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 61 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
40D
11E
5F
Potential for minimal harm
0A
0B
2C
April 17, 2026Standard inspection, Complaint inspection · 23 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an overall effective pressure ulcer prevention program to prevent the development and worsening of pressure ulcers, implement interventions for pressure injuries and effectively assess and monitor for new or worsening pressure injuries for 7 residents (Resident #41, #53, #61, #45, #7, #18 and #4) of 7 residents reviewed for pressure ulcers, resulting in Resident #41's pressure ulcer on the sacrum (coccyx, tailbone) worsening to a Stage 4, Resident #53's Stage 3 pressure ulcer on the sacrum deteriorated, Resident #61 developed a new facility acquired pressure ulcer, and the potential for skin breakdown or continued skin breakdown for Resident's #45, #7, #4, and #18 and overall decline in health status.
- F
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observation, interview and record review, the facility failed to fully implement a policy regarding use and storage of resident foods brought in from outside sources resulting in potentially hazardous foods being held passed their discard date, increasing the risk of contamination and food borne illness among residents who store food in resident refrigerators. Findings Include:On 4/14/26 at 10:06 AM, observation of the East Nourishment room found a plastic bag with containers of leftover dinner and dessert items labeled with a resident's name and dated 4-6-26. Further observation of the unit found an unopened package of yogurt labeled with a resident's name and having best by dates of March 23, 2026. [...]
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and record review, the facility failed to: 1) effectively identify quality deficiencies, develop, and implement appropriate action to correct deficiencies; and 2) sustain a system to ensure corrective measures related to resident rights, bowel/bladder incontinence/catheter care, infection control, monthly medication reviews, pressure ulcers, and quality of care as evidenced by repeated deficiencies on the past three surveys. This deficient practice has the potential to affect all residents that reside in the facility.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively implement an effective infection control program to include: 1). ensuring Enhanced Barrier Precautions (EBP) (an infection control intervention that uses targeted gown and glove use during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms (MDROs) were implemented in 3 residents (Resident #41, #45 & #53), 2). [...]
- F
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) employed by the facility received at least 12 hours of annual in-service education, resulting in the potential for inadequate care and unmet needs of residents. This had the potential to affect all residents who reside in the facility.
- E
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 observation, interview and record review the facility failed to develop and implement resident focused care plans based on a comprehensive assessment for 5 (Resident #41, #45, #53, #61, and #10) of 18 residents reviewed for comprehensive care plans, resulting in unidentified care needs and the potential for worsening of medical conditions.
- E
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 revise care plan interventions for pressure ulcer prevention for 1 (Resident #18) of 18 residents reviewed for care planning, resulting in staff being unaware of current pressure ulcer prevention interventions for the resident, and a potential for the resident to experience worsening of pressure ulcers.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThis citation pertains to intake 2642352. Based on observation, interview, and record review, the facility failed to ensure assistance with activities of daily living (ADL) care was provided for 4 (Resident #1, #57, #16, #26) of 7 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's dependent on staff for assistance.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThis citation pertains to intake #2616992Based on observation, interview and record review, the facility failed to ensure residents achieved their highest practicable physical well-being and follow professional standards of practice by: 1. [...]
- E
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 complete and accurate medical records for 8 of 18 residents (Resident #41, #45, #53, #61, #7, #81, #18 and #4) reviewed for complete and accurate documentation, resulting in the potential for staff and providers mismanaging care for residents.
