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 37 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
27D
9E
1F
Potential for minimal harm
0A
0B
0C
January 15, 2026Standard 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 best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteNumber of residents sampled: Based on observation, interview and record review, the facility failed to ensure that call lights were within reach, responded to in a timely manner, and that staff were respectful upon entering the residents' rooms and providing care for five confidential residents (#6, #35, #60, #75, #86) and a confidential group of residents.
- 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 an appropriate and timely Beneficiary Notification (NOMNC and ABN) to two (2) residents (Resident #95 and Resident #67) of 3 residents reviewed for Medicaid/Medicare Coverage/Liability Notice.
- 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 that nail care was provided, and handwashing was offered prior to dining for one resident (Resident #6), of one resident reviewed for Activities of Daily Living (ADL) care.
- 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 ensure that medications were securely stored for safe administration, for one resident (Resident #78 (R78)) of 12 residents, 1 medication storage room, and 4 wall-mounted medication storage units reviewed for medication storage, resulting in the potential for medication error or misappropriation. Resident #78 (R78):According to a review of R78's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to medical diagnoses of Chondrocostal junction syndrome (inflammatory condition affecting the cartilage where the ribs in sternum meet), subsequent fall, acute with chronic respiratory failure, Myocardial infarct (heart attack), chronic obstructive pulmonary disease (COPD) and Dementia. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP) for residents identified with qualifying wounds and percutaneous endoscopic gastrostomy tubes (PEG - delivers nutrition and medications directly into the stomach), for two residents Resident #9 and Resident #60 (R9 and R60)) of eight residents reviewed for infection prevention.
December 11, 2024Standard inspection · 10 citations
- E
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 dignity for 4 residents (Resident's #66, #73, #68, and #281) and 5 of 7 confidential Resident Council group meeting (held on 12/10/24) residents, regarding call lights within reach and the timely answering of the call lights. Findings Include: Resident #73: Review of the Face Sheet, care plans dated 10/29/24, nursing note's dated 11/24 through 12/10/24, and physician orders dated 12/24, revealed Resident #73 was 68 years-old, alert with memory deficient and confusion, and had a feeding tube; he was admitted to the facility on [DATE]. The resident was an 1 person assist with 2 persons for walker, and he has a history of falls at the facility and respiratory impairments with oxygen dependency. [...]
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the medication error rate was less than 5% when six medication errors were observed from a total of 29 opportunities for three residents (#'s 28, 34, and 288) of six residents reviewed. This deficient practice resulted in a medication error rate of 20.69% and the potential for adverse medication effects and decreased medication efficacy.
- 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 and interview, the facility failed to implement and operationalize policies and procedures to ensure appropriate labeling, storage, and disposal of medications and medical supplies, per professional standards of practice for two of two medication storage rooms in the 400 hallway and in two residents' rooms, resulting in medications left unattended and unsecured, lack of dating of medications with a shortened expiration date after opening, storage of contaminated medications and medical supplies with new medications and medical supplies.
- 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 interview and record review, the facility failed to ensure that two resident's (Resident's #28, and #55) care plans were updated and individualized, resulting in the potential for unsupervised outdoor activity, falls, and not meeting residents' needs. Findings Include: Resident #28: Review of the Face Sheet, fall report dated 1/22/24, nurse's note's dated 6/24 through 12/10/24, and care plans dated 10/23, revealed Resident #28 was [AGE] years old, alert with confusion, admitted to the facility on [DATE], had an extensive history of falls at the facility and required staff assistance with all Activities of Daily Living, and transfers. [...]
- 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 comprehensive skin care (assessments, treatment order, and documentation) for one resident (R#55) of 2 residents reviewed for skin and wound care of 41 total samples, resulting in the potential for severe pain, infection, and further delay in appropriate treatment.
- 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 implement policies and procedures to mitigate risk of injury during wheelchair transport for one resident (Resident #45) of five residents reviewed for accidents resulting in the potential for 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 wroteBased on interview and record review the facility failed to ensure that a physician's order was in place for indwelling catheter changes and that the indwelling catheter changes were documented for one resident (R69) of one resident reviewed for catheters, resulting in the absence of a physician's order for indwelling catheter changes and the absence of documentation of indwelling catheter changes.
- 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 enter a physician's order timely for dialysis perma-cath care and follow a physician's order to complete dialysis documentation for one resident (R289) of one resident reviewed for dialysis care, resulting in incomplete and missing dialysis record forms and the absence of documentation of the dialysis perma-cath site being monitored.
- D
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) Maintain food preparation and kitchen equipment in a sanitary and good working condition, and 2) Ensure proper maintenance of kitchen equipment (dishwasher), resulting in an increased likelihood for food borne illness with hospitalization, and cross contamination affecting 81 residents who consumed oral nutrition from the facility kitchen of a total census of 82 residents. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. On 12/9/24 at 10:05 a.m., during the initial tour of the kitchen accompanied by Culinary Specialist H and Executive Chief I, the following was observed: [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to implement and ensure hand hygiene per professional standards of practice during medication administration for two residents (#32 and #48) of six residents reviewed during medication pass observation resulting in the potential for cross contamination and spread of microorganisms.
