Inspection Report Summary
The most recent inspection on June 30, 2025 found no deficiencies, confirming that previously cited issues related to policies and procedures were corrected. Earlier inspections showed a pattern of deficiencies involving medication management, staffing shortages, respiratory protection for staff, and fire safety code violations. Complaint investigations substantiated problems with medication administration, delayed call light responses, and failure to maintain required medical evaluations for staff respirator use, with citations issued but no fines or enforcement actions listed in the available reports. Most complaints were substantiated, including a notable case involving a resident elopement due to an unsecured exit door, though abuse or neglect was unsubstantiated. The inspection history indicates improvement over time, with follow-up inspections confirming correction of prior deficiencies.
Deficiencies (last 4 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a June 2025 inspection.
Occupancy over time
Inspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Cathy Prentice | Complaint Investigator | Conducted the complaint investigation and on-site verification |
| Jamie Singer | Field Manager | Signed the follow-up inspection letter and plan of correction |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Cathy Prentice | Complaint Investigator | Conducted the complaint investigation and onsite verification |
Inspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Erin Steinbrenner | Nursing Consultant Institutional | Department staff who did the on-site verification |
| Faith Le | NCI | Department staff who did the on-site verification and inspection |
| Jamie Singer | Field Manager | Signed multiple letters and reports related to the inspection and follow-up |
| Staff B | Certified Nursing Assistant | Failed to complete national fingerprint background check |
| Staff F | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and side rail risks |
| Staff G | Licensed Practical Nurse (LPN) | Observed administering medications and documentation issues |
| Staff J | Certified Nurse Assistant | Interviewed about bed rail use for Resident 1 |
| Staff M | Director of Culinary Services | Observed during food service and kitchen tour |
| Staff K | Dishwasher | Observed not following handwashing protocol and wearing gloves |
| Staff L | Diet Aide | Observed plating and serving food, took temperature readings |
| Staff N | Cook | Did not have valid food handler's permit on file |
| Staff O | Dishwasher | Did not have valid food handler's permit on file |
| Staff P | Director of Human Resources | Could not produce food handler's permit records for Staff N and Staff O |
| Staff Q | Administrator | Acknowledged missing staff initials on MARs as documentation errors |
| Staff H | Human Resource Specialist | Interviewed regarding fingerprint background check for Staff B |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Cathy Prentice | Complaint Investigator | Investigator who conducted the complaint investigation and provided consultation |
| Jamie Singer | Field Manager | Field Manager who signed the letter regarding the complaint investigation |
Inspection Report
Life Safety| Name | Title | Context |
|---|---|---|
| Arthur Jesse Ward | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Phillip Smith | Facility Director | Named as facility representative on the report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Cathy Prentice | Complaint Investigator | Department staff who conducted the on-site verification and investigation |
Inspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Hayley Pinkham | ALF Licensor | Investigator who conducted complaint investigation |
| Jamie Singer | Field Manager | Named in enforcement and follow-up correspondence |
| Erin Steinbrenner | Nursing Consultant Institutional | Conducted on-site verification during follow-up inspection |
Report
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