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 41 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
28D
10E
1F
Potential for minimal harm
0A
0B
0C
April 1, 2026Standard inspection, Complaint inspection · 11 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 prevent two unstageable pressure ulcers (a severe wound with full-thickness tissue loss, fully covered by slough or eschar, making its true depth hidden) for one resident (Resident #164) of three residents reviewed for pressure ulcers, resulting in bilateral heel pressure ulcers.
- 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 who consume food from the kitchen.
- E
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 1) Follow care-planned interventions for one resident (Resident #12) , 2) Ensure supervision for one resident (Resident #164), and 3) Ensure safety with hot liquids for one resident (Resident #91) out of five residents sampled for safety, resulting in blisters from a hot liquid and the inability to propel freely.
- 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 eliminate dead end plumbing and ensure appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for contamination to the water supply, affecting all residents.
- 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 that residents were treated in a respectful and dignified manner to ensure toileting assistance for one resident (Resident #162), and provide dining assistance in the 1-South dining room, resulting in Residents having soiled briefs due to call lights not being answered timely, the potential for weight loss, and residents' feelings of frustration. Dining Observation: Residents in the 1st Floor South Dining Room On 3/30/2026 at 12:09 PM, during an observation in the 1st floor South dining room, a group of 10 residents were observed sitting in the dining room, for the lunch meal. Per Nurse Q, the meal usually started at 12:00 PM. Two Nurse Aides R and S were delivering the drinks to the residents. [...]
- 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 develop and implement a comprehensive care plan for one resident (Resident (#56) of 1 resident reviewed for smoking, resulting in Resident #56 lacking a care plan to identify where to store the resident's smoking materials including a lighter. Findings Include: Resident #56:Smoking A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #56 was admitted to the facility on [DATE] with diagnoses: History of a stroke, left sided weakness, history of traumatic brain injury, COPD, Nicotine dependence, with withdrawal. Anxiety, Depression, peripheral vascular disease, chronic pain syndrome. The MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status/BIMS score of 15/15, needed some assistance with care and used a motorized wheelchair. [...]
- 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 revise care plans for psychotropic medications for one resident (R2) of five residents reviewed for psychotropic medications resulting in an inaccurate care plan.
- 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 that professional standards of practice were followed with the assessment, monitoring, documentation and timely physician notification of a medication error for one resident (Resident 131) who had been administered in error a Norco 5mg/325 mg (an opioid pain medication of a combination of acetaminophen and hydrocodone), of one resident reviewed for a change in condition.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that an Enteral nutrition (tube feeding/nutrition through a feeding tube into the stomach or intestines) formula was identified when ordered for one resident (Resident #23) of 1 resident reviewed for enteral nutrition, resulting in the potential for Resident #23 to not receive the appropriate Enteral formula. Findings Include: Tube Feeding Resident #23: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #23 was admitted to the facility on [DATE] with diagnoses: history of a traumatic brain injury, epilepsy, quadriplegia, dysphagia (difficulty swallowing), gastrostomy tube (feeding tube into the stomach), and hearing loss. The MDS assessment dated [DATE] revealed the resident had a memory problem and needed assistance with all care. [...]
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that an oxygen administration and care plan was updated for one resident (Resident #1) of one resident reviewed for oxygen administration, resulting in an empty oxygen tank and low oxygen saturations.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview and record review, the facility failed to operationalize care-planned interventions for behaviors for one resident (Resident #74) who wandered through the unit propelling their wheelchair, going into other residents' rooms, and displacing items of other residents, of one resident reviewed for mood/behaviors.
November 21, 2025Complaint inspection · 1 citation
- 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 Number 2661843. Based on observation, interview and record review, the facility failed to ensure supervision was provided during mealtime for two residents (#1 and 2), who had safe swallow instructions during meals, of four Residents reviewed for dining and assistance with meals.
