Inspection Report
Complaint Investigation
Deficiencies: 17
Feb 18, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2012 to 2025 with deficiency history and enforcement data.
Findings
Across all inspections, the facility had multiple Class 3 deficiencies primarily related to medication management, resident care, staffing standards, and admissions criteria. Several complaint investigations found no deficiencies, while some inspections identified no deficiencies at all.
Complaint Details
Multiple complaint investigations were conducted, some resulting in no deficiencies, while others identified Class 3 and Class 4 deficiencies related to resident care, medication management, staffing, and background screening.
Severity Breakdown
Class 3: 15
Class 4: 1
2: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| A0025 — RESIDENT CARE - SUPERVISION: The facility failed to notify a licensed physician timely regarding residents exhibiting signs of dementia or cognitive impairment. | Class 3 |
| A0054 — MEDICATION - RECORDS: The facility failed to maintain proper medication records including prescription details and daily medication observation records. | Class 3 |
| A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN: The facility failed to properly assist residents with self-administration of medication as required. | Class 3 |
| A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES: The facility failed to post Resident Bill of Rights and maintain grievance procedures as required. | Class 3 |
| A0055 — MEDICATION - STORAGE AND DISPOSAL: The facility failed to ensure proper storage and disposal of medications. | Class 3 |
| A0010 — ADMISSIONS - CONTINUED RESIDENCY: The facility failed to properly determine continued residency appropriateness based on assessments and medical examinations. | Class 3 |
| A0053 — MEDICATION - ADMINISTRATION: The facility failed to ensure medications were administered by licensed staff according to orders and document unusual reactions. | Class 3 |
| A0152 — PHYSICAL PLANT - SAFE LIVING ENVIRON/OTHER: The facility failed to maintain a safe living environment free of hazards and ensure systems were in good working order. | Class 3 |
| CZ815 — BACKGROUND SCREENING; PROHIBITED OFFENSES: The facility failed to conduct required Level 2 background screenings for employees. | Class 4 |
| A0078 — STAFFING STANDARDS - STAFF: The facility failed to ensure newly hired staff submitted required health statements and met staffing standards. | Class 3 |
| A0007 — ADMISSIONS - CRITERIA: The facility failed to meet minimum admission criteria for residents including age and communicable disease status. | Class 3 |
| A0057 — MEDICATION - OVER THE COUNTER (OTC) PRODUCTS: The facility failed to properly label and manage OTC medications. | Class 3 |
| A0093 — FOOD SERVICE - DIETARY STANDARDS: The facility failed to plan meals based on current USDA Dietary Guidelines and Dietary Reference Intakes. | Class 3 |
| A0081 — TRAINING - STAFF IN-SERVICE: The facility failed to provide required in-service training to staff including infection control and sanitation procedures. | Class 3 |
| A0086 — TRAINING - ADRD: The facility failed to ensure staff received required Alzheimer’s Disease and Related Disorders training. | Class 3 |
| A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES: The facility failed to maintain resident rights and grievance procedures as required. | Class 3 |
| A0083 — TRAINING - FIRST AID AND CPR: The facility failed to ensure a staff member with valid First Aid and CPR certification was present at all times. | 2 |
Report Facts
Inspections on page: 38
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 18, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2012 to 2025 with deficiency history and inspection statuses.
Findings
Across all inspections, the facility had a mix of deficiency outcomes including cited deficiencies, corrected deficiencies, and many inspections with no deficiencies noted. Deficiencies were cited in both complaint and standard inspections over the years, with recent inspections showing no deficiencies.
Report Facts
Inspections on page: 52
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