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
3G
0H
0I
Potential for more than minimal harm
29D
4E
3F
Potential for minimal harm
0A
1B
1C
July 9, 2026Standard inspection, Complaint inspection · 11 citations
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and record review, the facility failed to address and resolve grievances reported in Resident Council Meetings as stated during a confidential Resident Council meeting resulting in unresolved concerns, unmet resident needs and frustration.
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on observation, interview and record review, the facility failed to notify residents of where to find grievance forms and how to file a grievance as stated during a confidential Resident Council meeting and one sampled residents (R169), resulting in unresolved concerns, unmet resident needs and frustration.
- 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 observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 143 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.
- D
Respond appropriately to all alleged violations.
Inspectors wroteThis Citation Pertains to Intake 3073823. Based on interview and record review, the facility failed to ensure an injury of unknown source was thoroughly investigated for one (Resident #98) of one reviewed for abuse.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure a Level I pre-admission screening was completed and referred for a Level II evaluation and determination for one (R14) of three reviewed.
- 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 provide medications timely and as prescribed for 2 residents (R33, R38) and failed to ensure physician orders for 1 resident (R26) of 27 residents reviewed.
- 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 ensure pain management was provided for a resident with severe pain in 1 resident (Resident #169) of 2 residents reviewed for pain management resulting in unrelieved pain that can impact the resident's functional status, quality of life, and increased their mental anguish.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview and record review the facility failed to maintain complete and accurate medical records for 3 of 27 residents reviewed (Resident #10, #14 and #33).
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on interview, and record review, the facility failed to coordinate care with hospice to ensure the accuracy of advance directives for one (R14) of two reviewed.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control standards during eye drop administration for one (R170) of seven reviewed.
- C
Post nurse staffing information every day.
Inspectors wroteBased on interview, and record review the facility failed to post the actual daily Nursing Staffing Data resulting in the potential for all 143 Residents and/or family and/or visitors to be well informed of the facility's staffing information. Findings Included:During observation on 07/09/2026 at 09:24 a.m. the facility document entitled 8(SP)Resident Care & Complaint Intake Staff was observed to be posted in a glass case across from the Nursing Home Administrators office. The document demonstrated a date of 07/08/2026 and a Resident Census of 146. The document revealed two columns that were listed by shift (Day shift, Afternoon Shift, and Midnight Shift). Below each shift was listed job classification and listed total and total Hours. [...]
May 14, 2026Complaint inspection · 1 citation
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteThis citation pertains to intake 2801978. Based on observation, interview and record review, the facility failed to prevent missing controlled substance medication for one (R2) and maintain accurate controlled substance records for five (R6, R7, R8, R9, R10) in two of seven medication carts reviewed.
December 15, 2025Complaint inspection · 1 citation
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's (R4) right to be free from neglect resulting in resident experiencing blunt force trauma and contributing to the resident's death. This citation pertains to intake number 2642837. Per the facility face sheet Resident #4 (R40 was an [AGE] year-old who resided at the facility since [DATE]. Diagnoses included muscle weakness, age related physical disability, and morbid severe) obesity due to excess calories. Review of an incident report dated [DATE] revealed Certified Nurse Aid (CNA) C informed a nurse that while providing a brief change R4 rolled out of bed onto the floor. The report further revealed R4 was assessed to have a skin tear to the left elbow, a hematoma (bruising) to the left knee, and left side of the head. [...]
April 10, 2025Standard inspection · 5 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 observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 134 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, reduced air quality, and inadequate sanitization of dishware and utensils.
- F
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 138 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and reduced air quality.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview and record review, the facility failed to consistently honor a resident's choices regarding his daily routine and failed to facilitate the ability to go outside when requested, in one of two residents reviewed for choices (Resident #117).
- 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 oral care was provided to one (R81) of two reviewed.
- B
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, interview and record review the facility failed to exercise reasonable care for the protection of one of two resident's, Resident #117 (R117) personal property from loss, resulting in loss of personal clothing and potentially affecting resident's psychological wellbeing.