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the cleanliness of resident shared equipment, resulting in the potential for cross contamination, infections, and bacterial harborage.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and ensure the right to safe self-administration of medication in 1 of 18 residents (Resident #16) reviewed for medication administration, resulting in the potential for unsafe self-administration of medication, medication errors, and medications not being stored in a secure manner.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that promoted resident dignity in 1 (Resident #29) of 4 residents reviewed for dignity, resulting in the potential of feelings of humiliation, embarrassment, and loss of self-worth.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to arrange room furniture in a functional manner, provide adequate power outlets for adaptive equipment and implement low-vision modifications to promote independence for one (Resident #2) of three residents reviewed for accommodation of needs, resulting in feelings of frustration, loss of independence and lack of an individualized environment.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interview and record review, the facility failed to allow resident choice regarding personal care in 1 of 1 resident (Resident #1) reviewed for self-determination, resulting in Resident #1 not receiving care (showers/baths) at her preferred time of day.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview, and record review, the facility failed to provide and document evidence of prompt resolution of grievances in 2 of 2 residents (Resident #2 & #1) reviewed for resolution of grievances, resulting in the potential to experience frustration, apprehension, helplessness, and a negative psychosocial outcome for the residents impacting their quality of life.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to 1.) provide adequate supervision and implement appropriate care planned interventions to prevent a fall in 1 resident (Resident #57) reviewed for falls, 2.) ensure safe transfer for 1 resident (Resident #5) and 3.) ensure safe wheelchair transport in 1 resident (Resident #37) of 3 residents reviewed for safety resulting in the potential for residents to sustain a fall and/or injury.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the necessary care and services were in place for a Foley catheter (tube inserted into bladder to drain urine) for 1 resident (Resident # 41) and failed to provide timely incontinence care for 1 resident (Resident #7), from a sample of 3 residents reviewed for incontinence care, resulting in the potential for trauma due to an unsecure Foley catheter, and skin breakdown and recurrent UTI's (urinary tract infections) due to inadequate incontinence care.
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on interview and record review, the facility failed to ensure a physician (provider) supervised the medical care of residents and participated in the resident's wound assessments and treatment plans for 1 resident (Resident #53) of 18 residents reviewed for physician supervised care, resulting in the potential for a decline in overall health due to worsening of wounds.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review, the facility failed to ensure timely physician follow up with pharmacy recommendations for 3 residents (Resident #3, Resident #10, and Resident #57) of 5 reviewed for medications resulting in the potential for residents to experience avoidable medication side effects and/or receive unnecessary medications.
- D
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Medical Director fulfilled their responsibility of implementing Medication Regimen Review (MRR) policies/procedures to include coordination of care between the facility and the consulting pharmacist/pharmacy for 3 (Resident #10, #57 and #3) of 5 residents reviewed for medications. This deficient practice has the potential to affect all residents that reside at the facility.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation and interview, the facility failed to ensure the most recent survey results were available to residents, family members, legal representatives, and/or visitors to the facility.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation and interview the facility failed to ensure daily staffing information was posted daily.
September 17, 2025Complaint inspection · 3 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteThis citation pertains to intake #2591271. Based on interview and record review, the facility failed to notify a resident's emergency contact regarding emergency incidents including 1) A resident fall, 2) resident injury, 3) An emergency transfer to an acute care hospital for 1 resident (Resident #3) of 4 residents reviewed for falls resulting in Resident #3's emergency contact being unaware of her fall, injury and subsequent transfer to an acute care hospital for evaluation and treatment.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThis citation pertains to intake #2591271 and #2581648. Based on observation, interview, and record review, the facility failed to ensure a resident received the necessary care and services, consistent with professional standards of practice to identify and promote the healing of a pressure ulcer in 1 resident (Resident #6) of 3 residents reviewed for pressure ulcers/skin conditions resulting in the potential for worsening and/or reoccurrence of pressure injuries due to not having the appropriate treatment in place to help with wound healing.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteThis citation pertains to intake #2591271. Based on interview and record review, the facility failed to maintain accurate documentation in resident medical records in 1 resident (Resident #1) of 4 residents reviewed for ADLs (activities of daily living) resulting in not knowing whether the resident received or refused a shower.
