The most recent inspection on May 29, 2025, included enforcement action resulting in a $2,000 fine that has been paid in full. Earlier inspections showed repeated deficiencies related to personnel documentation, medication administration records, environmental safety, and emergency preparedness, with fines imposed in April 2025 and April 2023. Inspectors cited issues such as incomplete caregiver training records, unsafe facility egress, missing medication documentation, and environmental hazards. Complaint investigations found multiple deficiencies but did not list any substantiated complaints. The pattern of citations and enforcement actions indicates ongoing challenges with documentation and safety compliance over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The facility was found to have multiple health and safety violations, including repeat deficiencies from a prior inspection, resulting in civil fines totaling $2000.
Fines & Penalties (1)
Amount
Reason
Status
$2,000.00
Civil fines for multiple health and safety violations including personnel documentation, facility safety, and medication administration.
Nine deficiencies found related to personnel documentation, service plans, medical records, emergency standards, medication documentation, environmental safety, and emergency responder information during complaint investigation.
Findings
Nine deficiencies found related to personnel documentation, service plans, medical records, emergency standards, medication documentation, environmental safety, and emergency responder information during complaint investigation.
Complaint Details
Investigation of complaints 00105395 and 00108238
Deficiencies (9)
Description
R9-10-806.A.10. — Personnel documentation incomplete or missing
R9-10-806.C.1.a-c. — Personnel records incomplete
R9-10-808.C.1.a-g. — Service plans not properly documented
R9-10-811.A.5. — Medical records not protected from loss or damage
R9-10-815.F.2.a-c. — Directed care services exit alarms missing
Twelve deficiencies found related to policies and procedures, documentation timeliness, personnel records, service plans, restraint use, medical record completeness, medication documentation, disaster drills, and environmental safety.
Findings
Twelve deficiencies found related to policies and procedures, documentation timeliness, personnel records, service plans, restraint use, medical record completeness, medication documentation, disaster drills, and environmental safety.
Deficiencies (11)
Description
C. A manager shall ensure that policies and procedures are established and implemented
E. A manager shall ensure documentation required by Article 8 is timely provided
C. A manager shall ensure personnel records include required documentation
B. A manager shall ensure acceptance documentation is timely submitted
A. A manager shall ensure resident service plans are reviewed and updated
B. A manager shall ensure residents are not subjected to restraint
C. A manager shall ensure medical records contain documentation of freedom from infectious diseases
C. A manager shall ensure medical records contain documentation of assisted living services
B. A manager shall ensure medication administration is properly documented
A. A manager shall ensure disaster drills are conducted and documented
A. A manager shall ensure premises and equipment are free from hazards
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