Inspection Report
Complaint Investigation
Deficiencies: 31
Mar 7, 2025
Visit Reason
State-compiled facility profile showing multiple complaint surveys from 2022 to 2025 with deficiency and citation history.
Findings
Across multiple complaint surveys from 2022 to 2025, the facility received various standard health and life safety code citations, mostly Level 2 severity, indicating no actual harm but potential for minor discomfort. All deficiencies were corrected within a few months after each inspection. No enforcement actions were reported.
Complaint Details
Facility received 29 complaints from November 1, 2021 to October 31, 2025, with 13 complaint-related on-site inspections and 3 complaint-related citations during this period.
Severity Breakdown
Level 0: 1
Level 1: 1
Level 2: 30
Deficiencies (31)
| Description | Severity |
|---|---|
| Accuracy of assessments: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Baseline care plan: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Drug regimen review, report irregular, act on: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Free of medication error rts 5 prcnt or more: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Increase/prevent decrease in rom/mobility: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Label/store drugs and biologicals: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Quality of care: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Right to refuse certain transfers: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Safe/clean/comfortable/homelike environment: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Sufficient nursing staff: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Discharge from exits: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Vertical openings - enclosure: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Accuracy of assessments: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 1 |
| Care plan timing and revision: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Food procurement,store/prepare/serve-sanitary: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Free from abuse and neglect: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Pain management: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Reporting of alleged violations: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Alcohol based hand rub dispenser (abhr): Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Corridor - doors: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Corridors - construction of walls: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Electrical systems - essential electric syste: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Means of egress - general: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Physical environment: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 0 |
| Portable fire extinguishers: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Soiled linen and trash containers: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Sprinkler system - installation: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Sprinkler system - maintenance and testing: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Stairways and smokeproof enclosures: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Subdivision of building spaces - smoke compar: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Reporting of alleged violations: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
Report Facts
Inspections on page: 9
Total citations: 20
Complaints: 29
Complaint-related inspections: 13
Complaint-related citations: 3
Complaint-related citations total: 31
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