August 5, 2025Complaint inspection · 2 citations
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteThis citation pertains to Intake: 2575125 Based on interview and record review, the facility failed to implement the abuse policy for reporting and response to allegations of abuse in 1 of 3 residents (Resident #102) reviewed for abuse, resulting in the potential for further allegations of abuse to be unreported.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThis citation pertains to Intake: 2575125 Based on interview and record review, the facility failed to provide adequate supervision to prevent a resident-to-resident altercation for 2 (Resident #101, Resident #102) of 3 residents reviewed for abuse, resulting in Resident #101 making racial accusations to Resident #102 and Resident #102 hitting Resident #101 in the stomach.
March 12, 2025Standard inspection, Complaint inspection · 12 citations
- 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 prepare and store 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 from the kitchen.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to respond timely to call lights to maintain resident dignity for 5 (Residents #4,#10, #22, #36 and #237) of 7 residents reviewed for dignity, resulting in episodes of incontinence and feelings of frustration and loss of self-worth with the potential for overall deterioration of psychological well-being.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure confidential resident health information was protected and private for 1 of 1 (Residents #71) residents reviewed for privacy and federally regulated HIPAA (Healthcare Insurance Portability and Accountability Act).
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview and record review, the facility failed to provide written notification to the State Long-Term Care (LTC) Ombudsman of facility-initiated transfers/discharges in November 2024 and December 2024 resulting in the potential for all residents to be discharged without an advocate who can inform them of their options and rights.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure adequate assessment for 1 (R237) of 1 resident reviewed for quality of care when, resulting in R237 receiving a delay in treatment for abrasions.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received proper treatment to maintain vision abilities for 1 of 1 resident (Resident #4), reviewed for vision services, resulting in the inability of the resident to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide coordination of care and services for a Foley catheter (flexible tube inserted through the urethra and into the bladder to drain urine) according to professional standards of practice for urinary catheters for 1 of 2 residents (Resident #42) reviewed for catheter care, resulting in Resident #42 continuing to experience urinary tract infections (UTI) with the potential for complications related to urinary tract infections.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview, and record review, the facility failed to ensure the physician reviewed and responded to the licensed pharmacist's monthly medication regimen review recommendations in a timely manner in 1 of 5 residents (Resident #14) reviewed for unnecessary medications, resulting in the potential for medication interactions and adverse side effects.
- D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide adaptive dining equipment for 2 (Residents #3 and #4) of 2 residents reviewed for adaptive dining equipment resulting in spills, frustration, decreased independence with eating and drinking, and the potential for weight loss or dehydration.
- D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased on interview and record review, the facility failed to ensure that Quality Assessment and Process Improvement (QAPI) meetings had the Medical Director as a mandatory attendee at least quarterly resulting in the potential for the Medical Director to not be notified of quality deficiencies occurring in the facility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to: 1.) use appropriate personal protective equipment for enhanced barrier precautions and/or appropriate infection control practices for 2 (Resident #38 and #42) of 3 residents reviewed for high contact care activities and catheter care and 2.) don appropriate personal protective equipment for 1 (Resident #27) of 5 residents reviewed for transmission based precautions, resulting in the potential for spread of infection.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interview and record review, the facility failed to ensure COVID-19 consents or declinations were obtained for 1 resident (Resident #71) of 5 residents reviewed for immunizations resulting in residents/family members not being aware of the vaccination and the risks/benefits of having it administered.
December 27, 2024Complaint inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteThis citation pertains to Intake MI00146941. Based on observation, interview, and record review, the facility failed to 1.) Follow enhanced barrier and contact precautions for 2 (Resident #104 and #105) of 5 sampled residents reviewed for infection prevention and control 2.)Provide notification of confirmed Covid-19 infections in the facility and 3.) Wear personal protective equipment (PPE) appropriately resulting in the potential for the development and transmission of communicable diseases and infections.
