Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 47 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
32D
6E
5F
Potential for minimal harm
0A
0B
0C
May 5, 2026Standard inspection · 10 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide food at a palatable temperature for 1 of 1 resident (R33), resulting in the potential for decreased food consumption for all residents who receive food from the kitchen and nutritional decline. Findings Include: Resident #33 During an interview on 5/3/2026 at 10:08 AM, Resident #33 reported ongoing concerns with cold food. Resident #33 reported she felt that the food was a bit warmer when served in the dining room, but when she ate meals in her room, the food was always cold. Resident #33 reported she had spoken with multiple facility staff members on numerous occasions about her concerns with food, but they were still serving cold food often. In a follow up interview on 5/4/2026 at 1:11 PM, Resident #33 was sitting in her chair in the dining room. [...]
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 5/4/26 at starting at 8:05 AM, a follow-up tour of the kitchen with Dietary Director (DD) W occurred. On 5/4/26 at 8:26 AM, observation of the shelf above the hand sink found a spray bottle with a yellow solution that didn't have a common name for labeling. According to the 2022 FDA Food Code section 7-102.11 Common Name. Working containers used for storing POISONOUS OR TOXIC MATERIALS such as cleaners and SANITIZERS taken from bulk supplies shall be clearly and individually identified with the common name of the material. [...]
- D
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.
Inspectors wroteBased on interview and record review, the facility failed to ensure updated and accurate advanced directive information was in place for 2 (Resident #10 and Resident #5) of 18 residents reviewed for advanced 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, or other healthcare providers.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 (Resident #67) of 4 residents reviewed for abuse resulting in Resident #67 being inappropriately touched by Resident #43.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review the facility failed to ensure that written bed hold notice was provided to 1 (Resident #95) of 3 residents reviewed for transfer and discharge from the facility.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, the facility failed to review and revise a comprehensive, individualized plan of care after a resident-to-resident abuse incident for 1 (Resident #43) of 18 residents reviewed for care plans, resulting in the potential for unmet care needs and impaired physical, mental, and psychosocial well-being.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review, the facility failed to implement pressure ulcer prevention interventions, consistent with professional standards of practice for 1 (Resident #42) of 1 resident reviewed for pressure ulcer prevention, resulting in the potential for the development of an avoidable pressure ulcer.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions for fall prevention for 1 (Resident #58) of 3 residents reviewed for accidents, resulting in the potential for falls and injury.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement person-centered dementia care interventions based on lifelong habits and personality for 2 (Resident #63 and Resident #18) of 7 residents reviewed for dementia care, resulting in Resident #63 experiencing agitation and avoidable stress and Resident #18 breeching other residents' personal space, being yelled at and at risk for aggressive responses from others.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records for 1 of 18 residents (Resident #5) reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents.
February 26, 2026Complaint inspection · 1 citation
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteThis citation pertains to intake #2674240Based on observation, interview and record review, the facility failed to protect the residents' right to be free from resident-to-resident physical abuse for 2 (Resident #103 and Resident #104) of 4 residents reviewed for abuse resulting in Resident #104 grabbing Resident #103 by the arm, and Resident #103 slapping Resident #104 in the face.
April 2, 2025Standard inspection, Complaint inspection · 16 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteR61 According to the Minimum Data Set (MDS) dated [DATE], R61 was cognitively intact as evidenced by her BIMS (Brief Interview Mental Status) score of 14/15. During an observation and interview on 3/31/25 at 12:15 PM, R61 was awake in bed with her head-of-bed (HOB) at the window. The windowsill track was littered with dead bugs, dust, and debris. The tile sill was cracked and chipped with a large chunk of it missing. The veneer around the bed head board was pulled away from the wood leaving an area large enough to put a hand through. R61 stated, I keep my house neat, tidy, and clean. I would never have my house like this. I have a handyman that helps me at home to keep things fixed. I'm glad I'm going home tomorrow. During an observation and interview on 4/1/25 at 8:00 AM, the window curtain at R61's HOB had a stain the size of a saucer cup at eye level of the resident. [...]
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards of nursing practice and notify the provider of missed medication doses, 2 of 19 residents (Resident #6 and Resident #338) reviewed for professional standards, resulting in missed medications and treatments, and the potential for the worsening of a condition and a delay in treatment.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure facial hair grooming was offered and/or provided and/or clean hair was maintained for 4 (Residents #12, 14, 17, 53) of 6 residents reviewed that were dependent on staff for activities of daily living resulting in unwanted facial hair, debris in hair, appearing unkempt, and the potential for feeling embarrassed or having decreased self-worth.
