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 45 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
29D
9E
5F
Potential for minimal harm
0A
0B
1C
May 28, 2026Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThis citation refers to Intake 3012437. Based on interview and record review, the facility failed to prevent a fall with injury for 1 of 3 residents (R2) reviewed for accident hazards, resulting in R2 sustaining a fractured nasal bone and lacerations to the face.
January 14, 2026Standard inspection · 21 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen in a current facility census of 87 residents. Findings Include:On 01/12/2026 at 9:27AM, observation in Dining room [ROOM NUMBER], the drain line for the ice machine was not air gapped, the flexible line from ice machine was sitting with the end sitting directly in the drain. On 01/12/2026 at 3:07PM, during interview with Maintenance Manager (MM) R it was found that MM R was not aware the drain line was not properly air gapped. [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Infection Prevention and Control Policies and Procedures and have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory and other infections among all residents in the facility.
- E
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/or implement Comprehensive Care Plans for 4 residents (R23, R25, R54 and R90) out of 19 residents reviewed for care planning. R90 Review of an admission Record reflected R90 admitted to the facility on [DATE] with diagnoses that included Amyotrophic Lateral Sclerosis (ALS), unspecified dementia, and an unspecified lack of expected normal physiological development in childhood. Review of an admission assessment dated [DATE] reflected R90 admitted to the facility with a right heel blister measuring 1.0 cm (centimeters) x 1.2 cm without any depth. Review of a Braden Scale-For predicting Pressure Ulcer Risk Evaluation dated 1/8/2026 reflected R90 was at risk for pressure ulcers. Review of a Care Plan initiated on 1/8/2026 reflected Resident (R90) has actual skin breakdown in the following locations: [...]
- E
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 observation, interview and record reviews, the facility failed to staff the 400 & 500 Hallways to meet the acuity and psychosocial needs of 25 residents including R6 and R70.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for 3 Residents (R3, R23 and R25) of 19 Residents sampled.
- 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 general cleanliness and repair of the premises affecting occupants of halls 100, 200 and 400.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation and interview the facility failed to provide a dignified dining experience for all residents for at least 3 of 5 residents (R19, R79 and R94) in a dining/activity room out of 19 residents reviewed for Resident Rights. During an observation of the noon meal in the dining/activity room on 1/12/2026 at 12:10 PM, R79 and her husband were complaining about being served cabbage too frequently. R79 received cabbage soup with her meal and at approximately 12:20 PM. R79 and her husband were asked if she would have preferred the tomato soup. They responded, yes. When asked if they wanted staff to get tomato soup, they responded they have to make meal choices before 10:00 AM for the lunch meal. They said they have been told no in the past when asking for substitutions. Several staff were in the area and did not respond to providing the alternate soup choice. [...]
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on observation, interview and record review the facility failed to follow its concern/grievance process and address family and resident concerns for 1 resident (R19) out of 19 residents reviewed for Resident Rights.
- 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 address Pre-admission Screening/Annual Resident Review (PASARR) in a timely manner for 2 Resident's (R11 & R12) out of 19 resulting in them being completed late.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on observation, interview and record review the facility failed to complete a baseline care plan within 48 hours of admission for 2 Residents (R23 and R25) of 2 residents reviewed for baseline care plans.
- 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 monitor care to potentially prevent sepsis/hospitalization for one (R1) and failed to assess and monitor moisture associated skin damage (MASD) for one (R4) of two residents reviewed for quality of care.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review the facility failed to provide care and services according to professional standards to prevent the development and/or worsening of pressure injuries for 3 residents (R23, R54 and R90) out of 5 residents reviewed for pressure injuries. R23 Review of R23's admission record dated 1/13/26 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Pressure-induced deep tissue damage of sacral region, Alzheimer's disease, and muscle wasting. R23 was not her own responsible party. [...]
