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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
9D
4E
3F
Potential for minimal harm
0A
0B
0C
March 17, 2026Standard inspection · 3 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 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 03/15/2026 at 8:55AM, observed in the residents' refrigerator, an open container of [NAME] Thickened Water (no flavor), without an open date, or a facility provided use by date. When asked who is responsible for dating the foods in the residents' refrigerator, Dietary [NAME] (DC) N said the [NAME] thickened water should have had a date on it, and that nursing staff is responsible for dating product used for med-pass, and resident's food. The container was discarded by DC N. On 03/15/2026 at 8:57AM, observed in the walk-in cooler, open container [NAME] Ready Care Cranberry Cocktail that did not have an open date or a use by date. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review, the facility failed to fully implement the employee illness surveillance practices when reviewed for infection control.
- 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 safely transfer one resident (Resident #28) out of three residents reviewed for accidents and hazards.
February 21, 2025Standard inspection, Complaint inspection · 7 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 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 in the kitchen.
- 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 honor Advanced Directives for 1 resident (R2) out of 2 residents reviewed for Advanced Directives and ensure that the competent resident made their own Medical Treatment Decisions.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered following nursing professional standards of practice, for 3 of 8 residents (R35, R11, and R30), resulting in medication errors and the withholding of medications without a physician order.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to administer and accurately document administration of controlled substances for 3 of 6 residents (Resident #17, #16, and #239) reviewed for the administration of controlled medications, resulting in the potential for ineffective management of pain and the potential for diversion of controlled drugs. Resident #17 (R17) Review of an admission Record revealed R17 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: anxiety, spinal stenosis, and severe osteopenia. Review of R17's Order Summary dated 7/20/24 revealed, hydrocodone-acetaminophen (Norco) tablet; 5-325 mg; [...]
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteThis citation pertains to intake # MI00146937 Based on interview and record review the facility failed to 1.) involve residents/resident representative in the medication management process and 2.) evaluate and track progress and/or decline towards the gradual dose reduction of a psychotropic medication for 2 of 5 residents (Resident #4 and #24) reviewed for psychotropic medication use.
- 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 a complete and accurate medical record for one resident (R29) out of 9 residents reviewed when the physician did not document an assessment or date mark a signature on an assessment of capacity.
- D
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on interview and record review, the facility failed explain terms of an Agreement to Resolve Legal Disputes Through Arbitration and ensure the validity of understanding/consent to enter into the agreement was witnessed for one resident's (R29's) Health Care Power of Attorney (HCPOA) out of 3 residents reviewed for Arbitration agreements.
April 4, 2024Standard inspection, Complaint inspection · 6 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: 1. Ensure proper cooling of potentially hazardous foods; 2. Properly date mark and discard food product; and 3. Ensure cleaning of food and non-food contact surfaces. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 33 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the walk-in cooler, starting at 9:03 AM on 4/1/24, it was observed that a cooked pork roast was found on the bottom shelf of the walk-in cooler covered and in one solid piece. When asked when the pork roast was cooked, Certified Dietary Manager (CDM) B stated that he cooked and cooled it yesterday. The surveyor and CDM B both took a temperature of the pork roast and found it to be 47F. [...]
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain call lights within sight and reach for 3 of 3 residents reviewed (Resident #27, Resident #138, and Resident #8).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThis citation pertains to intake # MI00-143546 Based on interview and record review, the facility failed to provide coordinated quality care for 1 of 3 residents (Resident #35) reviewed, resulting in (a) incorrect transfer status used by staff, (b) inconsistent/conflicting skin assessments, (c) an incorrectly completed baseline care plan that provided little guidance to direct care staff on how to meet the resident's immediate needs, (d) incomplete nursing assessments and documentation, (e) a significant delay in downgrading the residents weight bearing status as ordered, and (f) low blood pressures not reported to the physician.
- E
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 operationalize policies and procedures to store medications and secure narcotics, per standards of practice for 2 of 2 medication carts and for one resident (Resident #138).
- 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 monitor and assess equipment in the facility to ensure proper working condition, resulting in a shower chair breaking and one resident (Resident #19) hitting her head, out of 5 residents reviewed for accidents and hazards.
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician for 1 (Resident #9) of 1 resident reviewed for physician notifications when her insulin was not available and not given.
Fire safety inspections
23 fire safety citations on file: 16 on March 17, 2026, 5 on February 21, 2025, 2 on April 4, 2024.
Every fire safety citation23 citations
- F
Conduct testing and exercise requirements.
E 39 · March 17, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 17, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 17, 2026 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · March 17, 2026 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of flammable curtains.
K 751 · March 17, 2026 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 17, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 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 · March 17, 2026 · Corrected (the home has a date of correction)
- E
Have exits that are accessible at all times.
K 271 · March 17, 2026 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · March 17, 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 · March 17, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 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 · March 17, 2026 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 17, 2026 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · March 17, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 17, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 21, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 21, 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 · February 21, 2025 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 21, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · February 21, 2025 · 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 4, 2024 · Corrected (the home has a date of correction)
- D
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · April 4, 2024 · Corrected (the home has a date of correction)