Inspection Report
Complaint Investigation
Deficiencies: 18
Dec 16, 2024
Visit Reason
State-compiled facility profile showing multiple complaint surveys and inspections from 2021 to 2024 with deficiency and enforcement history.
Findings
The facility underwent multiple complaint surveys resulting in various standard health and life safety code citations, mostly Level 2 severity, with one Level 3 citation indicating actual harm. Deficiencies were corrected in a timely manner, and enforcement actions with fines were recorded.
Complaint Details
The facility received 2 complaints during the reporting period from November 1, 2021 to October 31, 2025, with 6 complaint-related on-site inspections and 3 complaint-related citations.
Severity Breakdown
Level 0: 1
Level 2: 15
Level 3: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Free of accident hazards/supervision/devices: Standard Health Inspection Citation pertaining to quality of care. | Level 3 |
| Accounting and records of personal funds: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Department criminal history review: Standard Health Inspection Citation pertaining to quality of care. | Level 0 |
| Pain management: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Reporting of alleged violations: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Surety bond-security of personal funds: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Electrical equipment - power cords and extens: Standard Life Safety Code Citation pertaining to life safety requirements. | Level 2 |
| Vertical openings - enclosure: Standard Life Safety Code Citation pertaining to life safety requirements. | Level 2 |
| Baseline care plan: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Bedrails: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Develop/implement comprehensive care plan: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Food procurement,store/prepare/serve-sanitary: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Physician visits - review care/notes/order: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Building construction type and height: Standard Life Safety Code Citation pertaining to life safety requirements. | Level 2 |
| Exit signage: Standard Life Safety Code Citation pertaining to life safety requirements. | Level 2 |
| Hazardous areas - enclosure: Standard Life Safety Code Citation pertaining to life safety requirements. | Level 2 |
| Sprinkler system - maintenance and testing: Standard Life Safety Code Citation pertaining to life safety requirements. | Level 2 |
| Free of accident hazards/supervision/devices: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
Report Facts
Inspections on page: 6
Date range of inspections: From August 9, 2022 to December 16, 2024
Total citations: 15
Total complaints: 2
Complaint-related inspections: 6
Complaint-related citations: 3
Total fines: 28000
Enforcement actions: 2
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