Inspection Report Summary
Most inspections found no deficiencies, with the facility generally maintaining compliance with safety, infection control, and medication management standards. The most recent report from October 20, 2025, was perfect with no deficiencies cited. Earlier, on October 17, 2024, a few minor technical issues were noted involving outdated physician reports, staff first aid certifications, and medication reconciliation in the memory care unit, but these were isolated and not severe. Several complaint investigations over the years were unsubstantiated, including allegations about medication errors, supervision, and resident assessments. Overall, the facility appears to have improved since those minor findings, with recent inspections showing no deficiencies.
Deficiencies per Year
4
3
2
1
0
Low
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 319
Capacity: 350
Deficiencies: 0
Oct 20, 2025
Visit Reason
The inspection was conducted as the required annual 1-year unannounced inspection of the facility.
Findings
The facility was found to be in compliance with no deficiencies cited. All safety measures, medication storage, resident and staff files, and facility conditions met licensing requirements.
Report Facts
Units in building: 264
Hot water temperature range: 105
Hot water temperature range: 120
Resident files reviewed: 5
Staff files reviewed: 5
Non-perishable food supply: 7
Perishable food supply: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the annual inspection |
| Lucy Ascalon | Director of Resident Health Services | Met with Licensing Program Analyst during inspection |
| Mark Nitsche | Executive Director/Administrator | Facility Administrator present during inspection |
| Akindele Omole | Healthcare Administrator | Met with Licensing Program Analyst during inspection |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 350
Deficiencies: 0
Dec 10, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation regarding an allegation that the facility did not provide resident records upon legal request.
Findings
The investigation found that the facility complied with the legal record request in a timely manner, providing all requested documents between 10/2/2024 and 10/8/2024. The complaint was determined to be unfounded with no deficiencies cited.
Complaint Details
Complaint alleged the facility did not provide resident records upon legal request. The allegation was found to be unfounded after investigation.
Report Facts
Facility capacity: 350
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ryan Banner | Healthcare Director | Met with Licensing Program Analyst during investigation |
| Mark Nitsche | Administrator | Facility administrator mentioned in the report |
| Andrea Medlin | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 298
Capacity: 350
Deficiencies: 3
Oct 17, 2024
Visit Reason
An unannounced annual required 1-year inspection was conducted to evaluate the facility's compliance with regulations and overall care environment.
Findings
The facility was found to be clean, well-maintained, and compliant with safety and dietary regulations. However, technical violations were issued for outdated resident physician reports, staff first aid certifications, and medication reconciliation issues in the memory care unit.
Severity Breakdown
Technical Violation: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Resident (R1) physician's report is in need of updating. | Technical Violation |
| 2 out of 5 staff reviewed are in need of updated 1st aid certification. | Technical Violation |
| Several medications in the memory care unit need reconciled start dates and input. | Technical Violation |
Report Facts
Residents reviewed: 5
Staff files reviewed: 5
Staff needing updated 1st aid certification: 2
Fire extinguisher last charged date: Jan 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Executive Director | Greeted inspectors and mentioned in findings |
| Ryan Banner | Healthcare Administrator | Greeted inspectors and mentioned in findings; holds active Administrator Certificate |
| Dominic Tobola | Licensing Program Analyst | Conducted inspection and signed report |
| Andrea Medlin | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Annual Inspection
Census: 297
Capacity: 350
Deficiencies: 0
Oct 11, 2022
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with health and safety regulations, including infection control practices and facility conditions.
Findings
No deficiencies were cited during the inspection. The facility demonstrated adequate infection control measures, proper storage of medications and supplies, and compliance with safety requirements.
Report Facts
Residents in memory care unit: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Ryan Banner | Health Services Administrator | Met with Licensing Program Analyst and provided facility tour |
| Cara Smith | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 306
Capacity: 350
Deficiencies: 0
Jul 19, 2022
Visit Reason
The visit was an unannounced walk-through/inspection of the facility's Memory Care Unit as part of Case Management - Other.
