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
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
31D
12E
0F
Potential for minimal harm
0A
0B
1C
March 18, 2026Standard inspection · 5 citations
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an appropriate call button was provided for use and placed within reach of one resident (R74) of one resident reviewed for accommodation of needsFindings include:On 3/16/2026 at approximately 8:42 a.m., R74 was observed in their room, laying in their bed. R74 was asked if they had any concerns with the care and they reported they wanted their bed raised up. R74 was asked if they could use the call button to call for help and they reported they could not find it. R74's call button was observed to be unclipped and hanging off the site of the bed on the floor. R74 was asked if they had the ability to use the call button and they reported they did not think so because they had trouble with their hands. R74 was asked how they get help from staff and they reported the did not know. [...]
- D
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 wroteBased on observation, interview and record review, the facility failed to ensure a safe, homelike environment for one (R71) of four residents reviewed for the environment.
- 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 one Resident (R8) of one resident reviewed for restraints had appropriate clinical justification/assessments for the use of a seatbelt.
- 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 enteral feeding was documented correctly and administered according to the Physician's order for one resident (R3) of one resident reviewed for enteral feeding.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care equipment was in safe operating condition for one (R116) of four residents reviewed for environment concerns.
April 3, 2025Complaint inspection · 5 citations
- 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 and interview, the facility failed to maintain a sanitary healthcare environment amongst residential common areas including a shared shower room, flooring, training bathroom and rehabilitation equipment, and shared Hoyer lift (lift device used to transfer residents). This deficient practice has potential to affect all residents that utilize these areas and equipment.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteThis citation pertains to Intake MI00149648. Based on observation, interview and record review, the facility failed to obtain consent to search personal belongings from one resident (R801) of one resident reviewed for Rights to Privacy and Confidentiality.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThis citation pertains to Intake Number(s): MI00150488. Based on observation, interview, and record review, the facility failed to provide assistance with dressing and getting out of bed in a timely manner to one (R806) of three residents reviewed for activities of daily living.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThis citation pertains to Intake Number(s): MI00149894. Based on observation, interview, and record review, the facility failed to promptly identify a new skin impairment and implement interventions to prevent reoccurrence for one (R806) of two residents reviewed for pressure ulcers.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThis citation pertains to Intake MI00149894 Based on observation, interview and record review, the facility failed to prevent pressure ulcer formation and ensure accurate skin assessments for one (R807) of two residents reviewed for pressure ulcers resulting in R807 developing a Deep Tissue Injury (DTI - persistent non-blanchable deep red, maroon or purple discoloration) to the left medial (inside) heel .
January 9, 2025Standard inspection · 10 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 wroteBased on observation, interview, and record review, the facility failed to ensure a clean, comfortable, homelike environment for for five residents, (R#'s 105, 46, 16, 17, 58, 84, and 30) of five residents reviewed for a homelike environment, and for 11 residents (who wished to remain anonymous) from the group meeting, resulting in verbalized complaints regarding the environment, housekeeping, and laundry services.
- 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 ensure medication were administered and documented per professional standards for two residents, (R#'s 47 and 104) of five residents reviewed for professional standards with medication administration and documentation resulting in verbalized complaints of not receiving as needed pain medications on time and inaccurate medical record keeping.
- 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 ensure Hospice services were provided per plan of care for one resident, (R4) of one resident reviewed for Hospice, resulting in R4 not receiving Hospice services per the provisions.
- 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 and interview, the facility failed to ensure proper storage of medications for four of four medication carts reviewed for medication storage.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review the facility failed to obtain an assessment and physician's order for self-administration of medications for one (R98) of one resident reviewed for self-administration of medication/treatments.
- 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 ensure timely and accurate advanced directives information was in place and ensure resident wishes were timely implemented for two R66 and R2 out of four residents reviewed for Advanced Directives.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident for alternative or augmentative communication methods to ensure functional communication for one Resident (R91) of one resident reviewed for activities of daily living.
