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 51 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
43D
2E
5F
Potential for minimal harm
0A
0B
0C
April 14, 2026Standard inspection · 6 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was served in a palatable manner and at the preferred temperature for six residents (R46, R56, R101, R116, R156, and R177) of six reviewed for food palatability.
- 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, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen.
- 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 maintain a clean, comfortable, homelike environment for one (R45) of four residents reviewed for sanitary environment.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dressing for a Peripherally Inserted Central Catheter (PICC) intravenous (IV) line was changed and dated timely for two residents (R169 and R171) of three residents whose IV sites were observed.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure biologicals were dated when opened and expired medications were discarded in five of six medication carts.
- 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 maintain a sanitary tube feeding pole for one (R191) resident of three residents reviewed for environmental concerns.
December 18, 2025Complaint inspection · 1 citation
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteThis citation pertains to Intake 2680407 Based on observation, interview, and record review, the facility failed to provide restorative therapy services (therapy to prevent or maintain range of motion - ROM) for one resident (R701) of two residents reviewed for ROM.
June 30, 2025Complaint inspection · 1 citation
- D
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
Inspectors wroteThis citation pertains to Intake MI00153957. Based on observation, interview, and record review the facility failed to ensure a mattress was comfortable and changed timely upon resident request for one resident (R901) of three reviewed for a room furnishings.
April 14, 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 M100151122: Based on observation, interview, and record review, the facility failed to prevent the fall of one (R705) of four residents reviewed for falls.
March 12, 2025Standard inspection, Complaint inspection · 11 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served in a palatable manner and at the preferred temperature for nine residents (R6, R21, R22, R24, R60, R74, R108, R146, R188) and six confidential group residents, of sixteen residents reviewed for food palatability.
- F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the dish machine area in the kitchen in a clean manner, resulting in the presence of gnats. This deficient practice had the potential to affect all residents, staff and visitors.
- 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 ensure call lights were in reach for five residents (R34, R86, R147, R612, and R613) of six residents reviewed for call light accessibility.
- D
Respond appropriately to all alleged violations.
Inspectors wroteThis citation pertains to Intake MI00150763. Based on interview and record review, the facility failed to timely complete an investigation for an allegation of abuse for one (R2) of two resident reviewed for abuse.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to complete an annual PASARR (Preadmission Screen and Resident Review) for two residents (R70 and R139) of 6 residents reviewed for PASARR screening.
- 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 a care plan addressing Post-Traumatic Stress Disorder (PTSD) for one resident(R62) out of three reviewed for mood/behavior care plans.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely assistance for two residents (R24, R154) out of six reviewed for Activities of Daily Living (ADLs).
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely podiatry care was provided for one resident (R201) of one resident reviewed for foot care.
- 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 label and date a tube feeding bottle for one resident (R75) out of two reviewed for tube feedings.
- 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 and interview, the facility failed to ensure medications were discarded when expired from one medication cart (U100 low numbers) of three medication carts reviewed.
- 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 resident equipment (two beside dressers, one overbed table) was in good, clean, and safe condition for three residents (R20, R143, R167) of residents reviewed for homelike environment.
February 19, 2025Complaint inspection · 1 citation
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThis citation pertains to intake M100150293 Based on interview and record review, the facility failed to complete weekly skin checks for one (R704) of ten residents reviewed for skin checks, resulting in the development of gangrene of the right great toe, right foot pain and hospitalization.
January 22, 2025Complaint inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThis citation pertians to Intakes MI00149291, MI00149568, and MI00149398. Based on observation, interview, and record review, the facility failed to ensure incontinence care, repositioning or water was provided for three dependent residents (R703, R706, and R707) of three reviewed for Activites of Daily Living (ADL) care.
October 22, 2024Complaint inspection · 1 citation
- D
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 MI00147415 and MI00147559. Based on observation, interview, and record review, the facility failed to ensure resident rooms, common areas, and shower rooms were homelike on two nursing units (units 100 and 200) of four units reviewed.
July 30, 2024Complaint inspection · 4 citations
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteThis citation pertains to Intake MI00145616. Based on interview and record review, the facility failed to develop and implement actions to prevent repeated falls for one (R703) of one resident resulting in nine falls without goals and interventions to prevent further falls.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteThis citation pertains in part to intake #145421. Based on observation, interview, and record review, the facility failed to serve food in a palatable manner and at the preferred temperature for three residents (R704, R705, R706 ) of three reviewed for food palatability, resulting in dissatisfaction during meals.
- D
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
Inspectors wroteThis pertains to Intake MI00145962. Based on observation, interview, and record review, the facility failed to maintain adequate lighting in one (East Dining Room) of two dining rooms reviewed for homelike environment. Findings Include: On 7/30/2024 at 10:30 AM, during an interview with R701 they said the East Dining Room lights had been out for some time. They further revealed staff had been made aware and were very frustrated with the maintenance in the facility. On 7/30/2024 observation was made regarding lighting in the East Dining Room. It was observed that 5 lights were not illuminated. With the assistance of the Activities Director, the surveyors tried all switches controlling the lights without success. [...]
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteThis pertains to Intake MI00145962. Based on based on observation, interview, and record review, the facility failed to maintain steam tables in a sanitary condition in one of three steam tables in the East Dining Room. Findings Include: On 7/30/2024 at 11:20 am, an observation was made of the steam tables in the East Dining Room. While observing the condition and cleanliness of the steam tables, loose crusted material and mold was noted on the third steam table with a small hood. When the material was touched, it fell onto the area where food would be sitting when in use. On 7/30/2024 at 12:35 pm, The Nursing Home Administrator (NHA) was shown the area of concern and indicated their expectation is the steam table hoods should be clean and free of mold and materials that could drop into food. [...]
