Inspection Report
Complaint Investigation
Capacity: 10
Deficiencies: 7
Aug 5, 2025
Visit Reason
State-compiled facility profile showing 2 inspections from 2024-09 to 2025-08 with deficiency history including complaint investigation and initial compliance review.
Findings
Across two inspections, seven deficiencies were found during the complaint and annual compliance inspection on August 5, 2025, involving modifications without approval, tuberculosis screening training gaps, incomplete service documentation, medication storage issues, unsafe storage of toxic materials, improper use of resident sleeping area as passageway, and inadequate in-service education. The initial compliance inspection in September 2024 found no deficiencies.
Complaint Details
The complaint investigation involved complaints 00138507 and 00104282 and was conducted on August 5, 2025.
Deficiencies (7)
| Description |
|---|
| R9-10-110.E. Modification of a Health Care Institution: Licensee implemented a modification of the facility without approval or amended license issued by the Department. |
| R9-10-113.A.1-2. Tuberculosis Screening: Failed to ensure documented tuberculosis infection control activities including annual training for employees. |
| R9-10-808.C.1.g. Service Plans: Failed to ensure caregiver documented services provided in residents' medical records for three of four residents reviewed. |
| R9-10-817.F.1. Medication Services: Medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. |
| R9-10-820.A.11. Environmental Standards: Poisonous or toxic materials were not maintained in locked areas inaccessible to residents. |
| R9-10-821.D.4.b.i-ii. Physical Plant Standards: Resident's sleeping area was used as a passageway to a common area or another sleeping area without required consent or exception. |
| R9-10-803.C.1.b. Administration: Failed to ensure policies and procedures covered orientation and in-service education for employees and volunteers. |
Report Facts
Inspections on page: 2
Total deficiencies: 7
Complaint inspections: 1
Total capacity: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Valean | Manager | Named as person responsible for all seven deficiencies found in the complaint and annual compliance inspection |
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