February 25, 2025Standard inspection · 13 citations
- 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 ensure call lights were within reach and responded to in a timely manner for 11 residents (R3, R16, R22, R36, R46, R52, R61, R63, R80, R116, R138) and a confidential group of residents, resulting in long call light wait times, delayed assistance and call lights not being accessible.
- 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 update and reviews care plans for psychotropic meds, pain, skin care and respiratory care for 4 Residents (R#3, R#32, R#47, & R#90) of 5 sampled residents reviewed for care plans.
- E
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 provide a safe and monitored environment to prevent falls and injuries for 4 Residents (# 21, #103, #126, #127) of 13 residents reviewed for falls, resulting in residents having multiple falls and Resident's #'s 126 and #127 sustaining large bruises on their faces. Findings Include: Resident #21 Accidents A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #21 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Alzheimer's dementia, History of a stroke, heart disease, hypertension, , orthostatic hypotension, history of repeated falls, anxiety, kidney disease, and arthritis. [...]
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a consistently operational call light system affecting three residents (Resident #46, Resident #63 and Resident #74) and a resident census of 158, resulting in extended call light times, unmet needs, and inconsistent tablet operability.
- 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 observation, interview, and record review, the facility failed to validate and update the care plan for DNR status for one resident (R#47) of 3 residents reviewed for advanced directives.
- 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 complete a comprehensive care plan for one resident (R32) of four residents reviewed for unnecessary 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 ensure nail care was provided for two residents (#46 and #78) of five residents reviewed for Activities of Daily Living (ADL).
- 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 1). Ensure coordination of Hospice Services for one resident (#151) reviewed for Hospice service. Findings Include: Resident #151: Hospice and End of Life A review of the Face sheet and MDS/Minimum Data Set assessment indicated Resident #151 was admitted to the facility on [DATE] with diagnoses: Seizures, history of falls with fractures: fourth cervical vertebra, nasal bones, maxilla, Dementia, anxiety, depression and hypertension. The resident wore a neck brace for the cervical fracture. A review of the physician orders indicated the resident was admitted to Hospice services on 1/21/2025 on admission. On 2/18/2025 at 12:17 PM, Resident #151 was observed sitting in a chair in his room watching TV. He was talkative and tried to answer question. He said he did not think he was receiving Hospice services. [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation interview and record review, the facility failed to assess and monitor pain levels and update a care plan for pain for one resident (Resident #3) with a diagnosis of Squamous Cell Carcinoma of the skin of scalp and neck requiring comfort in positing and wound care treatment of 3 residents reviewed for pain management.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on interview and record review the facility failed to ensure that clinical staff received completed yearly Performance Evaluations and competencies for 2 of 2 nurses (N and O) and Performance Reviews for 2 of 2 Nurse Aides (L and M), Findings Include: FACILITY Sufficient and Competent Nurse Staffing: On 2/24/2025 at 9:11 AM, during a review of the Nurse and Nurse Aide competency reviews for Nurses N (Charge Nurse) and O and Certified Nursing Assistants L and M, it was identified there were no yearly Performance reviews. The nurses' yearly competencies had not been completed. Nurse N's competencies were last completed 1/26/2024: greater than 1 year prior. Nurse O's competencies were last completed 1/22/2024: greater than 1 year prior. On 2/25/2025 at 10:30 AM, Staff Education Nurse C was interviewed about the yearly clinical staff Performance reviews. [...]
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that medication had arrived timely to the facility and that medication was administered following physicians' orders and professional standards of care for one resident (Resident #358) of six residents reviewed for medication administration, resulting in Resident #358 not receiving the medication Renvela and Cholestyramine as ordered and the medication Cholestyramine given with other medications.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure Infection Prevention and Control standards of practice were followed for 1) Personal Protection Equipment/PPE use during wound care for one resident (Resident #90) in Enhanced Barrier Precaution. Findings Include: Resident #90: A record review of the Face sheet and Minimum Data Set/MDS assessment for Resident #90 indicated an admission date of 3/12/2020 with diagnoses: Alzheimer's dementia, depression, arthritis, hypertension, heart disease, and anxiety. An unstageable pressure ulcer on the right heel was identified on 1/13/2025. The MDS assessment dated [DATE] identified the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 5/15 and the resident needed assistance with all care. [...]