October 24, 2024Complaint 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 Numbers MI00146582, MI00146860, and MI00147441. Based on observation, interview and record review, the facility failed to ensure Residents were treated with respect and dignity by not ensuring call lights were in reach and answered timely, ensure respectable customer service and ensure the provision of Resident rights with care planning that included Resident representative input/awareness of resident's care, for Residents (#1, 3, 6, 7, 8, and 10) of eight reviewed for call lights, abuse, and resident rights, resulting in care needs not met timely, lack of Resident/resident representative awareness in Resident's received care, feelings of frustration and anger and the potential for unmet care needs and lack of psychosocial wellbeing.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteThis Citation pertains to Intake Numbers MI00146860 and MI00147441. Based on interviews and record review, the facility failed to monitor and inform the physician promptly regarding the declining status post-fall for one resident (Resident #5), resulting in the delay in treatment and hospitalization for Resident #5, who sustained a brain bleed post-fall.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteThis Citation pertains to IntakeNumber MI00146582 Based on observation, interview and record review the facility failed to enter a physician's order for wound care and update a skin integrity care plan timely for one resident (Resident #7) of three residents reviewed for pressure ulcers, resulting in late physician's orders for wound care and late revision of a skin integrity care plan.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review the facility failed to store nebulizer equipment per facility policy and follow a physician's orders for oxygen administration for two residents (R3, R10) of three residents reviewed for nebulizer equipment, resulting in nebulizer equipment being stored on a bedside table and the medication chamber having fluid in it and not receiving the physician's ordered amount of oxygen administration.
- D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteThis Citation pertains to Intake Number MI00146860. Based on Interviews and record review, the facility failed to obtain Physician visit documentation of one resident (Resident #5) in a timely manner of three residents reviewed for physician visits, resulting in delayed implementation of treatment orders and the potential for inappropriate physician's orders.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to follow facility policy for EBP (enhanced barrier precautions) for one resident (R7) of one resident reviewed for EBP, resulting in the nurse performing wound care without the required PPE (personal protective equipment) for a resident on EBP.
August 22, 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 Numbers MI00143332 and MI00146115. Based on interview and record review the facility failed to document post-fall monitoring, complete neurological checks and implement appropriate interventions for two residents (Resident #701 and Resident #703) of two residents reviewed for falls, resulting in, Resident #701 sustaining a fall without facility post-fall monitoring and neurological checks and Resident #703 sustaining three falls with subsequent injuries, one day apart, without meaningful interventions implemented, consistent neurological checks and post-fall monitoring/documentation. Findings Include: Resident #701: On 8/21/2024 at approximately 2:00 PM, a review was completed of Resident #701's medical record. [...]
March 13, 2024Complaint inspection · 1 citation
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteThis Citation Pertains to Intake #'s: MI00142837, MI00142926 Based on observation, interview and record review, the facility failed to ensure communication between clinical services and social services to develop a person-centered care plan for one resident (Resident #501) of 4 residents reviewed for behavioral care, resulting in unmet care needs and a lack of individualized approaches to care with the likelihood of emotional and behavioral care needs being unassessed. Findings Include: Resident #501: A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #501 revealed the resident was admitted to the facility on [DATE] with diagnoses: history of a brain bleed, schizophrenia, GERD, visual loss, urinary retention and hypertension. [...]
December 6, 2023Standard inspection, Complaint inspection · 13 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 Numbers MI00138923 and MI00139581. Based on interview and record review, the facility failed to 1) Ensure that four residents' (Residents #6, Resident #19, Resident #56, and Resident #323) call lights were answered timely, and 2) Ensure that food was served warm for one resident (Resident #19), and 6 of 6 confidential residents from the Resident Council group meeting (held on 11/29/23) verbalizing complaints regarding staff answering their call lights, resulting in verbalizations of not wanting to eat cold food, embarrassment, accidents due to not being able to get to a toilet in time, shame and the potential of unmet care needs. Findings Include: Review of the facility Resident Rights/Dignity policy (un-dated), revealed all residents have the right to receive services in the facility with reasonable accommodation of their needs and preferences. [...]
- E
Honor the resident's right to choose his or her attending physician.
Inspectors wroteBased on interviews and record review, the facility failed to provide the residents an opportunity to choose their own attending physician and failed to honor their choice for an alternate physician for five of seven confidential residents during the Resident's Council group meeting, resulting in a lack of confidence and trust in health and medical decisions, lack of information and follow-up about their health status, feelings of intimidation and hopelessness on their rights to choose an attending physician for their best health and wellbeing.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to ensure that medication was supplied from the pharmacy or that the medication dispensing system was utilized to obtain the needed intravenous (IV) medication, Vancomycin, for one resident (Resident #221) of one resident reviewed for IV medication administration, resulting in IV medication not given as ordered, an interruption in the antibiotic treatment of an infection, with the potential for worsening of an infection and deterioration of health and well-being.
