The most recent inspection on May 6, 2025, identified deficiencies related to administration posting, residency agreements, service plan documentation, and medication storage. Earlier inspections showed a pattern of similar issues, including repeated deficiencies in service plan documentation, evacuation drills, and quality management reporting, which led to enforcement actions and fines totaling $2,750. Inspectors frequently cited documentation and procedural compliance as main areas of concern, with additional findings involving staff training, policy reviews, and emergency preparedness. Complaint investigations were conducted but did not result in substantiated deficiencies. The facility’s inspection history indicates ongoing challenges with administrative and documentation requirements, with no clear trend of improvement or worsening over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The enforcement resulted in a civil fine totaling $1,000 for repeated violations identified during compliance inspections on May 2, 2023, and December 16, 2024.
Fines & Penalties (1)
Amount
Reason
Status
$1,000.00
Civil fines for four repeat deficiencies: quality management reports not submitted timely, resident service plan not signed and dated, evacuation drills not conducted, and no fall prevention training documentation.
The facility was found to have repeat deficiencies from a prior compliance inspection, resulting in civil fines totaling $750.00 for failure to meet regulatory requirements in vaccination documentation, disaster plan review, and fire inspection.
Fines & Penalties (1)
Amount
Reason
Status
$750.00
Civil fines for three repeat deficiencies: failure to document vaccination notification, failure to review disaster plan annually, and lack of current fire inspection.
Nine deficiencies found related to staff training, policy reviews, reporting, service plans, medical records, food menu, disaster plan, evacuation drills, and fire inspection documentation.
Findings
Nine deficiencies found related to staff training, policy reviews, reporting, service plans, medical records, food menu, disaster plan, evacuation drills, and fire inspection documentation.
Deficiencies (9)
Description
36-420.01 — Staff training on fall prevention and recovery
Policies and procedures not reviewed every three years
Failure to submit documented reports to governing authority
Resident service plans not properly signed and dated
Medical records missing vaccination notification documentation
Food menu not including foods served each day
Disaster plan not reviewed annually
Evacuation drills not conducted semiannually
Fire inspection documentation not maintained
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