates.
Medications were not always administered as prescribed, including insulin and Torsemide administration errors.
Incomplete testing of wash and sanitation sink temperatures on multiple dates, raising concerns about proper sanitization of dishware.
Report Facts
Number of staff interviewed and/or observed: 18
Number of residents interviewed and/or observed: 34
Capacity: 116
Dates with missing narcotic count logs: 7
Dates with missing sanitization sink temperature tests: 4
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 19, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to keep a call light within reach of a resident, and concerns about improper maintenance and cleaning of outdoor waste receptacles.
Complaint Details
The complaint involved failure to keep a call light within reach of a resident (#12) and improper maintenance and cleaning of outdoor waste receptacles affecting 35 residents.
Findings
The facility failed to ensure a call light was kept within reach for one resident out of twelve reviewed, and failed to properly maintain and clean outdoor waste receptacles, increasing the risk of cross-contamination and pest attraction.
Deficiencies (2)
Failed to ensure a call light was kept within resident reach for one resident (#12) out of twelve residents reviewed.
Failed to effectively maintain 1 of 2 outdoor waste receptacles, clean the concrete receptacle pads and adjacent grounds, and clean the outdoor waste grease receptacles and adjacent concrete receptacle pad surfaces.
Report Facts
Residents reviewed: 12
Residents affected: 35
Damaged surface area: 864
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing H | Assistant Director of Nursing | Confirmed call light placement issue and apologized to resident |
| Clinical Care Coordinator I | Nursing Clinical Care Coordinator | Responsible for nursing units and confirmed call light placement issue |
| Director of Dining Services N | Director of Dining Services | Indicated he would contact maintenance and environmental services for repairs and cleaning of waste receptacles |
Inspection Report
Complaint Investigation
Capacity: 116
Deficiencies: 1
Date: Nov 6, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging neglect of Resident A, including failure to provide physical and occupational therapy, inadequate pain management, and poor meals.
Complaint Details
The complaint alleged neglect of Resident A, including failure to provide physical and occupational therapy, inadequate pain management, and poor meals. The neglect allegation was substantiated due to lack of timely medical treatment. The poor meals allegation was not substantiated.
Findings
The investigation substantiated neglect related to lack of timely medical treatment for Resident A, including delayed therapy orders and insufficient response to pain complaints. The allegation of poor meals was unsubstantiated as the facility maintained appropriate dietary options and Resident A had no documented complaints about food quality.
Deficiencies (1)
Failure to provide timely medical treatment and therapy services to Resident A.
Report Facts
Capacity: 116
Complaint Receipt Date: Oct 29, 2024
Investigation Initiation Date: Oct 29, 2024
Report Due Date: Dec 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LeAnn Pennington | Administrator | Administrator interviewed and involved in the investigation |
| Benjamin McKinnon | Authorized Representative | Authorized representative involved in the investigation |
| Jessica Rogers | Licensing Staff | Conducted the investigation and authored the report |
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 24, 2024
Visit Reason
The document serves as a renewal notification for the Home for the Aged license following an administrative review of licensing activity for the past year.
Findings
The administrative review revealed substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in license renewal.
Report Facts
License effective date: Feb 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Rogers | Licensing Staff | Signed the renewal notification letter |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Feb 15, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to provide therapy schedules, incomplete Do-Not-Resuscitate (DNR) documentation, failure to provide timely transfer/discharge notifications, incomplete Minimum Data Set (MDS) assessments, inaccurate care plans, failure to provide shower assistance, and issues with food service and facility cleanliness.
Complaint Details
This citation pertains to intake MI00140950.
Findings
The facility failed to provide therapy schedules to residents, resulting in frustration; did not complete DNR documents in accordance with Michigan law; failed to provide written transfer/discharge notifications and bed hold notices; did not complete timely quarterly MDS assessments; had inaccurate care plans regarding orthotic devices; failed to provide scheduled showers to a resident; and had food service and physical plant sanitation and maintenance deficiencies.
Deficiencies (11)
Failure to provide Physical and Occupational Therapy schedules upon request for three residents, resulting in feelings of frustration.
