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 40 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
30D
5E
2F
Potential for minimal harm
0A
0B
1C
March 27, 2026Standard inspection, Complaint inspection · 19 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 2803162 Based on observation, interview and record review the facility failed to prevent an avoidable fall as well as conduct a thorough root-cause analysis investigation into falls for five residents (R3, R17, R71, R98, and R106), of six residents reviewed for falls resulting in transfer to hospital and major injuries including fractures and subdural hematoma.
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and record review, the facility failed to develop and maintain a Quality Assistance and Process Improvement (QAPI) program which identified and prioritized quality deficiencies, systematically analyzed the underlying causes of systemic quality deficiencies, and implemented effective corrective action or performance improvement activities to remedy those deficiencies. This deficient practice has the potential to affect the safety and quality of life of all 93 residents at the facility. Findings Included: On 03/27/2026 at 01:01 p.m. an interview was conducted with Nursing Home Administrator (NHA) A regarding concerns identified during the current Recertification Survey. NHA A explained that during the last year the QAPI committee had identified areas of concerns as return to hospital, weight loss, falls, and dietary menus. [...]
- 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 adequately address and make good faith effort to resolve grievances for 7 of 7 Resident Council members. Finding incleude:Review of Resident Council meeting minutes dated 9/30/25 the council members complained in part, they were not receiving certain menu items and had concerns regarding the quality of the food. The response signed off by Nursing Home Administrator (NHA) A was to print menus ahead of time. There was no response provided the concern related to the quality of food being served. The Resident council meeting minutes 10/27/25 reflected the quality of food was bad and food was cold and some meals were being served late and menu items that were requested were not provided. [...]
- 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 interview and record review the facility failed to ensure that 7 of 7 of the Resident Council members were informed of their right on how to file a grievance with the facility.
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on interview and record review the facility failed to ensure 7 of 7 of the resident council members food preferences were met on a daily basis.
- 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 interview, and record review the facility failed to ensure accurate advance directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for one resident (#100) of two resident reviewed for advance directives.
- 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 wroteThrough interview and observations, the facility failed to maintain a homelike environment without the overpowering smell of urine for two residents (R7 and R11) of two residents reviewed for a homelike environment with the potential to affect all residents on that hall. Findings IncludeResident #11 (R11)Review of the medical record reflected that R11 was admitted to the facility on [DATE]. Diagnoses of paraplegia, acute kidney failure, encounter for fitting and adjustment of urinary device, abnormal gait and mobility. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/11/2026 revealed R11 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. [...]
- D
Assess the resident when there is a significant change in condition
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a significant change Minimum Data Set was completed timely in one (Resident 3) out of 19 reviewed for Significant Change Minimum Date Sets.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observations and interviews, the facility failed to revise care plans for three residents (R1, R4 and R7) to reflect a room change, use of hand rolls and receiving hospice services of 19 residents reviewed. Findings IncludeResident #1 (R1)Review of the medical record reflected that R1 was admitted to the facility on [DATE]. Diagnoses of chronic obstructive pulmonary disease with lower respiratory infection, weakness, presence of vascular implants and grafts, disorder of the brain, dementia, abnormalities of gait and mobility, colon cancer with a colostomy bag, anxiety and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/2025 revealed R1 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThrough observation, interview and record review the facility failed to ensure three residents (R1, R7 and R22) of four were bathed, had their hair washed, had their facial hair shaved to maintain the highest practicalable physical, emotional and psychological wellbeing. Findings IncludePertains to Intake #2728007Resident #1 (R1)Review of the medical record reflected that R1 was admitted to the facility on [DATE]. Diagnoses of chronic obstructive pulmonary disease with lower respiratory infection, weakness, presence of vascular implants and grafts, disorder of the brain, dementia, abnormalities of gait and mobility, colon cancer with a colostomy bag, anxiety and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/2025 revealed R1 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. [...]
- 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 observations, interview and record review this facility failed to maintain range of motion in one resident (R#4) of two residents reviewed for range of motion resulting in failure to participate in her activities of daily living. Findings IncludeResident #4 (R4)Review of the medical record reflected that R4 was admitted to the facility on [DATE]. Diagnoses of chronic obstructive pulmonary disease, urinary tract infection, dysphagia (difficulty swallowing) chronic respiratory failure, pressure ulcer of sacral region- stage 3, paraplegia- incomplete, chronic pain, muscle wasting and atrophy. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) revealed R4 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively impact) out of 15. [...]
- 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 respiratory care, including tracheal suctioning was provided consistent with professional standard of practice for one Residents (#6) of three Residents reviewed for respiratory care. Findings Included:Resident #6 (R6)Review of the medical record revealed R6 was admitted [DATE] with diagnoses that include dysphagia (difficulty swallowing), cerebral infarction (stroke), tracheostomy (a surgical opening in the trachea), gastrostomy (a feeding tube inserted through the abdomen directly into the stomach to provide nutrition), chronic respiratory failure, pressure injury to right heel, anxiety, insomnia, abnormal posture, lack of coordination, language deficits, paralysis right side of body, type 2 diabetes, hypertension, gastro-esophageal reflux, and protein-calorie malnutrition. [...]
