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 42 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
33D
5E
4F
Potential for minimal harm
0A
0B
0C
May 14, 2026Complaint inspection · 1 citation
- D
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 intakes #2998895 and #3000521. Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from resident-to-resident sexual abuse for 1 resident (Resident #2) of 4 residents reviewed for abuse when Resident #4 who had a known history of sexual behaviors and who could propel her wheelchair throughout the facility touched Resident #2 sexually when he did not give consent, resulting in Resident #2 experiencing fear, wanting Resident #4 to stop coming to his room and wanting to discharge from the facility.
February 19, 2026Complaint inspection · 1 citation
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteThis citation pertains to intake #2735635Based on interview and record review, the facility failed to provide 30-day notification of discharge and implement appropriate discharge processes for 2 (Resident #100 and Resident #101) of 4 residents reviewed for facility-initiated discharge resulting in a lack of resident education related to care needs, lack of medical supplies needed for care at home, and the unapproved discharge of both residents.
January 8, 2026Standard inspection · 10 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.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 infection among all residents in the facility.
- 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 and interview, the facility failed to maintain a clean and homelike environment for 4 residents (R91, R45, R5, and R14) of 4 residents reviewed for a safe, clean, and homelike environment resulting in a loud oxygen concentrator, unclean bed linens and wheelchair cushion, and holes in bed sheets, with the potential for a reasonable person to experience feelings of embarrassment, shame, and/or loss of self-esteem.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was consistently provided with showers/bathing for 3 of 4 residents (Resident #31, #36, and #41) and nail care for 1 (Resident #41) of 4 residents reviewed for activities of daily living, resulting in unmet personal hygiene needs with the potential for decreased self-esteem.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide resident centered activities designed to support leisure needs for 3 (Resident #70, Resident #60 and Resident #75) of 4 residents reviewed for activities, resulting in feelings of boredom and the potential for worsening symptoms of depression, as well as a decline in physical and cognitive well-being.
- D
Provide appropriate foot care.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment and care to maintain foot health in 1 (Resident #36) of 1 resident reviewed for foot care, resulting in delay of treatment for podiatry concerns and pain/discomfort of Resident #36's feet.
- 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 implement interventions for positioning and contractures for 2 of 2 residents (R5 and R41) reviewed for range of motion, resulting in the potential for worsening of contracture and developing skin breakdown.
- 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 provide care to prevent bowel incontinence for a continent resident in 1 (Resident #31) of 1 resident reviewed for bowel incontinence, resulting in delay of treatment for diarrhea and the potential for dehydration.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were assessed for risk of entrapment and informed consent was obtained prior to installation of bedrails for 1 (Resident #78) of 1 resident reviewed for bed rails, resulting in the risk for entrapment and injury.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered per the physician's order for 1(Resident #60) of 1 resident reviewed for significant medication errors, resulting in the potential for adverse effects of the administration of digoxin without checking the resident's pulse and/or administering the medication if below the parameter of <60 beats per minute as outlined in the physician order.
March 12, 2025Complaint inspection · 4 citations
- E
Ensure the activities program is directed by a qualified professional.
Inspectors wroteThis citation pertains to MI00149672, MI00150373, MI00150362, MI00150996 Based on interview and record review, the facility failed to employ an Activity Director who possessed the required qualifications resulting in the potential for unmet met psychosocial needs, feelings of boredom, isolation, and a lack of person-centered activities. This citation has the potential to impact any resident who relies on the activities program to support their leisure involvement.
- D
Provide activities to meet all resident's needs.
Inspectors wroteThis citation pertains to MI00149672, MI00150373, MI00150362, MI00150546 Based on observation, interview, and record review, the facility failed to provide individualized activities based on resident preferences, needs, and abilities for 4 of 4 Residents (Resident #100, Resident #101, Resident #102, and Resident#103) reviewed for activities, resulting in a potential for social isolation, decreased connectedness to the resident's environment, and decreased overall well-being.
- 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 intakes MI00150362 & MI00149672. Based on interview, and record review, the facility failed to maintain complete and accurate medical records for 1 resident (Resident #103) of 3 residents reviewed for complete and accurate medical records, resulting in the lack of proper documentation of involvement in activities programs.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to implement transmission-based precautions for 1 (Resident #104) of 3 residents reviewed for isolation precautions, resulting in the potential for the spread of infection, cross-contamination, and disease transmission for residents residing in the facility.
October 31, 2024Standard inspection, Complaint inspection · 14 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 and interview, the facility failed to: 1. Properly label/date and securely store food product once opened or prepared; 2. Discard expired food items; and 3. ensure cleanliness of food and non-food contact surfaces. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected all residents who consume food/supplement from the kitchen and from nourishment room refrigerators/freezers.
- E
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interview, and record review, the facility failed to honor mealtime preferences for 3 anonymous residents (attending a resident council meeting) and Resident #78, resulting in expressed feelings of discontent and a potential for increased loneliness.
- 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 provide timely notification of exhaustion of Medicare Part A benefits in 1 (Resident #90) of 4 residents reviewed for beneficiary notification resulting in Resident #90 being unaware of changes in regard to financial liability, and frustration.
- 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 interview and record review, the facility failed to develop comprehensive care plans for 2 (Resident #53 and Resident #90) of 20 residents reviewed for care planning resulting in the potential for unmet medical, physical, mental, and psychosocial 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 ensure residents received care in accordance with professional standards in 1 (Resident #353) of 3 residents reviewed for quality of care, resulting in Resident #353 having dysuria (pain with urination) for approximately 7 days and the potential for a decline in overall physical, mental and psychosocial well being.