Failure to ensure Do-Not-Resuscitate (DNR) documents were completed in accordance with the Michigan Do-Not-Resuscitate Procedure Act for three residents, risking potential non-adherence to code status wishes.
Failure to provide timely written notification of facility-initiated transfers to residents or representatives for three residents, risking uninformed residents and representatives.
Failure to notify residents or representatives in writing of the facility's bed hold policy for two residents, risking uninformed residents and representatives.
Failure to complete a timely quarterly Minimum Data Set (MDS) assessment for one resident, risking unrecognized and unmet care needs.
Failure to ensure accuracy on a 5-day MDS assessment and discharge MDS assessment for two residents, risking unmet care needs.
Failure to complete a Preadmission/Annual Resident Review after the 30-day exemption period and failure to notify the State Mental Health Authority for one resident, risking unmet mental health treatment and services.
Failure to revise the Care Plan for one resident, resulting in inaccurate Care Plans and potential unmet care needs.
Failure to provide showers as scheduled for one resident, resulting in unmet care needs.
Failure to effectively clean and maintain food service equipment, increasing likelihood for cross-contamination and bacterial harborage.
Failure to effectively clean and maintain the physical plant, increasing likelihood for cross-contamination, bacterial harborage, and decreased illumination.
Report Facts
Residents affected: 3
Residents affected: 3
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 42
Residents affected: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DOR E | Director of Rehab | Acknowledged therapy scheduling issues and staffing difficulties |
| SS D | Director of Social Services | Reported DNR document witness practice and transfer notification process |
| SWD D | Social Work Director | Described code status form process and transfer notification process |
| RDO C | Regional Director of Operations | Reported lack of written transfer/discharge notices and bed hold notices |
| LPN P | Licensed Practical Nurse | Described hospital transfer process and lack of written transfer notice |
| RN/ADON/IP J | Registered Nurse/Assistant Director of Nursing/Infection Preventionist | Confirmed Patient Transfer Form use and lack of written transfer notice |
| RN G | Registered Nurse/MDS Coordinator | Reported missed quarterly MDS assessment and discharge MDS coding error |
| DON B | Director of Nursing | Reported care plan modification process and orthotic device observations |
| ADON J | Assistant Director of Nursing | Reported lack of orthotic orders and shower documentation |
| Executive Chef S | Executive Chef | Conducted food service tour and noted sanitation issues |
| Registered Dietician T | Registered Dietician | Accompanied food service tour |
| Facilities Manager X | Facilities Manager | Reported maintenance issues and work order system |
| Maintenance Team Leader Y | Maintenance Team Leader | Accompanied environmental tour |
| Environmental Services Supervisor W | Environmental Services Supervisor | Reported sanitation issues and maintenance needs |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 15, 2024
Visit Reason
The inspection was conducted due to a complaint regarding failure to provide scheduled showers to Resident #48, resulting in unmet care needs related to Activities of Daily Living assistance.
Complaint Details
The complaint was substantiated based on interviews and record review showing missed showers for Resident #48 despite requests and no refusals documented.
Findings
The facility failed to provide showers to Resident #48 on scheduled days of 10/19/23 and 10/23/23 despite the resident's requests and no documented refusals. The Assistant Director of Nursing was unable to locate any shower documentation or refusals for these missed showers.
Deficiencies (1)
Failure to provide showers for Resident #48 on scheduled days, resulting in unmet care needs.
Report Facts
Missed shower dates: 2
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| J | Assistant Director of Nursing | Interviewed regarding missing shower documentation and refusals. |
Inspection Report
Renewal
Census: 15
Capacity: 116
Deficiencies: 2
Date: Mar 2, 2023
Visit Reason
The inspection was conducted as a Renewal Licensing Study to evaluate compliance with licensing rules and regulations for the facility.
Findings
The facility was found to be non-compliant with rules regarding designation of a supervisor of resident care on each shift and proper documentation of reasons for administration of as needed medications according to licensed health care professional orders.
Deficiencies (2)
A supervisor of resident care was not designated for the third shift as required.
Staff documented reasons for administration of as needed medications that were not pursuant to licensed health care professional orders.