- 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 remove all expired medications from two of four medication administration carts used to administer medications to residents with the potential to affect half of the facility census of 93. Findings Include During observation and interview on 03/25/2026 at 8:16 AM, writer asked to look through medication cart labeled Hall A. Writer found Allergy Relief 24 hr. 180mg tab expired 01/26. Naproxen Sodium 220mg tab expiration date has been removed, all white with no date. During observation and interview on 03/25/2026 at 8:36 AM, writer asked to look through medication cart labeled Hall B. Writer found Cetirizine HCI 10 mg tab- Expiration date had been removed, wiped off, plain white area where expiration date was. [...]
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the published menu was served as planned to six residents and residents were consistently informed in advance of any menu changes affecting all residents consuming food from the kitchen resulting in resident dissatisfaction with their meal experience and feelings of frustration related to meals voiced in confidential resident group the the potential to effect all 93 residents.
- D
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 palatable and appetizing food was served to two (Resident #2 and Resident #49) of 2 residents reviewed for receiving palatable and appetizing food, resulting in potential for decreased oral intake.
- D
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on observation, interview, and record review the facility Arbitration Agreement failed to explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission, or as a requirement to continue to receive care at the facility and state that the binding arbitration agreement allows the resident or anyone else to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health departement employees and representatives of the Office of the State Long Term Care Ombudsman for one resident (#73) of three Resident reviewed for Arbitration Agreements. [...]
- D
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Inspectors wroteBased on observation, interview, and record review the facility Arbitration Agreement failed to explicitly state that the agreement provided for the selection of a neutral arbitrator agreed upon by both parties for one resident (#73) of three Resident reviewed for Arbitration Agreements. [...]
- 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 observation, interview and record review the facility failed to provide coordination of care for hospice services for one resident (R7) of one reviewed for additional services above and beyond the facilities provides. Findings IncludeResident #7 (R7)Review of the medical record reflected that R7 was admitted to the facility on [DATE] and signed onto hospice 02/12/2026. Diagnoses of Huntington's disease, dementia, other disorders of the muscles, emotional deficit related to cerebrovascular disease, protein-caloric malnutrition, weakness and repeated falls. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/26/2025 revealed R7 had a Brief Interview of Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that appropriate hand hygiene was conducted during dressing changes for two residents (#63, #88) and during medication administration observation with the potential to affect facility census of 93.
January 6, 2026Complaint 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 wroteBased on observation, interview and record review, the facility failed to implement the Comprehensive Care Plan for one (R6) of three reviewed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThis citation pertains to intake 2697023. Based on interview and record review, the facility failed to 1) ensure the accuracy of medication orders for one (R4); and 2) administer medication according to Physician Orders for one (R4) of three reviewed.
May 29, 2025Complaint inspection · 1 citation
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the development of a pressure ulcers for two resident (#2, #8) of three residents reviewed for the development of pressure ulcers. Findings Included: Resident #2 (R2) Review of the medical record revealed R2 was admitted to the facility 11/21/2024 with diagnoses that included acute kidney failure, Alzheimer's disease, lack of coordination, difficulty walking, Peripheral Vascular Disease (PVD), stage 3 kidney disease, cognitive communication deficit, abnormal posture, protein-calorie malnutrition, congestive heart failure (CHF), insomnia, obesity, anxiety, depression, type 2 diabetes, hypertension, hyperlipidemia (high fat content in blood), atrial fibrillation, and arthropathy (any disease of the joints). [...]
December 20, 2024Standard inspection · 9 citations
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview and record review, the facility failed to revise the Care Plan for one (Resident #33) of 18 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 ensure nephrostomy tube care was ordered and completed for one (Resident #47) of one residents reviewed for nephrostomy care.
- 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 initiate intervention for the prevention of repeated falls at bedside for 1 resident (R38) of 3 residents reviewed for falls resulting in the potential for repeated falls at bedside. On 12/17/24 at 3:53 PM during observation and interview R38 pointed at her eye which appeared bruised extending around the entire eye. R38 responded, uh huh when asked if she had fallen. R38 was quite busy in her room, moving place to place independently in the wheelchair. A nurse on the unit said that R38 had recently fallen twice in one day. Review of the electronic medical record (EMR) revealed that R38's original admission date was 3/27/23 and recent admission date was 4/15/23. R38 had the following pertinent diagnoses: [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure water was available for 1 resident (R24) of 1 resident reviewed for hydration resulting in the potential for inadequate fluid intake. Findings Include: On 12/17/24 at 1:33 PM during observation and interview R24 was upright in bed and established strong eye contact and was able to participate in an interview. It was noted during observation that R24's water cup was on a bedside table positioned to the left side of the bed and up against the wall. This positioned the table and water to the left and behind her head and out of sight and reach. There was also a rolling type of bedside table near the bed, and within resident's reach, but no water cup on it. When asked if R24 enjoyed drinking water her response was, I love it. On 12/17/24 at 4:42 PM during observation and interview R24 smiled and said a few words. [...]
