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 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
0E
0F
Potential for minimal harm
0A
0B
0C
July 2, 2025Standard inspection · 1 citation
- 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 properly store, label, and date medications for one resident (R56) of four residents reviewed for medication administration.
April 2, 2025Complaint inspection · 1 citation
- 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 Intakes MI00151561. Based on interview and record review, the facility failed to document notification of family and physician for a change in condition for one resident (R901) of three reviewed for notice of condition change.
June 6, 2024Standard inspection · 3 citations
- 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 apply heel protector boots per physician orders for two residents (R5 and R24) out of two reviewed for skin conditions and apply positioning devices per physician orders for one resident (R1) out of two reviewed for positioning. Findings Include: R5 On 6/4/2024 at 9:15 AM, R5 was observed in their bed. Two heel protection boots were noted to be in a wheelchair. R5 was noted to have their heels resting on the mattress. R5 was asked if they wear heel boots while in bed. R5 said they sometimes do and sometimes don't. On 6/5/2024 at 9:16 AM, R5 was observed laying in bed. Two heel protection boots were noted to be in a wheelchair. R5 heels were noted to be resting on the mattress. [...]
- 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 secure smoking/vape pens for one sampled resident (R59) of two reviewed for accidents.
- D
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 the call light was within reach of one resident (R1) out of one reviewed for call lights.
September 5, 2023Complaint 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 MI00139026. Based on interview and record review, the facility failed to implement adequately supervision for one sampled resident (R901) of three residents reviewed for falls, resulting in multiple falls, and two hospital transfers.
April 4, 2023Standard inspection · 7 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 wroteBased upon observation, interview and record review, the facility failed to develop a care plan for use of a right hand orthosis (hand held splint) for one (R26) of two residents reviewed for orthotics resulting in limited resident access to and application of the orthosis.
- D
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 medications were administered per order for one resident (R38) of five reviewed for medications, resulting in the potential for the exacerbation of acute or chronic health conditions.
- 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 answer call lights in a timely manner, assist with brief changes and or failed to assist residents during meals for four residents (R1, R8, R62, R68) of seven residents reviewed for activities of daily living care (ADLs), resulting in dissatisfaction with care, dissatisfaction during meals, and the potential for compromised nutrition and weight loss.
- D
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. This citation pertains to Intake MI00135496. Deficient practice #1. Based on observation, interview and record review the facility failed to provide sufficient staff monitoring to prevent inappropriate wandering, for one (R109) of one sampled residents reviewed for wandering, resulting and multiple unwelcome entries into residents' rooms.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide thickened liquids per diet order for one resident (R38) of three reviewed for nutrition, resulting in the potential for difficulty swallowing and aspiration.
- 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 ensure a 14-day stop date was ordered for an as-needed (PRN) psychotropic medication and failed to document attempted non-pharmacological interventions prior to administration for one resident (R271) of five reviewed for unnecessary medications, resulting in the potential for adverse reactions and the prolonged use of psychotropic medication.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store and maintain nebulizer masks in a sanitary manner, for two residents (R21 and R34), resulting in masks left hanging on the side of the bed, and the potential for contamination of equipment and transmission of bacteria leading to respiratory infections from contaminated equipment.
Fire safety inspections
13 fire safety citations on file: 1 on July 2, 2025, 4 on June 6, 2024, 8 on April 4, 2023.
Every fire safety citation13 citations
- F
Provide a written emergency evacuation plan.
K 711 · July 2, 2025 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 6, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 6, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 6, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · June 6, 2024 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · April 4, 2023 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · April 4, 2023 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · April 4, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 4, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 4, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 4, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · April 4, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 4, 2023 · Corrected (the home has a date of correction)