March 19, 2025Complaint inspection · 5 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observations, interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act in one (R102) of four residents reviewed for abuse. Review of the medical record reflected R102 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, vascular dementia, and dementia with behavior disturbances. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/20/25, reflected R102 scored 11 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of a Nursing-Progress Note dated 3/8/25 at 4:26 PM revealed Resident [R102] verbally abusing resident. Resident stated he would smack another resident. [...]
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review the facility failed to, investigate allegations of abuse for one out of four residents (Residents #102). Findings Include: Review of the medical record reflected R102 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, vascular dementia, and dementia with behavior disturbances. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/20/25, reflected R102 scored 11 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of a Nursing-Progress Note dated 3/8/25 at 4:26 PM revealed Resident [R102] verbally abusing resident. Resident stated he would smack another resident. The note author was identified as Licensed Practical Nurse (LPN) T. In an interview on 3/19/25 at 1:14 PM, LPN T stated that she was familiar with R102. [...]
- 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 comprehensive care plans for two (Resident #102 and #103) of three reviewed. Review of the medical record reflected R102 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, vascular dementia, and dementia with behavior disturbances. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/20/25, reflected R102 scored 11 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R102's Care Plan revealed R102 ambulated independently with the use of a walker. Review of the medical record reflected R103 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included aphasia. [...]
- 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 showers per care plan for two (Resident #104, #105) of three reviewed for activities of daily living.
- D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteThis citation pertains to intake numbers MI00150030 and MI00150146. Based on observation, interview, and record review the facility failed to maintain sufficient staff to meet residents' needs timely and provide scheduled showers for three (Resident #101, #104, #105) of seven reviewed for staffing. Resident #101 (R101) Review of the medical record reflected R101 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle weakness and contractures of the left and right hand. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/9/25, reflected R101 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R101's Care Plan reflected she required assistance of two staff members via mechanical lift for transferring. [...]
November 21, 2024Complaint inspection · 2 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 MI00147863 Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 (R203) of 4 residents reviewed which would include intervention for communication and coordination with endocrinology for management of diabetes resulting in the potential for a lack of needed care.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThis citation pertains to Intake MI00147863 Based on interview and record review the facility failed to follow physician's order for communication and coordination with endocrinology for management of diabetes care for 1 (R3) of 4 residents reviewed resulting in high glucose levels.
August 7, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrotePertaining to Intake MI00145739: Based on interview and record review the facility failed to administer medications as ordered for one (R2) of three reviewed, resulting in R2's strong dissatisfaction with care, final refusal of continued stay, and resident leaving the facility to obtain medical care.
March 26, 2024Standard inspection · 12 citations
- G
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 coordination and timely follow-up related to medical appointments required for a surgical procedure for one resident (R3) of 26 residents reviewed for quality of care, resulting in an avoidable emergent surgery and overall decline in a resident's health condition and psychosocial harm with increased feelings of anxiety and mistrust.
- 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 sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 130 residents who receive meal services (1 nothing by mouth residents, or NPO) out of the facility's total census of 131 residents.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteResident #55 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE], R55 was admitted to the facility on [DATE] with diagnosis that included seizure disorder. R55 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) assessment. On 03/19/24 at 12:45 pm during an interview with R55, he reported he had a concern with the staffs chronic use of cell phones while providing care was upsetting to him. R55 elaborated that he believes the fact most staff do not wear name tags, exacerbates the issue. On 03/21/24 09:12 AM, during an interview with Registered Nurse (RN) V reported she was aware of complaints that staff talk on their phones/watches, and utilize the use of ear buds to try to conceal it. RN V stated for the most part this was agency staff. [...]
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and record review, the facility failed to address and resolve grievances reported in Resident Council Meetings as stated during a confidential Resident Council meeting, resulting in unresolved concerns and unmet needs of residents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of one discharge Minimum Data Set (MDS) assessment for one resident (resident #122) of 2 reviewed for discharge.
- 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 confirm that the Pre-admission Screening (PAS)/Annual Resident Review (ARR) (PASARR) Level I determination request was sent to the Community Mental Health Service Program (CMHSP) for a level II Omnibus Budget Reconciliation Act (OBRA) evaluation for one (Resident #26 ) of two reviewed for PASARR, resulting in the potential for delayed mental health services and unmet psychosocial needs.
