Ely Manor: Resident Missed Showers for Months - MI
The finding came out of a complaint investigation completed on August 21. Inspectors reviewed the bathing records for Resident 102 and found what the director of nursing, identified in the report as DON B, confirmed herself: one shower documented in April, none in May.
DON B told inspectors that residents should be offered showers or baths generally twice per week, based on their preferences. By that standard, Resident 102 should have received somewhere around eight to ten showers across those two months. The records showed one.
The facility's own written policy, dated March 12, 2025, states that residents receive the necessary assistance to maintain good grooming and personal hygiene, and that showers, tub baths, and shampoos are scheduled according to person-centered care. The gap between what that policy promised and what Resident 102's records showed stretched across at least two calendar months.
The inspection report notes that the facility had been working with its IT vendor to address a documentation issue sometime in May or June 2025. Whether that technical problem contributed to missing records, or whether the showers simply weren't given, the report does not resolve. What it establishes is that no completed shower or bath appeared in the documentation for May, and inspectors classified the harm level as minimal or potential.
That classification reflects the regulatory floor, not a judgment that nothing happened. A resident who goes weeks without bathing faces real consequences, even if they don't show up in a chart. Skin breaks down. Infections start. Dignity erodes in ways that don't get coded into a deficiency tag.
Ely Manor sits at 1200 Ely Street in Allegan, a small city in western Michigan. The August inspection was triggered by a complaint, meaning someone, whether a resident, a family member, or a staff member, contacted regulators before inspectors arrived. The report does not say who filed it or what specifically prompted the call.
DON B reviewed the records and reported the findings to inspectors directly. The report does not indicate that any corrective action had been taken before the inspection, or that the gap in Resident 102's care had been caught internally before someone went outside the facility to report it.
The facility's plan of correction is not included in the publicly available inspection document. Residents and families seeking that information are directed to contact Ely Manor or the Michigan state survey agency.
What the report leaves is a straightforward picture: a resident who, for at least a month and possibly longer, went without the basic hygiene care the facility's own staff said they should be receiving twice a week. The technical infrastructure explanation may account for missing documentation. It does not account for whether anyone noticed, whether anyone checked, or whether Resident 102 was asked during those weeks why no shower had been scheduled.
The inspection found few residents affected. That phrase, in the language of federal oversight, means the problem was identified in a small number of cases. It does not mean the experience of those residents was small.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ely Manor from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
Ely Manor in Allegan, MI was cited for violations during a health inspection on August 21, 2025.
The finding came out of a complaint investigation completed on August 21.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.