Inspection Report
Complaint Investigation
Deficiencies: 17
Jul 29, 2024
Visit Reason
State-compiled facility profile showing multiple inspections from 2021 to 2024 with complaint investigations, citations, and enforcement actions.
Findings
Across all inspections, the facility received multiple citations primarily related to quality of care and life safety code deficiencies, mostly at Level 1 and Level 2 severity, with no citations involving actual harm or immediate jeopardy. All deficiencies were corrected as noted.
Complaint Details
Facility received 13 complaints from November 1, 2021 to October 31, 2025, resulting in 13 complaint-related on-site inspections and 19 complaint-related citations across categories including dietary services, physical environment, quality of care, and resident rights.
Severity Breakdown
Level 1: 4
Level 2: 13
Deficiencies (17)
| Description | Severity |
|---|---|
| Encoding/transmitting resident assessments: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 1 |
| Facility assessment: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Pharmacy srvcs/procedures/pharmacist/records: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Resident records - identifiable information: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Sprinkler system - maintenance and testing: Standard Life Safety Code Citation pertaining to life safety code requirements established by the National Fire Protection Agency (NFPA). | Level 2 |
| Bowel/bladder incontinence, catheter, uti: Standard Health Inspection Citation pertaining 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 pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Investigate/prevent/correct alleged violation: Standard Health Inspection Citation pertaining 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 pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Building construction type and height: Standard Life Safety Code Citation pertaining to life safety code requirements established by the National Fire Protection Agency (NFPA). | Level 2 |
| Hospital cah and ltc emergency power: Standard Life Safety Code Citation pertaining to life safety code requirements established by the National Fire Protection Agency (NFPA). | Level 1 |
| Means of egress - general: Standard Life Safety Code Citation pertaining to life safety code requirements established by the National Fire Protection Agency (NFPA). | Level 2 |
| Sprinkler system - installation: Standard Life Safety Code Citation pertaining to life safety code requirements established by the National Fire Protection Agency (NFPA). | Level 2 |
| Subsistence needs for staff and patients: Standard Life Safety Code Citation pertaining to life safety code requirements established by the National Fire Protection Agency (NFPA). | Level 1 |
| Reporting - national health safety network (October 17, 2022): Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Reporting - national health safety network (July 25, 2022): Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Quality of care: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
Report Facts
Inspections on page: 6
Total citations: 21
Number of complaints: 13
Complaint-related citations: 19
Complaint-related on-site inspections: 13
Fine amount: 6000
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