Report Facts
Number of staff interviewed and/or observed: 20
Number of residents interviewed and/or observed: 15
Capacity: 116
Number of excluded employees followed up: 4
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 11, 2023
Visit Reason
The inspection was conducted based on complaints regarding resident rights to self-determination, notification of hospital transfers, IV treatment and care, food safety and sanitation, and physical plant maintenance.
Complaint Details
The complaint investigation included substantiated findings that the facility failed to honor resident preferences for sleep and medication timing, failed to notify residents and ombudsman about hospital transfers and bed hold policies, failed to provide appropriate IV treatment and maintenance, failed to maintain food safety and sanitation standards, and failed to maintain the physical plant.
Findings
The facility failed to honor resident preferences for sleep and medication timing, failed to notify residents and ombudsman timely about hospital transfers and bed hold policies, failed to properly order and maintain IV treatments, failed to maintain food safety and sanitation standards including cleaning and date marking, and failed to maintain the physical plant with issues such as non-functional lights, damaged drywall, and poor cleaning.
Deficiencies (5)
Failed to honor resident preferences for sleep and medication timing resulting in frustration and loss of autonomy for residents #4 and #31.
Failed to notify resident and ombudsman in writing prior to hospital transfer and failed to provide bed hold policy for resident #89.
Failed to provide appropriate treatment and care according to orders and resident preferences for resident #8 and failed to maintain PICC line dressing changes for resident #1.
Failed to procure food from approved sources and maintain food service equipment and date mark ready-to-eat foods, increasing risk of foodborne illness affecting 41 residents.
Failed to maintain the physical plant in a safe, clean, and functional condition, including non-functional lights, damaged drywall, and poor cleaning, affecting 41 residents.
Report Facts
Residents affected: 41
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Dates: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant P | Certified Nursing Assistant | Reported resident #4's preferences and complaints about medication administration timing |
| Licensed Practical Nurse Q | Licensed Practical Nurse | Reported efforts to accommodate resident #4's sleep preferences and medication timing |
| Licensed Practical Nurse R | Licensed Practical Nurse | Reported medication administration timing for resident #4 and observations of resident's behavior |
| Assistant Director of Nursing C | Assistant Director of Nursing | Discussed medication timing, resident preferences, and follow-up actions for residents #4 and #31 |
| Physical Therapy Assistant K | Physical Therapy Assistant | Discussed therapy scheduling and resident #31's preferences |
| Social Work J | Social Worker | Reported failure to notify ombudsman of resident #89's hospital transfer |
| Nursing Home Administrator A | Nursing Home Administrator | Confirmed failures in notification and bed hold policy for resident #89 |
| Licensed Practical Nurse M | Licensed Practical Nurse | Removed IV bag from resident #8 and reported lack of knowledge about IV maintenance |
| Registered Nurse X | Registered Nurse | Documented late entry clinical note for resident #8's IV order |
| Director of Dining Services D | Director of Dining Services | Reported food service equipment and sanitation issues |
| Clinical Nutrition Manager E | Registered Dietician | Participated in food service observations |
| Dining Room Supervisor W | Dining Room Supervisor | Reported food storage and temperature log issues in satellite kitchen |
| Director of Environmental Services F | Director of Environmental Services | Reported physical plant maintenance and cleaning deficiencies |
| Director of Maintenance G | Director of Maintenance | Discussed physical plant maintenance policies and work order system |
| Physical Therapist I | Physical Therapist | Reported non-functional lighting in therapy area |
Inspection Report
Original Licensing
Capacity: 116
Deficiencies: 0
Date: May 16, 2022
Visit Reason
The facility requested to reduce the licensed bed capacity from 301 to 116 beds, effective May 20, 2022. The visit was to review and approve this bed capacity reduction and related licensing changes.
Findings
The inspection confirmed the de-licensing of the second, fourth, and fifth floors, with the third floor and secured memory care unit remaining licensed. Room sizes and common areas exceeded administrative rule requirements, and no conflicts with the bed reduction were found.