- D
Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide individualized activities based on resident preferences, needs, and abilities for 1 of 2 Residents (Resident #55) reviewed for activities, resulting in a potential for social isolation, decreased connectedness to the resident's environment, and decreased overall well-being.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThis intake pertains to intake MI00146328. Based on observation, interview, and record review, the facility failed to prevent elopement for 1 (R82) of 6 residents reviewed for elopement, resulting in R82 leaving the facility alone, unbeknownst to staff, for an extended period, and was later found under a bush next to the facility resulting in potential for further successful elopements.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely and consistent weight monitoring for one resident (Resident #76) of 4 residents reviewed for nutritional status resulting in undetected weight loss, nutritional status decline and unmet nutritional needs.
- 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 provide documentation of education to the resident/representative on the intended or actual benefit versus potential risk(s) or adverse consequences associated with a psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) for 1 (Resident #35) of 5 residents reviewed for unnecessary medications, resulting in the potential for lack of awareness of medication risks versus benefits.
- 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 residents' food preferences at meals were consistently honored for 2 (Residents #27 and #78) of 18 residents reviewed for food concerns resulting in resident/representative complaints of food choices not being honored and the potential for decreased meal enjoyment, feelings of frustration, and the potential for weight loss and nutritional decline.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of infection control with resident's tube feeding equipment for one of one resident (R50) reviewed for infection control resulting in the potential for harborage and cross-contamination of pathogens in a vulnerable population.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were screened for eligibility to receive Pneumococcal vaccinations and receive vaccination if eligible for 3 (Resident #18, #35 and #48 ) of 5 residents reviewed for vaccinations, resulting in the potential of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia.
- 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 ensure COVID-19 immunization were offered to 2 (Resident #18 and #48) out of 5 residents, reviewed for COVID-19 immunizations, resulting in the higher likelihood of infection and complications from COVID-19.
- D
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, interview, and record review, the facility failed to ensure clean and sanitary room and equipment conditions for 2 (Resident #27 and #55) of 20 sampled residents reviewed for sanitary conditions resulting in: 1.) a stained and soiled privacy curtain and dusty blinds for Resident #27, and 2.) a visibly soiled wheelchair for Resident #55.
June 21, 2024Complaint inspection · 4 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteThis citation pertains to intake MI00143214 Based on interview and record review, the facility failed to report timely and accurately to the State Agency a required reportable incident of resident to resident abuse in 2 (Resident #104 and Resident #105) of 3 residents reviewed for reportable incidents resulting in the potential for additional reportable incidents go unreported and/or cause a delay in the investigative process.
- 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 safe transport of a resident in a wheelchair with foot pedals was in place in 1 (Resident #106) of 1 resident reviewed for accidents resulting in the potential for injury to the resident.
- 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) properly store medications in a secure manner in 3 of 3 treatment carts reviewed and (2) ensure that treatment carts remained secure resulting in the potential for residents, visitors, and/or staff to access the medication in the facility with a current census of 104 residents.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper hand hygiene was performed during medication administration in 3 (Resident #107, Resident #108, Resident #109) of 3 residents reviewed for hand hygiene during medication administration, resulting in the potential for the spread of infection, cross-contamination, and disease transmission for residents who receive medication while residing in the facility.
October 11, 2023Standard inspection, Complaint 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: 1. Ensure general cleaning and general repair of the kitchen; 2. Clean food and non-food contact surfaces to sight and touch; 3. Maintain an environment free from pests; 4. Properly store food product; and 5. Ensure a convenient number of hand sinks in the kitchen. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 93 residents who consume food from the kitchen.
- E
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 less than 5% (total error rate of 29.63%) in 3 of 4 sampled residents (Resident #15, Resident #70, and Resident #301) reviewed for medication administration, resulting in the potential for reduced medication efficacy, increased risk of adverse reaction and/or side effects, and administration of wrong medications.
- E
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 provide appetizing and temperature appropriate food products to 3 residents (Resident #53, #57, and #16) of 4 residents reviewed for food palatability, resulting in dissatisfaction with meals, and the potential for decreased food acceptance and nutritional decline.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the facility bed hold policy upon discharge to an acute care hospital for 2 ( Resident #1, Resident #72) residents reviewed for emergency hospital transfer resulting in the potential for unanticipated expense or the loss of desired room placement in the facility.
- 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 residents received care in accordance with physician orders in 1 of 20 residents (Resident #73) reviewed for standards of care, resulting in the delay in care and the potential for further health complications.
- 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 ensure assistance with Activities for Daily Living (ADL) care was provided for 1 (Resident #9) of 3 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for Resident #9.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on observation, interview, and record review the facility failed to adequately monitor and/or track resident's behaviors in 2 (Resident #44 and Resident #52) of 20 residents reviewed for behaviors, resulting in the potential for inadequate individualized care, insufficient behavioral data, and the inability to attain their highest practicable mental and psychosocial well-being.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteThis citation has 2 DPS Statements. DPS A Based on observation, interview, and record review, the facility failed to 1.) properly maintain infection control practices in a contact isolation room and 2.) adequately clean frequently touched surfaces, resident use equipment, and ensure general cleanliness in the facility for 3 of 25 residents (Resident #56, # 9 and #35) reviewed for infection control, resulting in the potential for the development and transmission of communicable diseases and infections to a vulnerable population.
Fire safety inspections
15 fire safety citations on file: 8 on January 8, 2026, 4 on October 31, 2024, 3 on October 11, 2023.
Every fire safety citation15 citations
- F
Provide properly protected cooking facilities.
K 324 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · January 8, 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 8, 2026 · Corrected (the home has a date of correction)
- F
Have proper medical gas storage and administration areas.
K 923 · January 8, 2026 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 8, 2026 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · October 31, 2024 · Waiver
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 31, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 31, 2024 · 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 that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · October 11, 2023 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · October 11, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 11, 2023 · Waiver