Inspection Report Summary
Most inspections found no deficiencies, with many complaint investigations unsubstantiated or unfounded, indicating generally adequate care and compliance. However, the facility has had some serious issues, including substantiated complaints related to timely medical response and supervision that resulted in multiple serious resident injuries and one death, leading to a $500 civil penalty assessed on April 8, 2025. Earlier substantiated findings from November 2021 involved insufficient staffing and failure to report changes in residents’ conditions, posing immediate health and safety risks. The most recent report from June 10, 2025, did not issue new citations but noted ongoing compliance issues and an open complaint with an outstanding appeal. Overall, the facility shows some improvement since the serious deficiencies in early 2025, but past issues remain a concern.
Deficiencies (last 5 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a June 2025 inspection.
Census over time
Inspection Report
| Name | Title | Context |
|---|---|---|
| Landon Pilegaard | Administrator | Facility administrator present at non-compliance conference |
| Erik Pilegaard | Licensee | Licensee present at non-compliance conference |
| Terry Howard | Managing Director | Managing Director present at non-compliance conference |
| Laura Munoz | Licensing Program Manager | Licensing Program Manager present and named in report |
| Troy Ordonez | Licensing Program Manager | Licensing Program Manager present at non-compliance conference |
| Talwinder Bains | Licensing Program Analyst | Licensing Program Analyst present at non-compliance conference |
| Lavinia Muscan | Licensing Program Analyst | Licensing Program Analyst present at non-compliance conference and contact for submission of compliance plan |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Landon Pilegaard | Administrator | Met with during the investigation and mentioned in findings |
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Named in report signature and oversight |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Landon Pilegaard | Administrator | Met with during complaint investigation and exit interview |
| Dej’ja Bracy | Memory Care Director | Provided statements regarding fall risk assessments and fall prevention plans |
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Oversaw complaint investigation and signed report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Oversaw the complaint investigation |
| Landon Pilegaard | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Landon Pilegaard | Administrator | Met with Licensing Program Analyst during investigation |
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Landon Pilegaard | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Jennifer Hinch | Assisted Living Director | Met with during inspection and toured facility |
| Lavinia Muscan | Licensing Program Analyst | Conducted the annual inspection |
| Talwinder Bains | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Landon Pilegaard | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Laura Munoz | Licensing Program Manager | Named in report header as Licensing Program Manager |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Oversaw the complaint investigation |
| Landon Pilegaard | Administrator | Facility administrator met during investigation and exit interview |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the unannounced case management visit and confirmed immediate exclusion orders. |
| Jennifer Hinch | Assisted Living Director | Met with Licensing Program Analyst during the visit and acknowledged the purpose of the visit. |
| Landon Pilegaard | Administrator | Named as facility administrator. |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Landon Pilegaard | Administrator | Met with Licensing Program Analyst during inspection and toured facility |
| Lavinia Muscan | Licensing Program Analyst | Conducted the annual inspection |
| Laura Munoz | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Landon Pilegaard | Administrator | Met with during investigation and exit interview |
| Talwinder Bains | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Landon Pilegaard | Administrator | Met with Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Landon Pilegaard | Administrator | Met with Licensing Program Analyst during investigation |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Lavinia Muscan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
| Erik Olson | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Erik Olson | Executive Director | Met with Licensing Program Analyst during the inspection and agreed to send in LIC500 and liability insurance |
| Lavinia Muscan | Licensing Program Analyst | Conducted the annual infection control inspection |
| Laura Munoz | Licensing Program Manager | Named in the report header |
Inspection Report
| Name | Title | Context |
|---|---|---|
| Eric Olson | Executive Director | Met during the visit and confirmed understanding of the immediate exclusion notice and termination of S1. |
Inspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Gregory Kanser | Administrator | Met with Licensing Program Analysts during the inspection and involved in the incident investigation |
| Erick Olson | Executive Director | Met with Licensing Program Analysts during the inspection and involved in the incident investigation |
| Talwinder Bains | Licensing Program Analyst | Conducted the inspection and signed the report |
| Laura Munoz | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Michael Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Greg Kasner | Administrator | Facility administrator met during the investigation |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Michael Smith | Licensing Program Analyst | Performed the infection control domain inspection. |
| Wendy Middleton | Contact person during the inspection. | |
| Laura Munoz | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Michael Smith | Evaluator | Conducted the complaint investigation visit |
| Greg Kasner | Facility Administrator | Met with investigator and provided information about document provision |
| Laura Munoz | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Michael Smith | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Laura Munoz | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Gregory Kasner | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Michael Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Greg Kasner | Administrator | Met with the investigator during the visit |
| Laura Munoz | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Michael Smith | Evaluator / Licensing Program Analyst | Conducted the complaint investigation |
| Gregory Kasner | Administrator | Facility administrator met during the investigation |
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