- 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 ensure proper positioning/support for one (R56) of 3 residents reviewed for positioning.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent falls for 1 (R1) of 2 residents reviewed for falls, and unsafe self-administration of medications left at the bedside for 2 (R13 and R27), of 2 residents observed with medications at the bedside.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure ordered supplements were provided to one resident with significant weight loss (R19) out of 2 residents reviewed for nutrition and hydration. Review of an admission Record reflected R19 admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition, nutritional deficiency, unspecified and dysphagia (difficulty swallowing). Review of a Care Plan initiated 7/25/2025 reflected R19 was at risk for repeated alteration in skin integrity related to . poor nutritional intake due to dysphagia. An intervention for this focus area of the care plan was to provide diet and supplements per physician order. The Care Plan also indicated R19 required assistance with ADLs (activities for daily living) that included needing set up assistance for eating. [...]
- 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 assess and monitor ongoing irritation and drainage of a PEG tube (Percutaneous Endoscopic Gastrostomy tube) insertion site for one (R20) of 2 residents reviewed for tube feedings.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review the facility failed to assess, monitor and treat 1 Resident's (R25) respiratory condition of 1 Resident reviewed for respiratory care.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate care consistent with the professional standards of practice by assessing and monitoring pre and post dialysis treatments, communicating and collaborating with the dialysis facility regarding care and medication reconciliation for one (R56) of 3 residents reviewed for dialysis.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review the facility failed to offer and provide Influenza and Pneumococcal Immunizations to 1 Resident (R54) of 5 Residents sampled for Immunizations.
- D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interview and record review the facility failed to offer and provide a COVID-19 Vaccination to 1 Resident (R54) of 5 Residents sampled for COVID-19 Vaccinations. Based on interview and record review the facility failed to offer and provide a COVID-19 Vaccination to 1 Resident (R54) of 5 Residents sampled for COVID-19 Vaccinations.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure surveys conducted by Federal or State surveyors and any plan of corrections in effect for the past 3 years was readily accessible to residents, family members and legal representatives of residents.
December 17, 2025Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to assess to determine if resident was appropriate for lone transfer in accordance with professional standards of care related to mental and physical conditions for one (Resident #1) of three residents reviewed for quality of care.
November 13, 2024Complaint inspection · 1 citation
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteThis citation is related to intake # MI00147858 Based on interview and record review, the facility failed to follow professional standards and ensure 1 out of 3 residents (Resident #400) received a physician ordered medication to treat an infection and failed to obtain ordered labs and tests required to monitor the efficacy and safety of the medication.
October 31, 2024Standard inspection · 8 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.
- 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 general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting residents in the 300, 400 and 500 halls.
- 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 provide care in a dignified manner for 2 residents (Resident #57 and Resident #73) out of 18 residents reviewed for quality care.
- 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 A) Develop, implement and evaluate the effectiveness of care planned interventions, B) Complete required assessments and follow-up after a fall, C) Accurately complete Minimum Data Set (MDS) assessments, and D) Track incidents and accidents as an aspect of Quality Assurance (QA) for 1 resident (Resident #69) out of 18 residents reviewed for quality care.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to assess and monitor a wound for 6 weeks for 1 Resident (R28) of 2 residents reviewed for pressure ulcers, resulting in the potential of R28's pressure ulcer to worsen due to missed assessments.
- 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 licensed staff carried out physician orders according to professional standards for the care of residents who receive enteral feeding for one resident (Resident #73), out of one resident reviewed for tube feeding from a total sample of 18 residents.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review, the facility failed to maintain complete and accurate medical records for 2 of 18 sampled residents (R8 and R12), resulting in the potential for providers not having an accurate and complete picture of the resident's stay at the facility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) according to facility policy for one resident (Resident #73) out of 18 residents reviewed for infection control from a total sample of 18 residents.
July 24, 2024Complaint inspection · 2 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThis citation pertains to Intake #MI00143516 Based on observation, interview, and record review, the facility failed to ensure effective hot water sanitization of resident dishes, utensils and facility cookware.
- 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 # MI00145822 Based on interview and record review, the facility failed to implement the mechanical lift transfer of one Resident (R105) in accordance with the facility policy.