- 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 an order for supplemental oxygen for one resident (R17) of one resident reviewed for oxygen.
- D
Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on interview and record review, the facility failed to provide appropriate interventions to prevent triggers for one Resident (R8) of one resident reviewed for trauma-informed care and Post Traumatic Stress Disorder (PTSD).
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate less than five percent when three medication errors were identified from a total of 41 opportunities for one resident (R104) of five residents observed during medication administration, resulting in a medication error rate of 7.32%.
November 19, 2024Complaint inspection · 1 citation
- D
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 #MI00146798. Based on observation and interview, the facility failed to provide an environment that promoted and enhanced residents' dignity for three (R805, R806 and R807) of seven residents reviewed for dignity and respect.
June 27, 2024Complaint inspection · 3 citations
- E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThis citation pertains to intake: MI00145092. Based on observation, interview, and record review the facility failed to timely implement effective wound interventions/treatments and ensure physician follow-up, assessment, and monitoring of a worsening wound for one (R502) of two residents reviewed for skin concerns.
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteThis citation pertains to intake #MI00145236 Based on observation, interview, and record review, the facility failed to ensure freedom from physical restraints for one resident (R503), of one resident reviewed for restraints, resulting in staff reported observations of the resident's feet and legs tied in a knot with blankets and multiple staff reports of having received an in-service education on restraints.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteThis citation pertains to intake #MI00145236 Based on observation, interview, and record review, the facility failed to ensure abuse was immediately reported to the abuse coordinator and reported to the State Agency for one resident, (R503) of two residents reviewed for abuse.
February 21, 2024Complaint inspection · 1 citation
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteThis citation pertains to intake #MI00142694 Based on observation, interview and record review the facility failed to ensure an oxygen dependent resident was provided continuous oxygen per Physicians order for one resident (R802) of one residents reviewed for respiratory care.
December 14, 2023Standard inspection, Complaint inspection · 20 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThis citation pertains to intake #MI00134966 and MI00141309. This citation has two deficient practices. Deficient Practice #1 Based on interviews and record reviews the facility failed to implement an order to obtain daily blood sugar (BS) levels upon admission, failed to identify and report to the physician abnormal lab results, and failed to timely report to the physician a change of condition for one (R104) of one resident reviewed for an expired closed record sample, resulting in a delay of care and services and the prompt intervention to transfer the resident to a higher level of care.
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThis citation pertains to intake #'s MI00138332 and MI00135446. Based on observations, interviews and record reviews the facility failed to implement adequate preventive interventions to prevent the development of pressure ulcers, failed to complete accurate skin assessments, failed to ensure implemented preventive interventions were consistently completed and treatment orders were consistently completed as ordered by the physician for two residents, (R's 44 & 27) of three residents reviewed for pressure ulcers, resulting in the development of a facility acquired unstageable pressure ulcer with slough identified to the right heel of R44 within five weeks after being admitted to the facility.
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThis citation has two deficient practices. Deficient Practice #1 This citation pertains to intake #MI00141309 Based on observation, interview, and record review the facility failed to ensure proper amount of staff were utilized for bed mobility for one resident (R75), of one resident reviewed for bed mobility, resulting in a fall with multiple fractures requiring a transfer to the emergency room.
- 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 #MI00138332 and MI00138733. Based on observation, interview and record review, the facility failed to ensure four residents (R20, R21, R62 and R81) of six residents reviewed for dignity were treated in a dignified manner.
- E
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 ensure equal choices of dining for seven of nine residents that attended the confidential resident council, and two (R42 and R55) of six residents reviewed for resident rights, resulting in expressions of frustration, feelings of isolation, and decreased fulfillment of personal autonomy and personal choices.
- E
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview and record review the facility failed to protect Protected Health Information (PHI) for four (R4, R17, R79 and R102) residents from being displayed in a manner viewable to anyone that passed by the nursing station.
