Inspection Report
Complaint Investigation
Deficiencies: 12
Jul 26, 2023
Visit Reason
State-compiled facility profile showing multiple inspections from 2020 to 2023 with complaint investigations, citations, and enforcement actions.
Findings
Across all inspections, the facility received multiple Level 2 deficiencies primarily related to quality of care and life safety code issues, all corrected within months. There were no citations related to actual harm or immediate jeopardy, and enforcement actions included a fine from 2020.
Complaint Details
Facility received 4 complaints from November 1, 2021 to October 31, 2025, resulting in 7 complaint-related inspections and 4 complaint-related citations across categories including dietary services, physical environment, and quality of care.
Severity Breakdown
Level 2: 11
Level 0: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Baseline care plan — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Care plan timing and revision — 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 |
| Free from misappropriation/exploitation — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Label/store drugs and biologicals — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | 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 |
| 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 |
| Investigate/prevent/correct alleged violation — 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 records - identifiable information — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Responsibilities of providers; required notif — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 0 |
Report Facts
Inspections on page: 4
Date range of inspections: From June 12, 2020 (enforcement survey) to July 26, 2023 (most recent inspection)
Total citations: 11
Total complaints: 4
Complaint-related inspections: 7
Complaint-related citations: 4
Fine amount: 6000
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