The most recent inspection on November 18, 2025, identified deficiencies related to tuberculosis infection control, medical record documentation, and storage of poisonous materials, resulting in a $1,000 civil fine. Earlier inspections showed a pattern of similar issues, including tuberculosis screening, medical records, environmental safety, treatment plans, and staff training, with a prior enforcement fine of $2,500 paid in full. Inspectors frequently cited deficiencies involving tuberculosis control measures and documentation of behavioral health services, along with environmental and safety standards. There were no complaint investigations reported in the available records. The facility’s deficiencies have persisted over time with repeated enforcement actions, indicating ongoing challenges in meeting regulatory requirements.
Deficiencies (last 3 years)
Deficiencies (over 3 years)6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The violations were repeated but caused no actual physical or psychosocial harm, with potential for minimal or more than minimal harm. A total civil fine of $1,000 was assessed.
Fines & Penalties (4)
Amount
Reason
Status
$250.00
Failure to implement tuberculosis infection control activities including baseline screening and assessing risks of prior exposure to infectious TB.
—
$250.00
Failure to ensure a resident provided evidence of freedom from infectious tuberculosis within seven calendar days after admission.
—
$250.00
Failure to ensure a resident's medical record contained documentation of behavioral health services provided.
—
$250.00
Failure to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents.
Ten deficiencies found related to tuberculosis screening, medical records, environmental safety, contracted services, treatment plans, behavioral health documentation, and emergency safety standards.
Findings
Ten deficiencies found related to tuberculosis screening, medical records, environmental safety, contracted services, treatment plans, behavioral health documentation, and emergency safety standards.
Eighteen deficiencies found including failures in staff training, personnel records, medical examinations, treatment plans, food safety, and environmental safety.
Findings
Eighteen deficiencies found including failures in staff training, personnel records, medical examinations, treatment plans, food safety, and environmental safety.
Deficiencies (8)
Description
36-420.01. Health care institutions; fall prevention and fall recovery; training programs
M. Administrator shall ensure inspection reports are posted and available
G. Personnel records maintenance
K. Daily staffing schedule requirements
A. Medical history and physical examination requirements
