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 20 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
2E
1F
Potential for minimal harm
0A
0B
0C
November 24, 2025Complaint 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 2674204. Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent elopement of one cognitively impaired resident (R901) of three residents reviewed for elopement risk.
August 20, 2025Standard inspection, Complaint inspection · 6 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 assess and treat a wound for one resident (R68) of one reviewed for wound care and failed to ensure appropriate positioning while in bed for one resident (R11) of one reviewed for positioning.
- 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:1359931Based on observation, interview, and record review, the facility failed to prevent a fall for one resident (R14) of three residents reviewed for falls.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide staff with education regarding (R68's) Wearable Cardioverter Defibrillator (WCD- a device that continuously monitors the heart and can automatically deliver a shock to restore normal rhythm if it detects life-threatening arrhythmias) for 3 of 3 direct care nursing staff.
- 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 of less than five percent for one (R2) of three residents reviewed during medication pass.
- 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 properly label medication in one of two medication carts.
- 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 that call lights were in reach for one dependent resident (R11) of five reviewed for call light accessibility.
December 4, 2024Complaint 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 relates to Intake # MI00148495. Based on interview and record review, the facility failed to notify the responsible party and physician of x-ray findings timely for one Resident (R901) of three residents reviewed for change of condition.
August 22, 2024Standard inspection, Complaint inspection · 6 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 the dish machine to ensure dishware was sanitized. This deficient practice had the potential to affect all residents that consume food from the kitchen.
- 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 Intake MI00146468. Based on interview and record review, the facility failed to notify the responsible party and obtain x-ray results timely for one resident (R123) of one resident reviewed for a change in condition, resulting in the responsible uninformed about a fall until hours later and a delay in treatment.
- D
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to facilitate and assist in obtaining eye glasses in a timely manner for one resident (R2) of one reviewed for ancillary services, resulting in R2 experiencing impaired vision.
- 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 MI00146468. Based on interview and record review, the facility failed to implement interventions to prevent a fall from the bed for one resident (R123) of two reviewed for falls, resulting in a fracture, facial trauma, skin abrasions and bruising.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dressing for a Peripherally Inserted Central Catheter (PICC) intravenous (IV) was changed timely for one resident (R27) of one whose line was reviewed.
- 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 label medications when opened in two of three medications carts reviewed.
July 12, 2023Standard inspection · 6 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteThis citation pertains to Intake MI00137133. Based on observation, interview, and record review, the facility failed to promote a dignified existence and value residents' private living space, for three residents (R29, R36, and R272), and potentially affecting all residents residing on the first floor, resulting in resident feelings of frustration and disrespect and the potential for diminished quality of life.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteThis citation pertains to Intake MI00137133. Based on observation, interview, and record review the facility failed to ensure that food was served in a palatable manner and at the preferred temperature for five confidential group residents of eight residents reviewed for food palatability, resulting in dissatisfaction during meals.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteThis citation pertains to Intake MI00137133. Based on observation, interview, and record review, the facility failed to timely respond to a resident's call light and request to be helped back into bed for one resident (R272), resulting in an extended wait, resident frustration and expression of discomfort, and ultimately, the resident initiating an attempt to self-transfer.
- 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 an individualized care plan for heel boots for one sampled Resident (R8) out of one reviewed for care plan for pressure ulcers, resulting in the potential for development of ulcer.
- 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 consistently implement interventions to maintain or improve strength and range of motion (ROM) affecting one resident (R50) of one reviewed for rehabilitation/restorative care, resulting in the potential for further functional decline in strength and mobility.
- 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 maintain maintaining the catheter drainage tubing and bag in a sanitary condition, for one sampled resident (R169) of one sampled resident reviewed for catheter care, resulting in the potential for infection.
Fire safety inspections
29 fire safety citations on file: 2 on August 20, 2025, 4 on August 22, 2024, 23 on July 12, 2023.
Every fire safety citation29 citations
- F
Have elevators that firefighters can control in the event of a fire.
K 531 · August 20, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 20, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · August 22, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 22, 2024 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · July 12, 2023 · Corrected (the home has a date of correction)
- F
Conduct risk assessment and an All-Hazards approach.
E 6 · July 12, 2023 · Corrected (the home has a date of correction)
- F
Establish policies and procedures for volunteers.
E 24 · July 12, 2023 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · July 12, 2023 · Corrected (the home has a date of correction)
- F
List the names and contact information of those in the facility.
E 30 · July 12, 2023 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · July 12, 2023 · Corrected (the home has a date of correction)
- F
Provide primary/alternate means for communication.
E 32 · July 12, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · July 12, 2023 · Corrected (the home has a date of correction)
- F
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
K 132 · July 12, 2023 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 12, 2023 · Corrected (the home has a date of correction)
- F
Have an enclosure around a vertical opening shaft.
K 311 · July 12, 2023 · Waiver
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · July 12, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · July 12, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 12, 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 · July 12, 2023 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · July 12, 2023 · Corrected (the home has a date of correction)
- E
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
K 342 · July 12, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 12, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 12, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · July 12, 2023 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · July 12, 2023 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 12, 2023 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 12, 2023 · Corrected (the home has a date of correction)