Most inspections found no deficiencies, showing the facility generally maintained compliance with regulations and infection control protocols. The most recent report from July 15, 2025, cited two deficiencies related to rodent droppings in the kitchen area and a staff member training without fingerprint clearance, which posed a health and safety risk. Earlier reports noted minor issues such as outdated resident medical assessments and incomplete staff training documentation, but no fines or enforcement actions were listed in the available reports. Several complaint investigations were not part of these inspections, and no substantiated complaints were noted. The record shows mostly stable compliance with some recent concerns about environment and staff clearance that should be addressed.
The visit was an unannounced required annual inspection to evaluate compliance with licensing requirements at the facility.
Findings
The facility was generally clean and well maintained with proper food storage and safety measures. However, rodent droppings and traps were found in the kitchen area, and a staff member was found to be training without fingerprint clearance, both resulting in cited deficiencies.
Severity Breakdown
Type A: 1Type B: 1
Deficiencies (2)
Description
Severity
Rodent droppings found in kitchen hand towel drawer and under the kitchen sink; rodent traps found in drawer above hand towel drawer.
Type B
Staff member (S1) training at the facility without fingerprint clearance, posing an immediate health, safety or personal rights risk.
Type A
Report Facts
Census: 5Total Capacity: 6Deficiencies cited: 2Plan of Correction Due Date: Jul 16, 2025Plan of Correction Due Date: Jul 29, 2025
Employees Mentioned
Name
Title
Context
Lisa Melo
Administrator
Administrator involved in inspection and cited in fingerprint clearance deficiency
The inspection was an unannounced annual required inspection conducted to evaluate compliance with licensing regulations.
Findings
The facility was found to be in compliance with regulations including proper temperature, unobstructed passageways, updated resident care plans, and current staff certifications. One staff member did not have all required training documentation available during the visit, resulting in a technical advisory. No deficiencies were issued.
Report Facts
Staff files reviewed: 3Resident files reviewed: 4Fire extinguisher last serviced: Dec 18, 2023Last disaster drill date: May 29, 2024
Employees Mentioned
Name
Title
Context
Lisa Melo
Licensee
Met with Licensing Program Analyst during inspection and named in training documentation finding
The inspection was an unannounced annual required inspection conducted by the Licensing Program Analyst to evaluate compliance with regulations.
Findings
The facility was generally compliant with regulations regarding environment, safety, and staff training; however, two out of five resident files lacked current medical assessments and care plans were not signed by responsible parties within the last 12 months, resulting in cited deficiencies.
Deficiencies (1)
Description
Two out of five resident medical assessments were not updated within the last 12 months as required.
Report Facts
Residents reviewed: 5Staff files reviewed: 3Deficiencies cited: 1Plan of Correction Due Date: Sep 15, 2023
Employees Mentioned
Name
Title
Context
Lisa Melo
Licensee
Met with Licensing Program Analyst during inspection and named in findings regarding medical assessments
The inspection was an unannounced annual required inspection conducted to evaluate compliance with licensing regulations and infection control protocols.
Findings
No deficiencies were cited during this inspection. The facility demonstrated compliance with COVID-19 mitigation measures, including PPE use, vaccination rates, and infection control plans.
The visit was an unannounced Case Management visit conducted to review the facility's status and compliance, including review of specific PINs and observation of ongoing construction.
Findings
The facility was observed to have an ongoing deck remodel with safety precautions in place to protect residents. Four residents' physician reports confirmed no diagnosis of dementia. No deficiencies were cited during the inspection.
Employees Mentioned
Name
Title
Context
Lisa Melo
Licensee
Met with Licensing Program Analyst during the visit and discussed safety precautions.
The inspection was an unannounced annual required inspection focused on infection control procedures and practices at the facility.
Findings
The facility maintained appropriate infection control measures including PPE supplies, vaccination rates, and Covid-19 mitigation plans. No deficiencies were cited during the inspection.