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview, and record review the facility failed to consistently provide residents with their food and beverage preferences for 12 residents (Residents #17, 53, 65, 2, 64, 85, 12, 14, 76, 22, 24, and 338) out of a facility census of 88 resulting in incorrect items provided, decreased satisfaction, and the potential for frustration, weight loss, and/or dehydration.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were cared for with dignity and respect for 1 (Resident #54) of 2 residents reviewed for dignity, resulting in the potential for feelings of embarrassment, frustration, depression, and loss of self-worth and an overall deterioration of psychological well-being.
- D
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.
Inspectors wroteBased on interview and record review, the facility failed to ensure an updated and accurate advanced directive information was in place for 1 of 19 residents (Resident #338) reviewed for advanced 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, or other healthcare providers.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview, and record review, the facility failed to notify the responsible party of a change in resident condition in 1 of 2 residents (R7) reviewed for notification of changes, resulting in the guardian/emergency contact not being made aware of an injury of unknown origin (R7) causing the inability to participate in timely medical decision-making.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteThis citation pertains to intake MI00150533 Based on interview, and record review, the facility failed to prevent the misappropriation of resident narcotic medications in 1 of 1 residents (Resident #64) reviewed for misappropriation of property, resulting in loss of resident's pain medication, and the potential for uncontrolled pain and discomfort.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to operationalize its abuse policy and procedure for 1 resident (R7) of 2 residents reviewed for potential sexual abuse, resulting in staff not reporting observations of abuse to the Nursing Home Administrator immediately, potential for further resident to resident observations of abuse to go unreported and uninvestigated.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the person centered care plan in a timely manner with appropriate interventions for the prevention of falls for 1 resident (#43) from a total sample of 19 residents, with the potential for physical, mental, and psychosocial unmet care needs and harm.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to prevent, treat, and promote healing of pressure ulcers in 1 of 1 residents (Resident #288) reviewed pressure ulcers, resulting in the potential for delayed healing of pressure ulcers, infection and the development of new ulcers.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safety precautions and use of assistive devices for 1 (Resident #33) of 4 residents which have the potential to negatively affect the residents highest practicable physical, mental, and psychosocial well-being.
- D
Provide or arrange emergency care by a doctor 24 hours a day.
Inspectors wroteBased on interview and record review, the facility failed to ensure emergency physician services were utilized by facility staff for one resident (R7) of 19 reviewed for emergency physician care needs, resulting in not receiving prompt physician emergency services and the increased potential for complications to a serious health condition.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent in 2 of 11 residents (Resident #338 and #6) reviewed for medication administration, resulting in a medication error rate 12% and the potential for adverse effects.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label, date, and store medications in 1 out of 1 medication carts resulting in the potential for decreased efficacy of medications and the exacerbation of medical conditions.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to effectively implement infection control measures that included: 1.) effective implementation of Enhanced Barrier Precautions (EBP) for 2 residents (R7 and R338) 19 residents reviewed for infection control, resulting in the potential for cross contamination of infection to a vulnerable population.
September 18, 2024Complaint inspection · 3 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThis citation pertains to intakes: MI00146150, MI00146185, MI00146924 This citation has 2 deficient practice statements. DPS #1: Based on observation, interview, and record review, the facility failed to ensure the safety and prevent elopement for 3 (Resident#100, Resident #101, Resident #105) of 5 residents reviewed for elopement, resulting in an Immediate Jeopardy when Resident #100 and Resident #101 left the premises alone, unbeknownst to staff, for an extended period, and were later found in the community and the likelihood for serious harm and/or injury for Resident #105.
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteThis citation pertains to intakes MI00146152, MI00146926 Based on interview, and record review, the facility failed to protect the residents right to be free from resident to resident abuse for 4 (Resident #102, Resident #103, Resident #107 and Resident #108) of 5 residents reviewed for abuse, resulting in Resident #102 physically assaulting Resident #103, and Resident #107 grabbing Resident #108 in a sexual manner.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThis citation pertains to intake # MI00146924. Based on interview and record review, the facility failed to ensure proper post-fall care and assessment for 1 (Resident #106) of 3 residents reviewed for falls, resulting in the potential for serious injury.
June 25, 2024Complaint inspection · 5 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThis citation pertains to intake #MI00143822. Based on interview and record review, the facility failed to use a sit-to-stand lift (a medical device used to assist individuals in transitioning from a seated to a standing position), as recommended by therapy and per care plan, during a transfer from the resident's bed to wheelchair in 1 (Resident #100) of 3 residents reviewed for safety, resulting in the resident sustaining a laceration requiring sutures.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's physician of a change in condition in 1 of 4 residents (Resident #103) reviewed for physician notification, resulting in lack of assessment and physician involvement following two unwitnessed falls, with known head trauma.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteThis citation pertains to intake #'s MI00144035 and MI00144038. Based on observation, interview, and record review the facility failed to protect the resident's right to be free from resident to resident physical abuse in 2 of 4 residents (Resident #105 and #104) reviewed for abuse, resulting in Resident #104 being physically abuse by Resident #105 twice in an 8 day period.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to recognize and report an injury of unknown origin for 1 resident (Resident #103) of 4 residents, reviewed for reporting, resulting in the lack of reporting and the potential for a delay in the investigation.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview, and record review, the facility failed to ensure complete and accurate documentation of post fall assessments for 1 of 12 residents (Resident #103) reviewed for complete and accurate medical documentation, resulting in the potential for insufficient follow up and lack of necessary interventions.
