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 38 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
24D
8E
2F
Potential for minimal harm
0A
0B
1C
February 24, 2026Standard inspection, Complaint inspection · 7 citations
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the dish machine in a state of repair that would allow for the machine's operational requirements to be met. Findings Include:On 2/22/26 at 10:00 AM, observation of the kitchen dish machine found that it was not reaching proper temperature or pressure for the wash and rinse cycles. A review of the machines' data plate (that shows the minimum requirements) found that the Wash temperature should be 150F - 160F, Rinse temperature should be 180F from the manifold (for a contact of 160F), and the final rinse pressure should be 20 pounds per square inch (psi). At this time, five cycles of the dish machine were run with the following characteristics observed: [...]
- 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 observation, interview, and record review the facility failed to consistently honor food preferences for 5 (Residents #106, 91, 31, 5, and 42) of 11 residents reviewed for dining resulting in being served disliked foods, frustration, decreased meal enjoyment, and the potential for unintended weight loss due to decreased oral intake.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for Medicare Part A services in 2 residents (Resident #73 and #92) of 3 residents, reviewed for timely provision of notifications, resulting in the potential for the resident or resident representative to be unaware of changes regarding financial liability, frustration, and a delay in the ability to file an appeal.
- 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 provide adequate supervision for 1 (Resident #5) of 5 residents reviewed for accidents and falls, resulting in the potential for injury.
- D
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 that irregularities identified by the pharmacist were acted upon for 1 resident (Resident #2) of 5 residents, reviewed for unnecessary medications resulting in Resident #2 receiving an excessive dose of Escitalopram (antidepressant medication) and the potential for medication side effects including life threatening effects from QT (a measurement that shows the heart's electrical activity) prolongation (when the electrical system in your heart takes too long to recharge).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteThis citation pertains to intake #2713932. Based on interview and record review, the facility failed to ensure residents were free from significant medication errors in 1 (Resident #29) of 3 residents reviewed for pain management services, resulting in Resident #29 missing a dose of scheduled pain medication and experienced pain, frustration and difficulty sleeping.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteThis citation pertains to intake #2713932Based on interview and record review, the facility failed to ensure accurate documentation in a medical record for 2 (Resident #29 and #2) of 18 residents reviewed for accurate medical records, resulting in inaccurate documentation of the services provided and inaccurate physician notes.
August 28, 2025Complaint inspection · 1 citation
- 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 wroteThis citation pertains to Intake 1326155. Based on observation, interview, and record review the facility failed to have sufficient staffing to ensure resident care needs were responded to timely for 5 (Residents #1, 2, 6, 7, and 8) of 7 residents reviewed for sufficient staffing, and the potential to affect all those living at the facility of the facility census of 97 resulting in feelings of anger, frustration, and/or embarrassment.
April 15, 2025Complaint inspection · 3 citations
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteThis citation pertains to intake MI00152092. Based on interview and record review, the facility failed to monitor and prevent resident to resident sexual abuse for 4 of 6 residents (Resident #101, #102, #104, and #105) reviewed for abuse, resulting in the potential for a decline in physical, mental, and psychosocial well-being.
- E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff implemented the abuse policy by immediately reporting an allegation of abuse to the abuse coordinator for 4 of 6 residents (Resident #103, #104, #105 and #106) reviewed for abuse, resulting in a resident to resident allegation of sexual abuse not being reported immediately to the facility Abuse Coordinator and the potential for additional allegations of abuse to go unreported.
- 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 interview and record review, the facility failed to develop and implement comprehensive, person centered care plans for 4 residents (Resident #102, #103, #104 and #105) of 6 residents reviewed, resulting in unmet care needs and the potential for negative physical, mental and psychosocial outcomes.