June 12, 2024Complaint inspection · 1 citation
- 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 wroteThis citation pertains to Intake MI00144848. Based on observation, interview, and record review, the facility failed to provide a clean and comfortable environment for two residents (R701 and R705 ) of three reviewed for environment, resulting in feelings of anger and frustration.
May 7, 2024Complaint inspection · 1 citation
- D
Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteThis citation pertains to Intake MI00143948. Based on interview and record review, the facility failed to notify guardian of transferring out to the hospital for one (909) of two residents reviewed for notification of changes resulting in the guardian not being informed of resident's condition.
February 1, 2024Standard inspection, Complaint inspection · 14 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 the ventilation covers in a clean manner, failed to maintain the ice machine rooms in a sanitary manner, and failed to ensure resident food items were labeled, dated and discarded when expired. This deficient practice had the potential to affect all residents that consume food.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteThis citation pertains to MI00141058. Based on observation, Interview, and record review, the facility failed to ensure that food was served in a palatable manner and at the preferred temperature for three residents (R167, R230, and R279) of six residents reviewed for food palatability and twelve anonymous group members, resulting in dissatisfaction during meals.
- 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 that a toilet was maintained in working condition for one resident (R136) of three reviewed for clean, comfortable, homelike conditions, resulting in resident dissatisfaction with living conditions.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to prevent resident to resident abuse for one (R38) of seven residents reviewed for abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and report a sexual abuse allegation for one (R38) of seven residents reviewed.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure a Level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification was completed timely and sent to the local community mental health (CMH) for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for one resident (R135) of one resident reviewed for PASARRs.
- 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 care planned interventions to prevent falls, and skin breakdown, for two sampled residents (R118 and R135) of seven residents reviewed for person centered comprehensive care plans.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThis citation pertains to Intake: MI00141406 and MI00141058. Based on observation, interview and record review, the facility failed to provide the preferred bathing method and frequency for one (R78) of seven residents reviewed for bathing.
- D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative services per therapy recommendation for one of one resident (R132) reviewed for range of motion.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen and tracheostomy (a surgical opening into the neck to allow for breathing) care, for one resident (R429) of one resident reviewed for tracheostomy care.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to ensure medications were available and provided timely for one resident (R230) of one whose medications were reviewed resulting in expression of poorly controlled pain.
- 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 interview and record review, the facility failed to implement a 14-day stop date on an anti-anxiety medication for two (R26, and R135) of seven residents reviewed.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store/label/discard expired medications for (a) one (500/600 unit) of three medication storage rooms, (b) two (200 unit and 700 unit) of four medication carts reviewed and (c) two of two refrigerators reviewed for medication storage.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteThis ciation pertains to Intake: MI00141406 and MI00141058. Based on observation, interview, and record review the Facilty failed to ensure that resident call lights were functioning properly for one resident (R79 ) of five residents reviewed for call lights, resulting in feelings of frustration.
December 19, 2023Complaint inspection · 7 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 MI00141632, MI00138084, and MI00137973. Based on interview the facility failed to ensure the responsible party was informed of a change in condition for one of two residents (R918) reviewed for a change in condition, resulting in lack of knowledge about a decline and or change in the resident's condition and the potential for a delay in advanced treatment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteThis citation pertains to MI00138087. Based on observation, interview, and record review the facility failed to ensure appropriate interventions were implemented and documented to prevent falls for one of three residents (R903) whose falls were reviewed.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThis citation pertains to Intake MI00138118, MI00138025 and MI00137992. Based on interview and record review the facility failed to provide activities of daily living care (ADLS) for dependent residents for one of seven residents (R905) reviewed for ADL care.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThis citation pertains to Intake MI00141644. Based on interview and record review, the facility failed to accurately assess and document vital signs for one of one sampled resident (R919) reviewed for professional standards, resulting in inaccurate vital sign recording.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThis citation pertains to MI00141632 and MI00138087. Based on observation, interview, and record review the facility failed to ensure an air mattress was in place, and or reposition a resident timely and or document wound care as completed for three residents (R922, R904, R918) of three reviewed for pressure ulcer care, resulting in the potential for decreased wound healing.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteThis citation pertains to Intake MI00140698. Based on observation, interview, and record review, the facility failed to ensure four (R903, R911, R921, and R923) of four residents reviewed for dietary services, received meals according to their preferences.
- D
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 MI00138084. Based on observation, interview and record review the facility failed to ensure rooms were cleaned appropriately and beds were in good condition for two room [ROOM NUMBER]-1 and 716-1 resulting in the potential for resident disatisfaction with their rooms and lingering debris on the floor.
October 2, 2023Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThis citation pertains to intake MI00137875. Based on interview and record review, the facility failed to obtain a stool (bowel movement) sample, initiate a new wound treatment timely, adequately document nursing assessment and monitor edema/swelling, affecting one resident (R003) of three reviewed for quality of care, resulting in decreased coordination of care and the potential for unmet care needs.
Fire safety inspections
20 fire safety citations on file: 6 on April 14, 2026, 8 on March 12, 2025, 6 on February 1, 2024.
Every fire safety citation20 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · April 14, 2026 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · April 14, 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 · April 14, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · April 14, 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 14, 2026 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 14, 2026 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · March 12, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 12, 2025 · Corrected (the home has a date of correction)
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 12, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 12, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 12, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 12, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · March 12, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · March 12, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 1, 2024 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · February 1, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 1, 2024 · Corrected (the home has a date of correction)
- E
Provide a written emergency evacuation plan.
K 711 · February 1, 2024 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · February 1, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · February 1, 2024 · Corrected (the home has a date of correction)