Inspection Reports for
Michigan Masonic Home
1200 Wright Avenue, Alma, MI, 48801
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% better than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
46% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Capacity: 138
Deficiencies: 1
Date: Jun 26, 2025
Visit Reason
The investigation was initiated due to complaints alleging that employees were not trained and competencies were not checked on medication administration.
Complaint Details
The complaint alleged that certified nurse assistants were administering medications without formal training. The violation was established based on interviews and documentation review.
Findings
The investigation found that the facility changed its staffing model to have resident assistants administer medications without formal training or competency testing. There was a lack of training documentation and competency checks on injection medications and catheter care, and employees had not acknowledged their position changes.
Deficiencies (1)
Employees are not trained, and competencies are not checked on medication administration.
Report Facts
Capacity: 138
Complaint Receipt Date: Jun 17, 2025
Investigation Initiation Date: Jun 20, 2025
Report Due Date: Aug 17, 2025
Training hours: 12
Training hours: 8
Passing grade: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kari Conn | Administrator | Interviewed regarding staffing model change and training. |
| Kimberly Horst | Licensing Staff | Conducted investigation and authored report. |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the report. |
Inspection Report
Complaint Investigation
Capacity: 138
Deficiencies: 1
Date: Jun 11, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging that care staff were rude to Resident A, Resident A's care needs were not met, and Resident A's room had not been cleaned.
Complaint Details
Complaint received on 2025-06-02 alleging care staff were rude to Resident A, Resident A's care needs were not met, and Resident A's room was not cleaned. The allegation of rudeness was not established; care needs not met was established; room cleanliness allegation was not established.
Findings
The investigation found that the allegation of care staff being rude to Resident A was not substantiated. However, a violation was established regarding Resident A's care needs not being fully met due to inconsistent shower documentation and lack of detailed information in the service plan. The allegation that Resident A's room was not cleaned was not substantiated.
Deficiencies (1)
Inconsistent shower documentation and lack of detailed information in Resident A's service plan regarding care needs and independence encouragement.
Report Facts
Capacity: 138
Shower dates documented: 5
Shower refusals documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kari Conn | Administrator/Authorized Representative | Interviewed regarding Resident A's care and facility operations |
| Kimberly Horst | Licensing Staff | Conducted the investigation and authored the report |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 138
Deficiencies: 1
Date: May 21, 2025
Visit Reason
The inspection was initiated due to multiple complaints alleging inadequate staffing at the facility, including concerns about resident falls, medication administration delays, and resident neglect.
Complaint Details
The complaint alleged inadequate staffing resulting in residents not being checked regularly, resident falls, elopements, and neglect. The complaint was substantiated with a violation established.
Findings
The investigation found that the facility had worked below their staffing ratios on several occasions, requiring use of staff from another licensed health care facility to fill shortages. Call light response times were sometimes prolonged, and staffing shortages impacted resident care and medication administration.
Deficiencies (1)
Inadequate staff at the facility.
Report Facts
Capacity: 138
Census: 64
Call light response time (minutes): 9
Staffing shortages: 3
Call light response times (minutes and seconds): Detailed daily average call light response times from 07/02/2025 to 07/09/2025 as listed in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kari Conn | Administrator | Interviewed regarding staffing and facility operations. |
| Kimberly Horst | Licensing Staff | Author of the Special Investigation Report. |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the report. |
Inspection Report
Routine
Census: 22
Deficiencies: 4
Date: Dec 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, fall prevention, infection control, and environmental safety at the Michigan Masonic Home nursing facility.
Findings
The facility failed to maintain resident dignity for one resident by not honoring his preference for male caregivers during showers. The facility also failed to implement adequate fall prevention interventions for three residents at high risk for falls. Additionally, the infection prevention program was deficient in managing water system risks, and environmental safety issues were noted including plumbing and sanitation concerns.
Deficiencies (4)
F 0550: The facility failed to maintain self-esteem and honor preferences for one resident by not documenting or accommodating his preference for male caregivers during showers, resulting in embarrassment and refusal of care.
F 0689: The facility failed to implement adequate fall prevention interventions and supervision for three residents at high risk for falls, despite known cognitive impairments and history of falls.
F 0880: The facility failed to have an active and ongoing infection prevention plan to reduce the risk of Legionella and other opportunistic pathogens in the water system, including lack of routine flushing and testing.
F 0921: The facility failed to maintain a safe, functional, sanitary, and comfortable environment, including plumbing issues, improper storage of linens, and potential contamination risks from equipment connections.
Report Facts
Residents reviewed for dignity: 22
Residents reviewed for falls: 6
Dates of showers refused: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN N | Registered Nurse | Aware of resident R47's preference for male caregivers but noted preference was not care planned |
| RN/ADON O | Registered Nurse/Assistant Director of Nursing | Reported familiarity with resident R47's shower preferences and need for better documentation |
| RN C | Registered Nurse | Provided information about resident R87's ambulation needs and fall risk |
| Unit Manager A | Unit Manager | Interviewed about fall interventions and care plan documentation for resident R38 |
| DOF J | Director of Facilities | Interviewed regarding water system flushing and infection control deficiencies |
| DES I | Director of Environmental Services | Interviewed regarding plumbing and sanitation issues |
| LSEM K | Life Safety Emergency Manager | Interviewed regarding water fixture flushing and environmental safety concerns |
| DDS M | Director of Dining Services | Interviewed regarding kitchen water fixture usage and flushing practices |
Inspection Report
Renewal
Census: 20
Capacity: 221
Deficiencies: 2
Date: Feb 22, 2024
Visit Reason
The inspection was conducted as a renewal licensing study for the Michigan Masonic Home to assess compliance with applicable rules and regulations.