- 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 comprehensive care plans for 2 (Resident #78 and Resident #110) of 26 residents reviewed, resulting in the potential for unmet care needs, weight loss and increased injury risk with recurrent falls.
- 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 assistance with activities of daily living (ADLs) for 1 (Resident #78) of 3 residents reviewed, resulting in unmet care needs and the potential for a decline in emotional and physical health.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review the facility failed to obtain catheter orders for catheter care for one (Resident #3) of one reviewed for catheters, resulting in the potential for increased risk of infection. Findings Include: According to the facility's policy titled Catheter Care with an issued date of 8/24/23 It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. General Guidelines: Catheter care will be performed every shift and as needed by nursing personnel . [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional and hydration needs were met and failed to obtain weights per policy for resident (Resident #110) of 5 residents reviewed for nutrition, resulting in the potential for altered nutrition status and unmet needs. Findings Include: Review of the facility's policy titled Weights with a revision date of 2/1/24 reflected the guidelines for obtaining weights. The policy stated .weights are obtained upon admission and then weekly for a total of four weeks . Review of an medical record revealed Resident #110 (R110) admitted to the facility on [DATE] with diagnoses which included repeated falls, muscle weakness, depression, pressure ulcers, severe protein-calorie malnutrition, and other drug induced secondary Parkinsonism. [...]
- D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staff to meet resident needs as reported in a confidential Resident Council meeting and Resident #'s (2,8,49, 55, 59 and 80) resulting in anger, frustration, increased risk of falls and the potential for unmet care needs.
- 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 opened medications were appropriately labeled and stored (R17, R60, R33) and that expired medications were disposed of in 4 of 8 medication carts reviewed for labeling and storage, resulting in the potential for decreased medication efficacy and adverse side effects.
February 8, 2024Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteThis citation pertains to Intake #MI00142268 Based on interview and record review the facility failed to thoroughly investigate an allegation of abuse, and report the findings to the State Agency for one resident (Resident #3) of three residents reviewed for abuse and neglect.
December 5, 2023Complaint inspection · 2 citations
- G
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 MI00141165. Based on observation, interview, and record review the facility failed to prevent a fall for one out of three residents (Resident #3) resulting in right and left tibia (shinbone), and right femur (large upper leg bone) fractures. Findings Included: Per Resident #3's (R3) Minimum Data Set (MDS), R3 was discharged to the hospital on [DATE] with an anticipated return to the facility. Review of an MDS dated [DATE], revealed R3 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 (moderately impaired cognition). The assessment revealed that both of R3's legs were impaired, and also R3 was totally dependent on staff for rolling right to left while in bed. Review of R3's list of diagnoses revealed R3 had multiple sclerosis (MS-a disease that affects the central nervous system). [...]
- 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 number MI00141165. Based on observation, interview, and record review the facility failed to ensure care plan interventions were followed for one out of eight residents (Resident #3), resulting in a right and left tibia (shinbone) and right femur (upper leg bone) fracture from a fall out of bed. Findings Included: Per Resident #3's (R3) Minimum Data Set (MDS), R3 was discharged to the hospital on [DATE] with an anticipated return to the facility. Review of an MDS dated [DATE], revealed R3 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 (moderately impaired cognition). The assessment revealed that both of R3's legs were impaired, and also R3 was totally dependent on staff for rolling right to left while in bed. Review of R3's list of diagnoses revealed R3 had multiple sclerosis (MS-a disease that affects the central nervous system). [...]
Fire safety inspections
11 fire safety citations on file: 2 on July 9, 2026, 6 on April 10, 2025, 3 on March 26, 2024.
Every fire safety citation11 citations
- F
Provide properly protected cooking facilities.
K 324 · July 9, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 9, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · April 10, 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 10, 2025 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · April 10, 2025 · Corrected (the home has a date of correction)
- E
Conform to length requirements for dead end corridors.
K 251 · April 10, 2025 · Corrected (the home has a date of correction)
- E
Install a fire alarm system that can be heard throughout the facility.
K 341 · April 10, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 10, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 26, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · March 26, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 26, 2024 · Corrected (the home has a date of correction)