April 9, 2025Complaint inspection · 2 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThis citation pertains to intake MI00151467. Based on interview and record review the facility failed to implement interventions, treatment, and monitoring for the prevention of pressure ulcers, prevent the development of pressure ulcers, implement monitoring to prevent the worsening of pressure ulcers, and implement treatment(s) to promote healing of pressure ulcers in 1 of 3 residents (Resident #3) reviewed for pressure ulcers, resulting in Resident #3 developing an unstageable pressure ulcer on the sacrum (tailbone) and an unstageable pressure ulcer on the right ear requiring hospitalization for a wound infection that lead to osteomyelitis (bone infection), gangrene (death of body tissue due to lack of blood flow or a serious bacterial infection) and ultimately the need for surgical intervention.
- 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 ensure dignified verbal interactions between staff and resident for 1 (Resident #9) of 4 residents reviewed for dignity and respect resulting in negative emotional feelings and the potential for decreased self-worth or self-esteem.
December 20, 2024Standard inspection · 4 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, and record review, the facility failed to timely report an injury of unknown origin to the State Agency in 1 of 1 resident (Resident #94) reviewed for abuse, resulting in the potential for a delayed/incomplete investigation.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, and record review, the facility failed to thoroughly investigate an injury of unknown origin in 1 of 1 resident (Resident #94) reviewed for abuse, resulting in an incomplete facility investigation.
- 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 2 (Resident #14 and #94) of 20 residents reviewed for medical records, resulting in an inaccurate reflection of personal hygiene acceptance, lack of nursing assessment documentation, and the potential for facility staff and providers not having all of the pertinent information to care for residents.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to post required nurse staffing information on a daily basis, for all 98 residents in the facility, resulting in a lack of available staffing information for residents and visitors.
May 16, 2024Complaint 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 #MI00144277. Based on interview, and record review, the facility failed to provide adequate supervision and accurately implement the elopement policy in 3 of 5 residents (Resident #203, #208, & #209), reviewed for safety and monitoring, resulting in the potential for injury.
October 25, 2023Standard inspection, Complaint inspection · 12 citations
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThis citation has 2 DPS statements, #1 and #2. DPS #1 Based on interview and record review, the facility failed to maintain professional standards when responding to an acute change in condition in 1 of 19 residents (Resident #54 ) reviewed for quality of care, when facility staff failed to ensure a physician was notified of Resident #54's extreme elevation in heart rate (pulse) and respirations, and adequately monitor and assess Resident #54 for further decline in health status, resulting in a delay in treatment and ultimately Resident #54 being found unresponsive, without an audible BP (blood pressure) or palpable pulse, and was transferred to the hospital via EMS (emergency medical services), where she later died.
- G
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 ensure COVID-19 immunization were offered to 2 (Resident #54 and #6) out of 5 residents, reviewed for COVID-19 immunizations, resulting in the increased likelihood of severe infection and complications/death related to COVID-19.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1.) provide appropriate and adequate tracheostomy care, 2.) maintain oxygen delivery rate, and 3.) maintain oxygen delivery equipment for infection control in 4 of 4 residents (Resident #50, Resident #24, Resident #10, and Resident #11) reviewed for respiratory care, resulting in the potential for breathing complications and respiratory infections.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteR50 Review of R50's Order Summary -10/21/2023 apply 44 gauze under right side of patient's neck and under the foam trach ties to prevent pressure every shift for Trach (tracheostomy) foam ties pressure prevention -10/3/2023 suction trach as needed -10/20/2023 trach care to be performed. Change inner cannula using size 4 every shift Review of R50's Care Plan, 12/16/2022, the resident had a potential for difficulty breathing and risk for respiratory complications related to NPO (nothing by mouth) status, and aspiration risk (taking in foreign material into the lungs), tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck via a tube), brain injury, with seizure risk. The goal was to display optimal breathing pattern daily/no labored breathing. [...]
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach for 1 (Resident #19) of 19 residents reviewed for call light placement, resulting in the inability to call for staff assistance, resident frustration, and unmet care needs.