March 26, 2024Standard inspection · 12 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement facility fall protocols and utilize gait-transfer belts/implement interventions before and after falls and provide adequate supervision for 2 residents (Resident #65 & #64) of 3 reviewed for falls/supervision resulting in a fall with a fracture needing surgical repair for Resident #65 and the potential for accidents and injuries to residents at risk for falls.
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on interview and record review, the facility failed to employ either a full time Registered Dietitian or Certified Dietary Manager to provide oversight of kitchen and clinical nutritional services. This deficient practice has the increased potential to result in food service sanitation failures, food borne illness, or inadequate assessment of high-risk residents.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Clean food and non-food contact surfaces to sight and touch; 2. Ensure proper cooling of potentially hazardous foods; 3. Ensure proper working order of the dish machine; 4. Provide accurate sanitizer test strips; 5. Maintain equipment in good repair; 6. Ensure general cleaning of the kitchen; 7. Properly wash hands and protect food from contamination; and 8. Properly date mark and discard food product. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 83 residents who consume food from the kitchen. Findings Include: 1. During a tour of the kitchen, at 9:14 AM on 3/25/24, observation of the top gaskets on unit #4 and unit #2 were observed with an accumulation of debris. [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective infection control surveillance plan, ensure cleaning of shared equipment between residents, maintain resident equipment in clean condition, store resident care supplies in a manner to prevent the spread of infection, and prevent cross-connections for plumbing fixtures, with the potential to affect all 83 residents who reside at the facility, resulting in the potential for the spread of infection without timely identification and response, disease exposure, cross-contamination, and the development and spread of infection to a vulnerable population.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration and post-fall assessments in 6 of 11 residents (Resident #135, #56, #77, #24, #78, & #65) reviewed for medication administration, and 1 of 3 residents (Resident #47) reviewed for falls, resulting in medications left unattended at the bedside, medications being pre-set for administration with the potential for medication errors and adverse effects, ordered medications not being delivered and administered, and neurological checks not being completed after an unwitnessed fall.
- E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to meet resident needs in 2 of 5 residents (Resident #59 & #45) reviewed for sufficient staffing, with the potential for all residents to be affected, resulting in missed showers/baths, a lack of supervision of residents at risk for falls and elopement, and long call light wait times. For additional information see citations F677 and F689.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from physical restraints for staff convenience in 1 (Resident #60) of 3 residents reviewed for restraint use, resulting in potential for injury, and/or psychological harm.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for reporting an allegation for potential abuse for 1 (Resident #64) of 18 residents reviewed for reporting, resulting in the potential for continued unidentified, unreported neglect to occur.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on obsevation, interview and record review, the facility failed to conduct a thorough investigation into an alleged staff to resident abuse (restraint with gait belt to a wheelchair) for 1 (Resident #64) of 18 residents reviewed for abuse/neglect, resulting in an incomplete and thorough investigation and the potential for abuse to continue.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement person centered comprehensive care plans for 1 (Resident #33) of 18 residents reviewed for care plans, resulting in missed assessments and monitoring for potential side effects related to use of psychotropic medications.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine showers to dependent residents for 2 or 4 residents (Resident #45 and #59) reviewed for activities of daily living, resulting in residents feeling dirty and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately maintain, store and label respiratory treatment supplies for 3 residents (Resident #8, #76 & #13) reviewed for respiratory care, resulting in the potential for respiratory infections and the exacerbation of respiratory conditions cross-contamination of respiratory equipment, and growth of infectious microorganisms.
Fire safety inspections
21 fire safety citations on file: 9 on May 5, 2026, 7 on April 2, 2025, 5 on March 26, 2024.
Every fire safety citation21 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · May 5, 2026 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · May 5, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · May 5, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 5, 2026 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · May 5, 2026 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · May 5, 2026 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · May 5, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · May 5, 2026 · Corrected (the home has a date of correction)
- D
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · May 5, 2026 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · April 2, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 2, 2025 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · April 2, 2025 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 2, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · April 2, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · April 2, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · April 2, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · March 26, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 26, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · March 26, 2024 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · March 26, 2024 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 26, 2024 · Corrected (the home has a date of correction)