- 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 ensure communication with the dialysis center, pertaining to a fluid restriction, for one (Resident #42) of one reviewed.
- 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 observation, interview and record review, the facility 1) failed to ensure justification for an increase in psychotropic medications and 2) failed to attempt nonpharmacological interventions for two (Resident #9, Resident #33) of five reviewed for unnecessary medications.
- 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, 1) ensure appropriate storage of medications, including narcotics; and 2) ensure one medication cart was free of expired medications.
- 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 observation, interview, and record review the facility failed to coordinate hospice services for one resident (#56) out of one resident reviewed for coordination of hospice services. Findings Included: Resident #56 (R56) Review of the medical record revealed Resident #56 (R56) was admitted to the facility on [DATE] with diagnoses that included senile degeneration of brain. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/1/24, reflected R56 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS revealed that R56 was utilizing hospice services. On 12/18/24 at 12:23 PM, R56's Hospice Communication binder was reviewed. R56's Hospice Care Plan was not located in the binder. [...]
- C
The resident has the right to receive notices in a format and a language he or she understands.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 11 of 12 residents in group knew what their resident rights were, where the posting of resident rights, the Ombudsman and State Agency contact information was located. Findings Included: During group meeting on 12/19/2024 at 11:03 AM, 11 of the 12 residents in attendance did not know who the Ombudsman was, or where the posting was located with the Ombudsman contact information. The 11 residents also did not know where the State agency contact information was located nor were the 11 residents aware that they had the right to put in a complaint with the State agency. 11 of the residents also stated they did not know what resident's right were, and were not ever told of them. [...]
October 11, 2023Standard inspection · 9 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteDPS B: Based on observation, interview, and record review, the facility failed to implement ordered devices to prevent accidents/falls for 1 resident (Resident #31) of 2 reviewed for accidents, from a total sample of 19, resulting in the risk for falls and potential for injury.
- 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) effectively date mark all potentially hazardous ready-to-eat food products, (2) effectively don hair and beard restraints, (3) effectively clean and maintain food service equipment, and (4) monitor food for safe temperatures prior to serving and maintain temperature logs effecting 74 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness.
- 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 maintain a safe, clean, and comfortable bathroom for one of 19 sampled residents (Resident #42), resulting in an environment in disrepair.
- 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 1. Dispose of expired eye drops; 2. ensure medications/treatment carts remained secured in 1 of 2 medication/treatment carts reviewed, resulting in the potential for medications given to residents to have decreased potency, reduced strength, effect, and medication errors.
- 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 updated and accurate advance directive information was in place for three residents (Resident #8, #18 and #52) of four reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings Include: Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 revealed that, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: [...]
- 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 care plans, for one of 19 residents reviewed for care plans (Resident #42), resulting in the potential for falls, pressure ulcers, and unmet needs.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician ordered parameters upon administration of blood pressure medications for 1 resident (Resident #37) of 5 reviewed for unnecessary medications, resulting in the potential for adverse drug consequences.
- 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 3 medication errors were observed from a total of 39 opportunities for one resident (R1) of nine residents observed during medication administration, resulting in a medication error rate of 7.69%.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food preferences were honored for 1 resident (Resident #30) of 3 reviewed for food preferences and for 9 of 9 residents in the confidential group, resulting in meal dissatisfaction and frustration when food choices were not honored and disliked foods continued to be served on meal trays. Resident #30 Review of the medical record reflected that Resident #30 (R30) was readmitted to facility 6/19/2023 with diagnoses including obesity, gastro-esophageal reflux disease, and diabetes mellitus. Review of the Minimum Data Set with an Assessment Reference Date (ARD) of 9/16/23 reflected that R30 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). [...]
Fire safety inspections
11 fire safety citations on file: 1 on March 27, 2026, 5 on December 20, 2024, 5 on October 11, 2023.
Every fire safety citation11 citations
- E
Install an approved automatic sprinkler system.
K 351 · March 27, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 20, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · December 20, 2024 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · December 20, 2024 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · December 20, 2024 · 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 · December 20, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 11, 2023 · Corrected (the home has a date of correction)
- E
Have horizontal exits used in accordance with safety requirements.
K 226 · October 11, 2023 · Corrected (the home has a date of correction)
- E
Provide properly sized and located linen or trash receptacles.
K 754 · October 11, 2023 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of flammable curtains.
K 751 · October 11, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · October 11, 2023 · Corrected (the home has a date of correction)