October 18, 2023Standard inspection · 11 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure proper storage of food and clean and sanitary supplies; 2. Clean food and non-food contact surfaces to sight and touch; 3. Properly store food product under refrigeration; and 4. Ensure proper instillation of an air gap on food contact equipment. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 74 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the kitchen, at 8:15 AM on 10/16/23, it was observed that two boxes of shell eggs were found stored on the middle shelf above cartons of milk. When asked if these eggs were appropriately stored, Dietary Manager H stated he will move the eggs to the bottom. [...]
- E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review, the facility failed to ensure monthly pharmacy drug regimen review recommendations were reviewed by the physician and/or acted upon in a timely manner for 3 of 5 residents reviewed (R23, R59, and R62), resulting in the potential for the physician not knowing of a pharmacy recommendation, the potential for a delay in implementing a pharmacy recommendation, and the potential for adverse effects from medications that the pharmacy identified as potential medication issues.
- 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 wroteOn 10/16/23 at 0:23 AM a review was conducted of the 400 Hall medication cart with Licensed Practical Nurse (LPN) L. Review of the top drawer of the 400 Hall medication cart revealed an in-use undated Humalog Quick pen for Resident #17 (R17). LPN L reported that insulin devices are to be dated when first placed in service. On 10/17/23 at 11:30 AM a review was conducted of the 300 Hall medication cart with LPN B. Review of the top drawer of this medication cart revealed an in-use vial of Lispro insulin for R40. The vial was dated 9/1. LPN B reported that insulin vials are to be dated when opened and are good for twenty-eight or thirty days. Further review of the top drawer of the medication cart revealed a Novolog insulin pen dated 9/15/23 also for R40. A Novolog insulin pen for R33 was observed to be undated. [...]
- 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 clean, sanitary, and comfortable environment in one soiled utility room (100 Hall), one shower room (200 Hall), one clean utility room (200 Hall), and four resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]), resulting in an unclean, unsanitary, and uncomfortable environment.
- 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 coordinate with the appropriate, State-designated authority, to ensure that 1 of 2 residents (R33) reviewed received timely follow-up PASSAR II evaluations, resulting in the potential for a delay in care and services appropriate to their needs.
- 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 ensure fresh water and a call light were accessible for one physically and cognitively impaired Resident (R25) resulting in thirst, inability to request assistance, anxiety, and the potential for all facility residents to not be monitored or assisted with activities of daily living.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an Activities program was implemented to meet the interests and needs for two Residents (R475 and R47) resulting in a lack of life enrichment and the potential for social isolation and boredom for these and all facility residents.
- 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 the facility failed to discard expired tube feeding supplements. These conditions resulted in an increased risk for contaminated foods and an increased risk of food borne illness for individuals who are prescribed these specific supplements.
- 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 oxygen tubing was changed for one Resident (R21) resulting in the potential for infection and failure to follow facility protocol and the potential for all facility residents that use oxygen devices to not have them properly maintained.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% for 2 of 5 residents (R44 and R59) observed for medication administration, resulting in a medication error rate of 6.8% (2 errors from 29 opportunities).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for 4 residents (R21, R33, R59, and R62), resulting in incomplete and inaccurate medical records and the potential for providers not having an accurate and complete picture of the resident's stay at the facility.
Fire safety inspections
27 fire safety citations on file: 17 on January 14, 2026, 5 on October 31, 2024, 5 on October 18, 2023.
Every fire safety citation27 citations
- F
List the names and contact information of those in the facility.
E 30 · January 14, 2026 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · January 14, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · January 14, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · January 14, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 14, 2026 · Corrected (the home has a date of correction)
- F
Install an approved automatic sprinkler system.
K 351 · January 14, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 14, 2026 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · January 14, 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 · January 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 · January 14, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · January 14, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · January 14, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 14, 2026 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · January 14, 2026 · Corrected (the home has a date of correction)
- E
Provide a written emergency evacuation plan.
K 711 · January 14, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · January 14, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · January 14, 2026 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · October 31, 2024 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · October 18, 2023 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 18, 2023 · Corrected (the home has a date of correction)
- E
Install properly constructed and protected linen or trash chutes.
K 541 · October 18, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 18, 2023 · Corrected (the home has a date of correction)
- D
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 · October 18, 2023 · Corrected (the home has a date of correction)