Report Facts
Licensed bed capacity reduction: 185
Licensed bed capacity: 116
Room square footage: Room sizes on third floor ranged from 185 to 566 square feet, exceeding requirements
Day/dining/activity space square footage: 2686
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Rogers | Licensing Staff | Conducted review and authored the report |
| Andrea Moore | Manager, Long-Term-Care State Licensing Section | Reviewed and approved the licensing bed capacity reduction |
| Kathleen Butler | Administrator | Facility administrator who notified licensing of bed de-licensing |
| Andrew Weber | Health Facilities Engineering Section Staff | Conducted on-site inspection and room measurements |
Inspection Report
Original Licensing
Capacity: 301
Deficiencies: 0
Date: May 13, 2021
Visit Reason
The facility requested a reduction in licensed bed capacity from 331 to 301 beds, which was reviewed and documented in this addendum to the original licensing study report.
Findings
The licensing staff reviewed the room sheets and found no conflicts with the requested licensed bed reduction. The recommendation was made to lower the licensed capacity to 301 beds.
Report Facts
Licensed bed capacity reduction: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Rogers | Licensing Staff | Conducted review and signed the addendum report |
| Russell Misiak | Area Manager | Signed the addendum report |
| Craig Courts | Facility authorized representative who requested the bed capacity reduction | |
| Kathleen Butler | Administrator | Named as facility administrator |
Inspection Report
Original Licensing
Capacity: 331
Deficiencies: 0
Date: Mar 1, 2021
Visit Reason
The visit was conducted as an addendum to the Original Licensing Study Report to define the Manor at Glacier Hills memory care area and to approve an increase in licensed bed capacity from 287 to 331 beds.
Findings
The inspection found that the Care and Rehabilitation Center building and the designated Long Term Assisted Living memory care area met or exceeded all administrative rule requirements, including room sizes, safety features, and program compliance. The facility was recommended for a license bed capacity increase to 331.
Report Facts
Licensed bed capacity increase: 44
Total licensed capacity: 331
Day, dining, and activity space: 1812
Single occupancy room sizes: 139
Single occupancy room sizes: 169
Double occupancy room size: 237
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Rogers | Licensing Staff | Conducted the inspection and signed the report. |
| Russell Misiak | Area Manager | Reviewed and signed the report. |
| Craig Courts | Authorized representative of the licensee. | |
| Kathleen Butler | Administrator | Facility administrator. |
Inspection Report
Original Licensing
Capacity: 287
Deficiencies: 0
Date: Feb 14, 2019
Visit Reason
The visit was conducted to review and approve an application to increase the licensed capacity of The Manor at Glacier Hills Home for the Aged by adding 17 rooms, increasing capacity from 257 to 287 beds effective 4/1/19.
Findings
The proposed addition of 17 rooms, including 16 resident rooms and one chapel, meets the required square footage per occupant and bathing facility requirements. The facility was found to be in substantial compliance with life safety and emergency preparedness requirements as of 10/1/18.
Report Facts
Licensed capacity increase: 30
Room count: 17
Double occupancy rooms: 14
Single occupancy rooms: 2
Square footage per occupant: 160
Square footage of day/dining/activity space: 9983
Required square footage for day/dining/activity space: 8610
Bathing facilities: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Krausmann | Licensing Staff | Author of the addendum report |
| Russell Misiak | Area Manager | Reviewed proposed space and signed report |
| Angie Hanson | Authorized Representative | Licensee authorized representative who submitted the application |
| Katy Kurili | Executive Director | Reviewed proposed area at the facility |
Inspection Report
Renewal
Capacity: 257
Deficiencies: 0
Date: Dec 9, 2009
Visit Reason
The visit was an unannounced on-site renewal licensing inspection conducted to verify the facility's current floor plan and capacity after renovations and construction changes.
Findings
The inspection found that renovations and construction changes reduced the facility's licensed capacity from 302 beds to 257 beds. The Bureau of Fire Services issued an approved fire safety certification, and the Bureau of Health Facilities Engineering Section confirmed the physical capacity to support 257 licensed beds.
Report Facts
Licensed capacity reduction: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Krausmann | Licensing Staff | Author of the report and recommendation |
| Katy Kurili | Authorized representative of the facility who provided information about renovations |
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