- 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, interview and record review, the facility failed to ensure warm water availability in residents' rooms and that sink drainage was adequate for three residents (#23, #25 and #70), of a sample of 17 reviewed for environmental concerns.
July 31, 2024Complaint inspection · 1 citation
- 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 Number MI00145825. Based on observation, interview and record review, the facility failed to properly apply restraints in a transportation van and operationalize facility policy for one resident (Resident #1) of three residents reviewed for incident and accidents resulting in the resident falling out of their rolling walker during transportation and getting assisted off the floor of the van before being assessed by a license nurse.
December 19, 2023Standard inspection, Complaint inspection · 15 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 ensure appropriate interventions were in place and supervision was provided to prevent a fall with injury for one resident (Resident # 401) of 6 residents reviewed for accidents and falls, resulting in Resident #401 experiencing multiple falls and sustaining several fractures. Findings Include: Resident #401: Accidents: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #401 was admitted to the facility on [DATE] with diagnoses: Alzheimer's Dementia, anxiety, depression, arthritis, and history of urinary tract infections. The MDS assessment dated [DATE] revealed the resident had severe cognitive decline with a Brief Interview for Mental Status (BIMS) score of 3/15 and Resident #401 needed assistance with all care. [...]
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteThis Citation pertains to Intake Numbers MI00136997 and MI00139597. Based on observation, interview and record review, the facility failed to ensure dignified and respectful treatment for three residents (Resident #33, Resident #49, and Resident #106) reviewed and nine of nine Confidential Group Residents, resulting in Resident #106's indwelling urinary catheter drainage bag being exposed and not contained/covered, meals being served on aluminum foil, call lights not being answered in a timely manner, a lack of available staff, staff speaking to staff in a rude manner, and resident verbalizations of feeling unimportant and unvalued.
- 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 ensure that care plan interventions were evaluated/revised for effectiveness and updated with changes/interventions for two resident (Residents #7, and Resident #403) of 27 residents reviewed for care plans, resulting in in the lack of care plan revision, implementation of appropriate interventions and the potential for unmet care needs relating to activities of daily living, weights and call bell use.
- E
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 coordinate care for four residents (Resident #7, Resident #127, Resident #134, and Resident #135) of four residents reviewed for changes in condition, resulting in a delay in treatment of skin infestation for Resident #127 and Resident #135 with the potential of worsening, itching, pain and infection; a delay in assessment and potential treatment of rectal pain for Resident #134, and a failure to assess and monitor a 10 pound weight gain in seven days for Resident #7 with the potential adverse health conditions to go undetected and untreated.
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nurses (RN's-Registered Nurses and LPN's-Licensed Practical Nurses) received yearly evaluations/competencies to assure resident care and safety, and attain or maintain the highest practicable physical, mental and psychosocial wellbeing of residents in accordance with the facility assessment and residents' plans of care for five nurses of five nurses reviewed for education and competencies, affecting all 152 residents residing in the facility, resulting in the potential nursing staff lacking necessary training, skills, and competencies to adequately care for the needs of the residents residing in the facility.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteThis Citation pertains to Intake Number MI00141186. Based on interview and record review, the facility failed to inform and invite a resident and the resident's representative to regularly scheduled care conferences for one resident (Resident #403) of one resident reviewed for care conferences (meeting to discuss residents' plans of care), resulting in the resident and the residents' representatives being uninformed and not involved in their plan of care or able to make choices for care at the facility.
