Deficiencies per Year
20
15
10
5
0
Severe
High
Low
Inspection Report
Complaint Investigation
Deficiencies: 20
Jan 10, 2024
Visit Reason
State-compiled facility profile showing multiple complaint surveys and inspections from 2021 to 2024 with deficiency and citation history.
Findings
Across multiple complaint surveys from 2021 and 2024, the facility received several standard health and life safety code citations, mostly Level 2 severity, with no actual harm or immediate jeopardy reported. All deficiencies were corrected as of early 2024 or 2022 depending on the inspection.
Complaint Details
The facility received 12 complaints from November 1, 2021 to October 31, 2025, with 6 complaint-related on-site inspections and 3 complaint-related citations during this period. Complaint-related deficiencies include 3 in dietary services, 3 in physical environment, 10 in quality of care, and 6 in resident rights.
Severity Breakdown
Level 0: 1
Level 1: 1
Level 2: 17
Deficiencies (20)
| Description | Severity |
|---|---|
| Accuracy of assessments — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Hospice services — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Menus meet resident nds/prep in adv/followed — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Posted nurse staffing information — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 1 |
| Reasonable accommodations needs/preferences — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Requirements before submitting a request for — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 0 |
| Right to participate in planning care — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Corridor - doors — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Corridors - construction of walls — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Discharge from exits — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Electrical systems - essential electric syste — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Hvac — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Portable fire extinguishers — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Sprinkler system - installation — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Sprinkler system - maintenance and testing — Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic. | Level 2 |
| Bedrooms assure full visual privacy — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Develop/implement comprehensive care plan — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Reporting of alleged violations — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Resident rights/exercise of rights — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Treatment/svcs to prevent/heal pressure ulcer — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
Report Facts
Inspections on page: 3
Total citations: 12
Number of complaints: 12
Complaint-related on-site inspections: 6
Complaint-related citations: 3
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