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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
5E
5F
Potential for minimal harm
0A
0B
0C
July 22, 2026Complaint inspection · 1 citation
- 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 store medications in a safe and secure manner for 4 Residents (#9, #42, #21, #8) of 18 residents reviewed and three of five treatment/medication carts reviewed for medication storage.
April 7, 2026Complaint inspection · 1 citation
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteThis deficient practice pertains to Intake 2808680. Based on interview and record review, the facility failed to obtain informed consent from the responsible party before prescribing a psychotropic drug to one Resident (#1) of three Residents reviewed for planning and implementing care.
May 8, 2025Standard inspection · 2 citations
- E
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the correct therapeutic diet was prescribed for 4 Residents (#36, #43, #321, & #325) of 10 residents reviewed for nutritional concerns. This deficient practice resulted in the potential for unmet nutritional needs and the potential for health complications.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review, the facility failed to obtain consent for an antipsychotic medication prior to initiation for one Resident #324 (R324) of five residents reviewed for antipsychotic medications. This deficient practice resulted in R324 not giving consent prior to initiation of medication.
June 11, 2024Standard inspection · 2 citations
- F
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 food in a manner that was a palatable (preferable) temperature for 15 of 27 residents interviewed. This deficient practice resulted in frustration with meals and the potential for weight loss and diminished nutrition.
- 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 76 residents.
December 5, 2023Complaint inspection · 1 citation
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteIntake: MI00141230 Based on interview and record review, the facility failed to implement abuse policies to report and investigate allegations of abuse for one Resident (R2) of three residents reviewed for abuse. This deficient practice resulted in the delay of investigation and the potential for continued abuse for facility residents.
August 24, 2023Standard inspection · 9 citations
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on observation, interview and record review, the facility failed to employ a dietary manger with the appropriate skills to carry out the food and nutrition services, as evidenced by the lack of having the proper credentials of a certified Dietary Manager (CDM) and being able to demonstrate adequate knowledge related to the operations of the kitchen. This deficient practice has the potential to create unsanitary conditions in the kitchen and result in menus which are inadequate for the dietary requirements of all 71 residents.
- 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure staff person washed their hands after being potentially contaminated. 2. Failing to ensure the high temperature dish machine was being tested for proper sanitization of food contact surfaces. 3. Failing to properly cool potentially hazardous foods after cooking and before being served. 4. Failing to properly clean the exterior rind of melons prior to cutting and serving. 5. Failing to maintain kitchen/food service equipment in a sanitary manner. 6. Failing to ensure food brought in from outside the facility, for residents, was labeled and safe for consumption. 7. [...]
- F
Provide and implement an infection prevention and control program.
Inspectors wroteB.) Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene was performed during care provided for 3 of 4 residents reviewed for infection control practices. This deficient practice resulted in the potential for the development and spread of infection, and complications associated with infections.
- 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 wroteThis citation pertains to intake MI00138612 Based on observation and interview, the facility failed to ensure a homelike environment, in 3 (R25, R16, and R45) of 18 residents reviewed for homelike environment, resulting in the potential for decreased quality of life.
- E
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, monitor, document, and provide treatment per professional standards of practice for four Residents (#8, #19, #51 and #67) out of 18 residents reviewed for quality of care. This deficient practice resulted in outcomes/potentials associated with poor diabetes care and colostomy care.
- E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to properly monitor resident refrigerators and follow protocol for 3 residents (R33, R16, and R25) of 4 residents reviewed to ensure food brought into the facility and stored in resident refrigerators was labeled and dated with an expiration date, resulting in the potential for food born illness. R33 According to the Minimum Data Set (MDS) 7/6/1023, R33 scored 15/15 (cognitively intact) on his BIMS (Brief Interview Mental Status), he was independent with his ADLs (Activities of Daily Living), with diagnoses that included dementia. During an observation an interview on 8/23/2023 at 8:10 AM, R33 had a personal refrigerator in his room. The refrigerator had food in paper bags and clear plastic bags that were not dated or labeled. [...]
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review the facility failed to perform a resident assessment for the self-administration of medication for 3 residents (R16, R57, and R51) of 18 residents reviewed for self- administration of medication, resulting in the potential for the mismanagement of medication and adverse side effects.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen services per standards of practice and per physician orders for one Resident (#52) of one resident reviewed for oxygen services. This deficient practice resulted in the potential for the development of respiratory complications, including infections.
- 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 there was consistent communication with the dialysis center for 2 of 2 residents (Resident #19 and Resident #28) reviewed for dialysis and failed to assess dialysis access sites for 1 of 2 residents (Resident #19) for dialysis care needs. This deficient practice resulted in the lack of assessment for a blood clot to develop, narrowing/stenosis to develop, and blocked access resulting in the potential for a blocked access/lifeline.
Fire safety inspections
9 fire safety citations on file: 3 on May 8, 2025, 3 on June 11, 2024, 3 on August 24, 2023.
Every fire safety citation9 citations
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · May 8, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · May 8, 2025 · Corrected (the home has a date of correction)
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · May 8, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 11, 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 · June 11, 2024 · Corrected (the home has a date of correction)
- D
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · June 11, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · August 24, 2023 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · August 24, 2023 · Corrected (the home has a date of correction)
- D
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · August 24, 2023 · Corrected (the home has a date of correction)