- 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 and handle medications in accordance with acceptable pharmaceutical standards of practice: 1.) for one medication room, one narcotics cupboard and 2 resident rooms (Resident #1 and Resident #41); 2.) ensure medication refrigerator temperatures outside of acceptable parameters were addressed; 3.) ensure narcotic keys for the 100 hall were secured; 4.) ensure two nurses sign that they completed a shift to shift narcotics count; [...]
- D
Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteThis Citation pertains to Intake Number MI00138923. Based on observation, interview, and record review, the facility failed to ensure that one resident's (Resident #22 [R#22]) authorized financial representative was able to make decisions regarding their choice for ancillary health insurance of one resident reviewed for rights exercised by representatives, resulting in the feeling of fear of exploitation and that the facility failed to uphold the resident's rights and ensure that the resident was protected from financial exploitation and/or misappropriation. Findings Include: Resident #22 (R#22): A record review was conducted on 11/29/23 at 4:30 PM. According to the Electronic Medical Record (EMR), R#22 was admitted to the facility on [DATE]. According to the most recent PASARR (dated 7/29/23), R#22 had the following diagnoses: [...]
- D
PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR), Level 1 and Level 2, was completed for one resident (Resident #13) of two residents reviewed, resulting in the potential for inappropriate admissions and the absence of available services for mental disorders or intellectual disability. Findings Include: Medicaid.gov: Preadmission Screening and Resident Review: Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that Medicaid-certified nursing facilities: 1. Evaluate all applicants for ser Evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID) 2. [...]
- 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 provide timely assistance with Activities of Daily Living (ADL) showers and nail care for one resident ( Resident #25) of five residents reviewed for ADL's, resulting in Resident #25 not receiving showers/baths as scheduled or nail care. The lack of care caused the resident to feel frustrated, discouraged and lowered their quality of life. Findings Include: Resident #25: Activities of Daily Living: A record review of the Face Sheet and the Minimum Data Set MDS) assessment indicated Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, congestive heart failure, Crohn's disease, COPD, Atrial fibrillation, anxiety, chronic pain, history of strokes, hypothyroidism, GERD. [...]
- 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 that wounds were assessed, monitored, wound care was provided and appropriate interventions were in place for one resident (Resident # 25) of 9 residents reviewed for wounds, resulting in Resident #25 developing a wound on the right knee and left ankle with no treatment or monitoring ordered after identification. Findings Include: Resident #25: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, congestive heart failure, Crohn's disease, COPD, Atrial fibrillation, anxiety, chronic pain, history of strokes, hypothyroidism, GERD. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status (BIMS) score of 10/15. [...]
- 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 Number MI00140875. Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and supervision was provided after a fall with injury for one resident (Resident #2) of 4 residents reviewed for falls, resulting in Resident #2 falling out of bed while reaching for the call light, hitting her head and suffering a femur fracture. Findings Include: Resident #2: Accidents: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #2 was admitted to the facility on [DATE] with diagnoses: Cerebral Palsy, Diabetes, asthma, depression, bipolar disorder, hypertension, Chronic pain syndrome, GERD, and anxiety. [...]
- 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 that the integrity of the intravenous (IV) tubing was maintained during administration of IV antibiotics, flush a Midline IV while the Midline IV was not in use and document the changing of the dressing and measurements for the Midline IV for one resident (Resident #221) of one resident reviewed for IV care, resulting in the potential for infection, malfunction of the PICC line and lack of documentation of performed procedures in the medical record.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to store nebulizer treatment equipment in a clean and sanitary manner for one resident (Resident #222) of two residents reviewed for oxygen therapy, resulting in the potential exposure to infectious organisms, respiratory infection and deterioration of health and well-being.
- 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 monitor sedating medications for one resident (Resident #41) of 5 residents reviewed for unnecessary medications, resulting in Resident #41 repeatedly requesting not to take the medications and having lethargy and falls. Findings Include: Resident #41: Unnecessary Meds, Psychotropic Meds, and Med Regimen Review A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #41 was admitted to the facility on [DATE] with diagnoses: Dementia, diabetes, heart disease, hypertension, hypothyroidism, cardiac defibrillator, anxiety history of falls with right fibula fracture prior to admission, and pain left hip. [...]
- 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 administration error rate of less than 5% when 2 medication errors were observed from a total of 28 opportunities for two residents (Resident #221 and Resident #223) of four residents observed for medication administration, resulting in an error rate of 7.14% with the potential for adverse reactions, uncontrolled pain and the change in medication regimen related to the omission of the 4% Lidocaine patch (topical medication used to help relieve pain, works as a local anesthetic and can be used for nerve pain) for Resident #223 and the medication Tramadol (medication used for moderate to severe pain) 50 mg (milligrams) not given at the appropriate time for Resident # 221.
Fire safety inspections
10 fire safety citations on file: 2 on January 15, 2026, 3 on December 11, 2024, 5 on December 6, 2023.
Every fire safety citation10 citations
- F
List the names and contact information of those in the facility.
E 30 · January 15, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · January 15, 2026 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 11, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · December 11, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · December 11, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · December 6, 2023 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · December 6, 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 · December 6, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · December 6, 2023 · Corrected (the home has a date of correction)
- D
Have restrictions on the use of highly flammable decorations.
K 753 · December 6, 2023 · Corrected (the home has a date of correction)