- 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 wroteThis citation pertains to intake #MI00134994 Based on observation, interview and record review, the facility failed to provide a clean, comfortable, safe and home-like environment to ensure that hallways, ceilings, lights, shower rooms, and equipment used for multiple residents were clean and in good repair affecting multiple residents (including R57, R86 and R63) as well as seven of nine that attended the confident resident council meeting, resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness and upkeep.
- 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 ensure proper storage, labeling, and discarding of drugs and biologicals, resulting in the potential for misuse, contamination, and medication administration errors.
- E
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 ensure resident food items were labeled, dated, and discarded when expired, and failed to maintain the resident popcorn machine in the activity room in a sanitary manner. This deficient practice had the potential to affect all residents that store food in the resident refrigerator and consume popcorn from the activity room.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on observation, interview and record review the facility failed to consistently provide translator services in a language that could be understood for two residents (R7 and R99) of two residents reviewed for communication and understanding, resulting in the potential for inaccurate assessments, unmet care needs and the potential for the resident to not participate in their care.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure two (R31 and R84) of two residents reviewed for medication were assessed for the safe self-administration of medication and to have medication kept at bedside.
- D
Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteThis citation pertains to intake #MI00138733 Based on observation, interview, and record review, the facility failed to ensure the resident's right to private and confidential mail delivery for one resident (R62) of one residents reviewed for private communications, resulting in resident mail being opened by the facility prior to delivery to the resident and violation of their privacy.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteThis Deficient practice is linked to intake MI00140318. Based on interviews and record review, the facility failed to protect the resident's(R255) right to be free from physical abuse by R99.
- 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 ensuring an allegation of neglect/mistreatment was reported to the State Agency in accordance with section1150B of the Act for one resident (R62) of one residents reviewed for abuse/neglect/mistreatment.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation of an allegation of neglect/mistreatment for one resident (R62) of one residents reviewed for abuse/neglect/mistreatment resulting in the increased potential for retaliation and continued mistreatment.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to administer oxygen as ordered by the physician for one (R44) of one resident reviewed for respiratory care.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide medically related social services to ensure accurate guardianship/legal representation for two (R7 and R99) of two residents reviewed, resulting in a residents with cognitive impairment not having a guardian/legal representative in place to assist in medical decisions.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate less than 5% when two medication errors were observed from a total 25 opportunities, resulting in a medication error rate of 8%. This deficient practice affected two (R19 and R319) of three residents observed during medication administration.
- D
Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteThis citation pertains to intake #MI00135446 Based on observation, interview and record review the facility failed to ensure Physician Ordered Occupational Therapy services were provided for one resident (R62) of two residents reviewed for Specialized Rehabilitation Services.
- C
Post nurse staffing information every day.
Inspectors wroteBased on interview and record review the facility failed to ensure the daily nurse staff postings were updated daily and reflected the staffing at the facility potentially affecting all residents and visitors at the facility.
October 11, 2023Complaint inspection · 2 citations
- 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: MI00139857. Based on observation, interviews, and record reviews the facility failed to ensure adequate and resident specific fall interventions were implemented in an attempt to prevent further falls for two (R's 802 & 804) of two residents reviewed for accidents.
- D
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspectors wroteThis citation pertains to intake: MI00139857. Based on interviews and record reviews the facility failed to timely complete a STAT (immediate) X-ray as ordered by the physician for one (R802) of three residents reviewed for a change of condition.
Fire safety inspections
7 fire safety citations on file: 1 on March 18, 2026, 2 on January 9, 2025, 4 on December 14, 2023.
Every fire safety citation7 citations
- F
Provide a written emergency evacuation plan.
K 711 · March 18, 2026 · Corrected (the home has a date of correction)
- F
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
K 111 · January 9, 2025 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · January 9, 2025 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · December 14, 2023 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · December 14, 2023 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of highly flammable decorations.
K 753 · December 14, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · December 14, 2023 · Corrected (the home has a date of correction)