May 23, 2024Standard inspection, Complaint inspection · 11 citations
- E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review the facility failed to ensure that an agreement between themselves (the facility) and the dialysis provider (Name Omitted) was established and maintained, for 4 residents (Resident #61, #28, #20, & #75) of 4 reviewed for dialysis services resulting in the potential for disruption in the continuity of care and/or the interruption of dialysis treatments.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteResident #335 Review of an admission Record revealed Resident #335 was a male, with pertinent diagnoses which included osteomyelitis of vertebra (bone infection), bacteremia (bacteria in the blood), sepsis (an immune response triggered by an infection), and diabetes. Review of an Order Summary Report for Resident #335 revealed the active physician order .cefTRIAXone Sodium Injection Solution Reconstituted 2 GM (Ceftriaxone Sodium) Use 2 gram intravenously one time a day . with a start date of 5/20/24. No active physician order noted for Enhanced Barrier Precautions (EBP). Review of a current Care Plan for Resident #335 revealed the focus .I am on IV (intravenous) Medications for osteomyelitis . revised 5/20/24. [...]
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely care and services to promote dignity and ensure a dignified environment during meal times in 3 of 5 residents (Resident #10, #331, & #6) reviewed for dignity/respect, resulting in long call light wait times with incontinence, meals left in front of a resident without timely assistance provided, and the potential for feelings of diminished self-worth, sadness, and frustration.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate a resident's right to make choices that were consistent with their assessment and plan of care for 1 of 20 sampled residents (Resident #61) reviewed for resident choices, resulting in the resident not meeting their highest practicable level of well-being.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteThis citation pertains to intake MI00144151 Based on interview and record review the facility failed to provide written notice of transfer for 1 (Resident #15) of 1 resident reviewed for hospitalization resulting in the potential for the resident and/or the resident's representative to be unaware of the resident's transfer out of the facility, the reason for the resident's transfer out of the facility, and/or the resident's rights.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteThis citation pertains to intake MI00144151 Based on interview and record review the facility failed to provide written notice of bed hold policy for 1 (Resident #15) of 1 resident reviewed for hospitalization resulting in the potential for the resident and/or the resident's representative to be unaware of the facility's bed hold policy, including duration, expense, and return process.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 (Residents #41 and #43) of 20 sampled residents reviewed for MDS accuracy, resulting in an inaccurate reflection of the residents' health status.
- 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 observation, interview, and record review, the facility failed to implement resident comprehensive care plans for 1 (Resident #6) of 20 residents reviewed for care planning resulting in a lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review the facility failed to ensure residents received care in accordance with professional standards of nursing practice for 2 of 20 residents (Resident #6, #61) reviewed for physician orders and documentation, resulting in the potential for the worsening of a condition and a delay in treatment.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician reviewed and responded to the registered pharmacist's monthly medication regimen review recommendations in a timely fashion for 1 (Resident #41) of 5 residents reviewed for medication regimen review, resulting in the registered pharmacist's recommendations not being addressed timely, and the potential for negative medication side effects or unnecessary medications as a result of the delayed response.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview the facility failed to ensure a sanitary environment for 1 of 1 (Resident #6) and personal and shared medical equipment reviewed for sanitary conditions, resulting in the potential for cross-contamination, infections, and bacterial harborage.
April 17, 2024Complaint inspection · 3 citations
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThis citation pertains to Intake # MI00143491. Based on observation, interview, and record review, the facility failed to immediately treat a hot liquid burn per professional standards of practice in 1 of 5 residents (Resident #103) reviewed for quality of care, resulting in an Immediate Jeopardy when on 2/22/24 Resident #103 spilled a cup of hot liquid on her lap. Facility staff did not immediately apply cool liquid to the site to stop the burn, resulting in additional skin breakdown, prolonged healing, infection requiring IV (intravenous) antibiotics, and ongoing pain.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteThis citation pertains to Intake # MI00143491. Based on observation, interview, and record review, the facility failed to ensure catheter tubing was secured to prevent pulling per physician order in 1 of 2 residents (Resident #103) reviewed for indwelling catheter care, resulting in the potential for dislodgement of the catheter tubing, the potential for urethral damage, and pain/discomfort.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteThis citation pertains to Intake # MI00143491. Based on observation, interview, and record review, the facility failed to implement physician orders for pain management during wound care in 1 of 5 residents (Resident #103) reviewed for medication administration, resulting in pain during wound care and the potential for decreased quality of life.