Findings
The inspection found that fire clearance was granted recently, egress doors functioned properly, water temperatures were within safe ranges, grab bars were installed, and emergency exits and corridors latched properly. No deficiencies were cited.
Report Facts
Memory Care Unit Capacity: 15
Water Temperature Range: 105.4
Water Temperature Range: 109.2
Egress Door Delay: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christina Spence | Administrator | Met with Licensing Program Analyst during the inspection and discussed the report |
| Murial Han | Licensing Program Analyst | Conducted the unannounced walk-through/inspection |
| Julio Montes | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 306
Capacity: 350
Deficiencies: 0
Jul 19, 2022
Visit Reason
The visit was a follow-up to deliver findings of an investigation initiated after a serious incident involving resident #1 who was found unresponsive with a head injury after falling from a balcony.
Findings
The investigation concluded that the incident was due to self-inflicted harm with no evidence of lack of supervision or neglect by the facility. No deficiencies were cited.
Complaint Details
The investigation was initiated following a serious incident report concerning resident #1. The incident was deemed unfounded with no substantiation of neglect or lack of supervision.
Report Facts
Capacity: 350
Census: 306
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christina Spence | Administrator | Met with during the visit and discussed report findings |
| Murial Han | Licensing Program Analyst | Conducted case management visit and follow-up investigation |
| Julio Montes | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 306
Capacity: 350
Deficiencies: 0
May 20, 2022
Visit Reason
The visit was an unannounced Case Management inspection concerning a serious incident reported by the facility that occurred on 2022-05-14 involving resident #1.
Findings
The Licensing Program Analyst met with the administrator and health services administrator, requested additional documents related to the incident, and collected staff work schedules. The incident requires further investigation.
Complaint Details
The visit was triggered by a serious incident reported by the facility on 2022-05-14 involving resident #1. Further investigation is required.
Report Facts
Census: 306
Total Capacity: 350
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christina Spence | Administrator | Met with Licensing Program Analyst during the visit |
| Ryan Banner | Health Services Administrator | Met with Licensing Program Analyst during the visit |
| Murial Han | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Julio Montes | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 306
Capacity: 350
Deficiencies: 0
May 5, 2022
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with health and safety regulations, including infection control practices and overall environment safety.
Findings
The inspection found no deficiencies. COVID-19 safety measures were observed throughout the facility, infection control practices were adequate, medications and hazardous materials were stored properly, and the environment was safe and comfortable for residents.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Banner | Health Services Administrator | Met with during inspection and discussed report findings |
| Christina Spence | Administrator | Discussed report findings |
| Murial Han | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 298
Capacity: 350
Deficiencies: 0
Jun 11, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 05/20/2021 regarding medication dispensing errors and lack of supervision resulting in resident falls.
Findings
The investigation found that the allegation of staff not dispensing medication as prescribed was unsubstantiated, as Resident 1 was initially managing medications with assistance but later required facility administration. The allegation of lack of supervision causing multiple falls was also unsubstantiated, with only one fall reported and no evidence supporting the complaint.
Complaint Details
The complaint involved allegations that facility staff were not dispensing medication as prescribed and that lack of supervision resulted in multiple resident falls. Interviews with staff and review of records found no preponderance of evidence to substantiate these allegations, resulting in an unsubstantiated determination.
Report Facts
Capacity: 350
Census: 298
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christina Spence | Executive Director | Met with Licensing Program Analyst during investigation |
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Reviewed and signed the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 298
Capacity: 350
Deficiencies: 0
Jun 11, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility was not having residents re-appraised after changes in condition or hospital readmission.
Findings
The investigation found that the complaint was unfounded as records showed documentation of Resident Functional Evaluation completed by the Registered Nurse after hospital returns. The allegation was dismissed due to lack of evidence.
Complaint Details
The complaint alleged that many residents were failing and not properly assessed after a change of condition or readmission from hospital. The complaint was found to be unfounded and dismissed.
Report Facts
Facility capacity: 350
Census: 298
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Christina Spence | Executive Director | Met with Licensing Program Analyst during the investigation |
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