- 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: 1.) notify a physician of a missed medication dose 2.) failed to enter physician order for a change in oxygen flow rate 3.) obtain a re-weight for a resident with potential nutritional concerns in 2 (Resident #11 and Resident Resident #73) of 19 residents reviewed for standards of practice, resulting in the potential for worsening of health conditions.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wrote`This citation pertains to intake: MI00139865 Based on observation, interview, and record review the facility failed to ensure PRN (as needed) oral care was performed for 1 of 19 resident (R50) reviewed for ADL (activities of daily living), resulting in dried oral secretions, dry cracked lips, and the potential of gum disease.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThis citation pertains to intake: MI00139865 Based on observation, interview, and record review, the facility failed to implement and revise pressure ulcer interventions for 1 of 2 residents (R50) reviewed for skin integrity, resulting in the potential of an impaired skin integrity condition.
- 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 ensure safety precautions were in place and accurate in 1 of 1 residents (Resident #48) reviewed for safety, resulting in the potential for elopement.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review the facility failed to ensure pre and post dialysis (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) assessments were completed for 1 (Resident #42) of 1 resident reviewed for dialysis care, resulting in the potential of being unprepared for a potential decline in resident condition, due to the adverse effects from dialysis.
- 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 PRN (as needed) orders for psychotropic drugs were limited to 14 days and/or document the rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #29) of 6 residents reviewed for unnecessary medications, resulting in the prolonged use of psychotropic medication and the potential for residents to receive unnecessary psychotropic medications.
- 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 3 of 19 residents (Resident #54, #11 and #29) reviewed for comprehensive and accurate medical records, resulting in an inaccurate reflection of the resident's medical conditions and needs, and the potential for providers to not have an accurate picture of resident status and condition.
September 20, 2023Complaint inspection · 3 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 update a care plan to reflect current actual skin impairment for 1 resident (Resident #4) of 4 residents reviewed for accuracy of care plans, resulting in the potential for staff to provide care that was inconsistent with the needs of the resident.
- 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 obtain a physician order to reflect current wound treatment for 1 resident (Resident #4) of 4 residents reviewed for skin conditions, resulting in the potential for residents to have received inappropriate care and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThis citation pertains to intake MI00139243 and MI00139388. Based on interview and record review, the facility failed to identify, monitor and treat a skin condition for 1 (Resident #1) of 4 residents reviewed for skin treatment, resulting in lack of assessment, monitoring, and documentation and the potential for worsening of the condition and delay of treatment.
September 6, 2023Complaint inspection · 5 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteThis citation pertains to intake: MI00133188, MI00136070, & MI00137867 Based on interview and record review, the facility failed to assure a registered nurse was on duty for eight consecutive hours a day seven days a week, resulting in the potential for a decrease in the quality of care for all residents residing in the facility.
- 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 wroteThis citation pertains to intake MI00133188, MI00136070, & MI00137867 Based on observation, interview, and record review, the facility failed to ensure adequate nurse staffing to promote the physical, mental, and psychosocial well-being in 4 of 9 sampled residents (Resident #100, #103, #107, & #108) reviewed for staffing, resulting in unmet care needs and the potential for physical and psychosocial harm for all residents in the facility.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThis citation pertains to Intake: MI00133188 & MI00136070 Based on interview and record review, the facility failed to ensure a resident was consistently provided with showers/bathing for 2 of 9 residents (Resident #103 and #108) and 1 of 1 residents (Resident #107) with eating assistance reviewed for activities of daily living, resulting in unmet personal hygiene needs and the potential for weight loss.
- 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 utilize wheelchair footrests for safe wheelchair transport in 2 of 2 residents (Resident #105 & Resident #106) reviewed for accidents and hazards, resulting in the potential for falls and injury.
- 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 wroteThis citation pertains to Intake: MI00133188 & MI00136070 Based on observation, interview, and record review, the facility failed to thoroughly assess and provide care per the standards of care for an indwelling catheter in 1 (Resident #103) of 3 residents reviewed for indwelling catheter care, resulting in the potential of a urinary tract infection.
Fire safety inspections
7 fire safety citations on file: 4 on February 24, 2026, 1 on December 20, 2024, 2 on October 25, 2023.
Every fire safety citation7 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · February 24, 2026 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · February 24, 2026 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 24, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 24, 2026 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 20, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 25, 2023 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · October 25, 2023 · Corrected (the home has a date of correction)