November 20, 2023Complaint inspection · 6 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 Intake # MI00137543. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopement and ensure a functional alarm system was in place in 1 of 5 residents (Resident #103) reviewed for wandering/elopement, resulting in an Immediate Jeopardy when on [DATE] at approximately 5:50 PM, Resident #103, who was cognitively impaired, exited the facility unbeknownst to facility staff and traveled on foot along a busy four lane road with a speed limit of 30 miles per hour to a store to purchase a beverage. Resident #103 was found by a staff member who was driving in to work between 6:00 PM-6:15 PM. The resident had an alarm bracelet in place, however, it was not functional. The facility had initiated 15-minute checks prior to the elopement. The last observation of Resident #103 was at 5:48 PM. [...]
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteThis citation pertains to Intake # MI00137543. Based on interview, and record review, the facility failed to ensure a functional alarm system was in place in 1 of 5 residents (Resident #103) reviewed for elopement/supervision, resulting in the potential for elopement.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteThis citation pertains to Intake # MI00140204. Based on interview, and record review, the facility failed to provide showers per resident preference and plan of care in 1 of 4 residents (Resident #106) reviewed for Activities of Daily Living (ADL) care, resulting in dissatisfaction with care and the potential for poor hygiene, skin breakdown, and infection.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteThis citation pertains to Intake # MI00137543. Based on interview, and record review, the facility failed to notify the responsible party of a change in condition in a timely manner in 1 of 5 residents (Resident #103) reviewed for notification of changes, resulting in the responsible party being unaware of an elopement on the date of occurrence, and the potential for the responsible party to not be fully informed and involved in care decisions.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteThis citation pertains to Intake # MI00137543. Based on interview and record review, the facility failed to immediately report an elopement incident (a situation involving possible neglect and a system failure) to the State Survey Agency in 1 of 5 residents (Resident #103) reviewed for elopement/supervision, resulting in the potential for a delayed/incomplete investigation.
- D
Respond appropriately to all alleged violations.
Inspectors wroteThis citation pertains to Intake # MI00137543. Based on interview and record review, the facility failed to thoroughly investigate situations involving potential neglect in 1 of 5 residents (Resident #103) reviewed for elopement/supervision, resulting in an incomplete facility investigation and a lack of documentation.
Fire safety inspections
29 fire safety citations on file: 11 on April 17, 2026, 9 on March 12, 2025, 9 on May 23, 2024.
Every fire safety citation29 citations
- F
Develop Emergency Preparedness policies and procedures.
E 13 · April 17, 2026 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · April 17, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 17, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 17, 2026 · 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 17, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 17, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 17, 2026 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · April 17, 2026 · Corrected (the home has a date of correction)
- E
Provide a written emergency evacuation plan.
K 711 · April 17, 2026 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · April 17, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · April 17, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · March 12, 2025 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 12, 2025 · Corrected (the home has a date of correction)
- F
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 12, 2025 · Corrected (the home has a date of correction)
- F
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · March 12, 2025 · Corrected (the home has a date of correction)
- F
Have exits that are accessible at all times.
K 271 · March 12, 2025 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · March 12, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 12, 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 · March 12, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · March 12, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 23, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · May 23, 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 · May 23, 2024 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · May 23, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · May 23, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 23, 2024 · Corrected (the home has a date of correction)
- E
Have an externally vented heating system.
K 522 · May 23, 2024 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · May 23, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · May 23, 2024 · Corrected (the home has a date of correction)