- 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 appropriate documentation, consent, assessment, a physician's order, evaluation, and re-evaluation of a restraint for one resident (Resident #33 [R33]) of two residents reviewed from a total sample of 27 residents, resulting in a resident confined in a Broda chair without a consent, evaluation for appropriateness, physician's order, and re-evaluation for appropriateness.
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure completion of comprehensive investigations for injuries of unknown origin for one resident (Resident #64) of one resident reviewed resulting in a lack of completion and documentation of a thorough investigation to identify a cause of injury, lack of reporting to the State Agency, and the potential for further injury and unidentified abuse.
- 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 develop and implement a comprehensive person-centered care plan for two residents (Resident #27 and Resident #33) of two residents reviewed for care plans pertaining to the use of Broda chair R33 and use of supportive device for positioning R27's Right Upper Extremity (RUE) and Right Lower Extremity (RLE) from a total sample of 27 residents reviewed for care planning, resulting in not having an active and comprehensive care plan to ensure safety and appropriate care for positioning was followed and to ensure range of motion (ROM) was maintained and prevent further decline in functional abilities.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record, the facility failed to provide Activities of Daily Living (ADL) care per care plan for two residents (Resident #53 and Resident #128), resulting in unkept facial hair, long dirty nails, missed showers, unchanged clothing and dirty hair with the likelihood of decreased moods.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that oxygen tubing was stored appropriately and turn off wall-mounted oxygen while not in use for one resident (Resident #68), resulting in a cross-contamination of oxygen tubing and unsafe oxygen storage with the possibility of combustion causing a fire.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview and record review, the facility failed to monitor Vancomycin blood trough levels and hold IV (intravenous) antibiotic medication, Vancomycin, according to abnormal trough laboratory levels for one resident (Resident #7), of two residents reviewed for antibiotic medication administration, resulting in Resident #7 receiving IV Vancomycin when Vancomycin trough levels were high with the potential for adverse drug consequences and side effects of the medication.
- 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 wroteBased on observation, interview and record review, the facility failed to ensure an as needed (PRN) antipsychotic medication had a 14-day stop date for one resident (Resident #74), resulting in the lack of physician follow up of the needed PRN antipsychotic medication with the likelihood of side effects going unnoticed.
- 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 1) Failed to store and handle medications in accordance with acceptable pharmaceutical standards of practice for one of 2 medication rooms, 2) Failed to ensure that medication refrigerators were clean and temperatures outside of acceptable parameters were addressed, 3) Failed to ensure that controlled medications had administration orders, and 4) Failed to ensure that medications were stored according to professional standards of practice, including vaccinations, resulting in the potential for contamination of medications, incorrect administration of medications, a lack of therapeutic benefits necessary to promote healing for residents, increase the potential for adverse effects. Findings Include: [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely treatment and care for a contagious rash for two residents (Resident #127 and Resident #135), resulting in the potential worsening of symptoms, a decline in condition and spread of infection. Findings Include: Resident #127: A review of Resident #127 revealed an admission into the facility on 8/31/22 and re-admission on [DATE] with diagnoses that included stroke, dementia, heart disease, diabetes, psychotic disorder, mood disorder, Alzheimer's disease and atopic dermatitis. A review of the MDS dated [DATE], revealed the Resident had severely impaired cognition and needed substantial/maximal assistance with most ADL's. A review of Resident #127's progress notes included the following: [...]
Fire safety inspections
15 fire safety citations on file: 3 on April 1, 2026, 6 on February 25, 2025, 6 on December 19, 2023.
Every fire safety citation15 citations
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
K 225 · April 1, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 1, 2026 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · April 1, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · February 25, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 25, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 25, 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 25, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · February 25, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for the use of electrical equipment.
K 919 · February 25, 2025 · Corrected (the home has a date of correction)
- F
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
K 908 · December 19, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 19, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 19, 2023 · 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 · December 19, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · December 19, 2023 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · December 19, 2023 · Corrected (the home has a date of correction)