Inspection Report
Complaint Investigation
Deficiencies: 26
Mar 12, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2022 to 2025 with complaint investigations, certification surveys, Covid-19 survey, and deficiency history.
Findings
Across all inspections, the facility received multiple standard health and life safety citations primarily at Level 1 and Level 2 severity, with deficiencies corrected in a timely manner. No enforcement actions were recorded during the reporting period.
Complaint Details
Facility received 2 complaints during the reporting period from November 1, 2021 to October 31, 2025, with 7 complaint-related on-site inspections and 4 complaint-related citations, primarily in the Quality of Care category.
Severity Breakdown
Level 0: 1
Level 1: 4
Level 2: 22
Deficiencies (26)
| Description | Severity |
|---|---|
| Residents are free of significant med errors: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Encoding/transmitting resident assessments: Standard Health Inspection Citation pertaining to quality of care. | Level 1 |
| Food procurement,store/prepare/serve-sanitary: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Increase/prevent decrease in rom/mobility: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Nutrition/hydration status maintenance: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Posted nurse staffing information: Standard Health Inspection Citation pertaining to quality of care. | Level 1 |
| Qaa committee: Standard Health Inspection Citation pertaining to quality of care. | Level 1 |
| Resident rights/exercise of rights: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Safe/clean/comfortable/homelike environment: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Sufficient nursing staff: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Sprinkler system - installation: Standard Life Safety Code Citation pertaining to life safety code requirements. | Level 2 |
| Free from involuntary seclusion: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Accounting and records of personal funds: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Care plan timing and revision: 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 |
| Free from misappropriation/exploitation: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Infection prevention & control: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Pharmacy srvcs/procedures/pharmacist/records: 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 |
| Respiratory/tracheostomy care and suctioning: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Rn 8 hrs/7 days/wk, full time don: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Subsistence needs for staff and patients: Standard Health Inspection Citation pertaining to quality of care. | Level 1 |
| Fire drills: Standard Life Safety Code Citation pertaining to life safety code requirements. | Level 2 |
| Infection control: Standard Life Safety Code Citation pertaining to life safety code requirements. | Level 0 |
| Ramps and other exits: Standard Life Safety Code Citation pertaining to life safety code requirements. | Level 2 |
| Sprinkler system - installation: Standard Life Safety Code Citation pertaining to life safety code requirements. | Level 2 |
Report Facts
Inspections on page: 6
Total citations: 13
Complaint-related inspections: 7
Complaint-related citations: 4
Complaints received: 2
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