Inspection Report
Complaint Investigation
Deficiencies: 18
Oct 28, 2024
Visit Reason
State-compiled facility profile showing multiple inspections from 2022 to 2024 including complaint and Covid-19 surveys with deficiency history and enforcement summary.
Findings
Across all inspections, the facility received multiple Level 2 deficiencies primarily related to reporting to the national health safety network and life safety code issues, with no actual harm or immediate jeopardy noted. Deficiencies were mostly corrected or ongoing with no enforcement actions during the reporting period.
Complaint Details
Facility received 18 complaints from November 1, 2021 to October 31, 2025, with 49 complaint-related inspections and 3 complaint-related citations during this period.
Severity Breakdown
Level 1: 1
Level 2: 30
Deficiencies (18)
| Description | Severity |
|---|---|
| Activities meet interest/needs each resident — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Sufficient nursing staff — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | 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 |
| Hazardous areas - enclosure — 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 |
| Illumination of means of egress — 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 |
| Maintenance, inspection & testing - doors — 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 |
| Means of egress - general — 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 |
| Physical environment — 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 |
| Subdivision of building spaces - smoke compar — 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 |
| Reporting - national health safety network — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Accuracy of assessments — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 1 |
| Increase/prevent decrease in rom/mobility — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | 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 |
| Treatment/service for dementia — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Fire alarm system - installation — 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 |
| Physical environment — 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 |
| Subdivision of building spaces - smoke barrie — 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 |
Report Facts
Inspections on page: 42
Total citations: 54
Number of complaints: 18
Complaint-related inspections: 49
Complaint-related citations: 29
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