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| Deficiency Category | Inspection Date: 5/23/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 4/19/23 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 1/6/22 Complaint Reporting Period: 4/1/22 - 3/31/23 |
|---|---|---|---|
| Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
| Quality of Life and Care Deficiencies | |||
| Infection Control Deficiencies | |||
| Resident Assessment and Care Planning Deficiencies | |||
| Nursing and Physician Services Deficiencies | |||
| Resident Rights Deficiencies | |||
| Nutrition and Dietary Deficiencies | |||
| Pharmacy Service Deficiencies | |||
| Environmental Deficiencies | |||
| Administration Deficiencies |
| Date of last standard health inspection: | 5/23/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 12/27/24Read the full report (PDF) 5/23/24Read the full report (PDF) 4/17/24Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Michigan: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide safe, appropriate pain management for a resident who requires such services. | 4/17/24 | 5/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | 5/23/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 4/17/24 | 5/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 4/17/24 | 3/1/24 | 4 - Immediate jeopardy to resident health or safety | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 5/23/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 12/27/24 | 1/31/25 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 5/23/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 5/23/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 5/23/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 5/23/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | 5/23/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 5/23/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 5/23/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 5/23/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 5/23/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 4/19/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 11/20/23Read the full report (PDF) 4/19/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Michigan: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 11/20/23 | 12/19/23 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 11/20/23 | 12/19/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide safe, appropriate pain management for a resident who requires such services. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 11/20/23 | 12/19/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Few |
| No Infection Control Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Few |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
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. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Few |
Allow residents to self-administer drugs if determined clinically appropriate. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 11/20/23 | 12/19/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | 11/20/23 | 12/19/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide special eating equipment and utensils for residents who need them and appropriate assistance. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Few |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Many |
| No Pharmacy Service Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Some |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 11/20/23 | 12/19/23 | 2 - Minimal harm or potential for actual harm | Some |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 1/6/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 8/11/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Michigan: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide care and assistance to perform activities of daily living for any resident who is unable. | 1/6/22 | 2/7/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 8/11/22 | 9/8/22 | 3 - Actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 8/11/22 | 9/16/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure staff are vaccinated for COVID-19 | 6/1/22 | 6/28/22 | 3 - Actual harm | Many |
Provide and implement an infection prevention and control program. | 1/6/22 | 2/7/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 6/1/22 | 6/28/22 | 4 - Immediate jeopardy to resident health or safety | Some |
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. | 6/1/22 | 6/28/22 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Assure that each resident’s assessment is updated at least once every 3 months. | 1/6/22 | 2/7/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure services provided by the nursing facility meet professional standards of quality. | 8/11/22 | 9/8/22 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 1/6/22 | 2/7/22 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 1/6/22 | 2/7/22 | 2 - Minimal harm or potential for actual harm | Few |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Reasonably accommodate the needs and preferences of each resident. | 8/11/22 | 9/8/22 | 2 - Minimal harm or potential for actual harm | Some |
Reasonably accommodate the needs and preferences of each resident. | 6/1/22 | 6/28/22 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 1/6/22 | 2/7/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 1/6/22 | 2/7/22 | 2 - Minimal harm or potential for actual harm | Some |
| No Pharmacy Service Deficiencies were found during this inspection period. |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide safe, appropriate pain management for a resident who requires such services. | 4/17/24 | 5/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 4/17/24 | 5/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 4/17/24 | 3/1/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide and implement an infection prevention and control program. | 12/27/24 | 1/31/25 | 2 - Minimal harm or potential for actual harm | Some |
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. | 5/23/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 5/23/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 4/19/23 | 5/26/23 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 11/20/23 | 12/19/23 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 11/20/23 | 12/19/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 11/20/23 | 12/19/23 | 4 - Immediate jeopardy to resident health or safety | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 11/20/23 | 12/19/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | 11/20/23 | 12/19/23 | 2 - Minimal harm or potential for actual harm | Few |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 11/20/23 | 12/19/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 8/11/22 | 9/8/22 | 3 - Actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 8/11/22 | 9/16/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure staff are vaccinated for COVID-19 | 6/1/22 | 6/28/22 | 3 - Actual harm | Many |
Provide and implement an infection prevention and control program. | 6/1/22 | 6/28/22 | 4 - Immediate jeopardy to resident health or safety | Some |
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. | 6/1/22 | 6/28/22 | 2 - Minimal harm or potential for actual harm | Many |
Ensure services provided by the nursing facility meet professional standards of quality. | 8/11/22 | 9/8/22 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 8/11/22 | 9/8/22 | 2 - Minimal harm or potential for actual harm | Some |
Reasonably accommodate the needs and preferences of each resident. | 6/1/22 | 6/28/22 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure staff are vaccinated for COVID-19 | 6/1/22 | 6/28/22 | 3 - Actual harm | Many |
Provide and implement an infection prevention and control program. | 6/1/22 | 6/28/22 | 4 - Immediate jeopardy to resident health or safety | Some |
Reasonably accommodate the needs and preferences of each resident. | 6/1/22 | 6/28/22 | 2 - Minimal harm or potential for actual harm | Some |