Inspection Report Summary
The most recent inspection on June 5, 2025, was a complaint investigation that found no rule violations. Earlier inspections included a February 11, 2025 complaint investigation where inspectors cited multiple deficiencies related to resident safety, staff training, background checks, and timely reporting following a fatal physical abuse incident by an agency caregiver. The facility failed to ensure residents were free from abuse, maintain sufficient specially trained staff in the memory care unit, and report the serious injury promptly. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The inspection history shows a significant issue earlier in the year, but the most recent visit did not identify ongoing deficiencies.
Deficiencies (last 1 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
| Description | Severity |
|---|---|
| Failure to implement policies and procedures supporting resident dignity, respect, and safety, including protection from harm by non-employees. | J |
| Failure to obtain criminal background checks for direct access employees. | J |
| Failure to staff memory care unit with sufficient specially trained staff to meet residents' unique needs. | J |
| Failure to provide required dementia-specific orientation and training to staff assigned to memory care unit. | J |
| Failure to ensure residents are free from physical abuse; agency caregiver physically assaulted Resident #1 causing fatal injury. | J |
| Failure to report serious injury incident involving Resident #1 to the Department within 24 hours. | D |
| Name | Title | Context |
|---|---|---|
| AS | Agency Direct Caregiver | Named in physical abuse incident involving Resident #1 |
| Staff A | Executive Director | Notified of Resident #1's death and reviewed video footage; responsible for oversight |
| Staff C | Med Tech | Witnessed aftermath of assault; lacked proper training |
| Staff D | Staff Member | Third shift staff who responded to incident; did not witness assault |
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