Findings
The facility was found to be in non-compliance with rules related to medication administration documentation and food handling practices, specifically incomplete medication logs and leftover food not destroyed as required.
Deficiencies (2)
Staff did not complete the medication administration record (MAR) on 02/06 for Resident A as prescribed by the physician.
Leftover food was found in a refrigerator on the second floor, which should have been destroyed.
Report Facts
Number of staff interviewed and/or observed: 10
Number of residents interviewed and/or observed: 20
Facility capacity: 221
Inspection Report
Deficiencies: 2
Date: Oct 26, 2023
Visit Reason
The inspection was conducted to evaluate compliance with safety and medication regimen review requirements at the Michigan Masonic Home.
Findings
The facility failed to safely transport one resident in a wheelchair without foot pedals, creating a risk of serious injury. Additionally, the facility did not ensure timely physician review of a pharmacy drug regimen recommendation, resulting in prolonged use of an unnecessary medication.
Deficiencies (2)
F 0689: The facility failed to ensure safe wheelchair transportation by pushing a resident without foot pedals, risking falls or injury.
F 0756: The facility failed to ensure timely physician review of a pharmacy drug regimen recommendation, resulting in extended use of an unnecessary medication.
Report Facts
Days delay for physician review: 42
Days medication continued after recommendation: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse B | Observed pushing resident R25 in wheelchair without foot pedals | |
| Registered Nurse E | Interviewed about policy against pushing residents in wheelchairs without foot pedals | |
| Registered Nurse D | Interviewed about risks of pushing residents in wheelchairs without foot pedals | |
| Assistant Director of Nursing (ADON) A | Interviewed regarding pharmacy recommendation process and timing | |
| Director of Nursing (DON) | Interviewed regarding physician review timing and pharmacy recommendation re-issuance |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 24, 2023
Visit Reason
Annual survey inspection of the Michigan Masonic Home nursing facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Notice
Deficiencies: 0
Date: May 8, 2023
Visit Reason
The document serves as a notification of license renewal following an administrative review of licensing activity for the past year, confirming substantial compliance with public health code and administrative rules.
Findings
The administrative review revealed substantial compliance with applicable regulations, resulting in the renewal of the Home for the Aged license effective May 4, 2023.
Report Facts
License duration: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Horst | Licensing Staff | Signed the license renewal notification letter |
Inspection Report
Routine
Census: 111
Deficiencies: 3
Date: Oct 27, 2022
Visit Reason
Routine inspection to assess compliance with regulatory standards related to resident dignity, activities, and food safety at Michigan Masonic Home.
Findings
The facility failed to treat residents with dignity and respect, resulting in unmet care needs and potential loss of self-worth. Meaningful activities were insufficiently provided, leading to resident boredom and disengagement. The kitchen failed to maintain proper sanitary conditions and food temperature controls, increasing the risk of foodborne illness.
Deficiencies (3)
F 0550: The facility failed to honor residents' rights to dignity and respect, as evidenced by inadequate care and neglect of residents' needs, including inaccessible call lights and poor hygiene.
F 0679: The facility failed to provide meaningful activities for residents, resulting in boredom and disengagement, particularly for a cognitively impaired resident.
F 0812: The facility failed to maintain sanitary conditions in the kitchen and properly monitor food temperatures, risking cross contamination and foodborne illness for all residents.
Report Facts
Total resident census: 111
Food temperature: 44
Food temperature: 45
Food temperature: 47
Food temperature: 46
Food temperature: 44
Discarded dairy products: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager Q | Nurse Manager | Interviewed regarding staff interaction with residents during meals and expectations for resident care |
| Registered Nurse Z | Registered Nurse | Informed about resident care concerns including inaccessible call light and drooling |
| Life Enrichment Director U | Life Enrichment Director | Interviewed about resident activity engagement and staffing shortages in Activities department |
| Staff A | Director of Dining Services | Interviewed and observed regarding refrigerator temperature monitoring and food safety procedures |
| Registered Nurse Y | Registered Nurse | Observed during meal supervision and resident care related to feeding and hygiene |
| Certified Nurse Aide O | Certified Nurse Aide | Observed interacting with resident but failing to address care needs such as call light placement and drooling |
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 4, 2022
Visit Reason
The document is a licensing renewal notification following an administrative review of licensing activity for the past year, confirming substantial compliance with public health code and administrative rules for home for the aged facilities.
Findings
The review revealed substantial compliance with applicable regulations, resulting in the renewal of the facility's 12-month license effective 2022-05-04.
Report Facts
License duration: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Horst | Licensing Staff | Author of the licensing renewal letter |
Inspection Report
Original Licensing
Capacity: 221
Deficiencies: 0
Date: Jun 22, 2021
Visit Reason
The document is an addendum to the Original Licensing Study Report for Michigan Masonic Home, reflecting renovations and changes to the facility.
Findings
The facility renovated the former memory care unit on the third floor into a common living area, dining area, nurse station, laundry room, storage, and eight resident suites allowing double occupancy. The apartments include studio and two-bedroom floor plans with bathrooms equipped with emergency pull cords. No marketing of memory care programming was found for the aged areas.
Report Facts
Licensed beds: 221
Resident suites: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Horst | Licensing Staff | Author of the report and recommendation |
| Russell Misiak | Area Manager | Signed the recommendation |
| Michael Logan | Authorized Representative of the facility | |
| Kari Conn | Administrator | Facility Administrator |
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