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 Earlier, on October 17, 2024, a few minor technical issues were noted involving outdated physician reports, staff first aid certifications, and medication reconciliation in the memory care unit, but these were isolated and not severe.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 (last 4 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a October 2025 inspection.
Census over time
Inspection Report
Annual Inspection| 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| 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| 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| 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
| 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| 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| 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| 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| 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| 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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