The most recent inspection on October 13, 2025, identified multiple deficiencies related to resident care, training, records, and reporting requirements. Earlier inspections showed a consistent pattern of deficiencies primarily involving resident care supervision, staff training, records management, and compliance with background screening and emergency procedures. Complaint investigations did not list any substantiated complaints, and enforcement actions such as fines or license suspensions were not mentioned in the available reports. Prior reports also noted issues with medication management, dietary standards, physical plant safety, and admissions procedures. The facility’s inspection history reflects ongoing challenges in these areas without a clear trend of significant improvement or worsening over time.
Deficiencies (last 8 years)
Deficiencies (over 8 years)11.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Multiple Class 3 and lower severity deficiencies related to resident care, training, records, and reporting requirements were identified during this complaint inspection.
Findings
Multiple Class 3 and lower severity deficiencies related to resident care, training, records, and reporting requirements were identified during this complaint inspection.
Severity Breakdown
Class 3: 62: 11: 1
Deficiencies (8)
Description
Severity
Tag A0025 — RESIDENT CARE - SUPERVISION
2
Tag A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES
1
Tag A0076 — DO NOT RESUSCITATE ORDERS (DNROS)
Class 3
Tag A0081 — TRAINING - STAFF IN-SERVICE
Class 3
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Class 3
Tag A0160 — RECORDS - FACILITY
Class 3
Tag ZZ821 — REPORTING REQUIREMENTS; ELECTRONIC SUBMISSION
State-compiled facility profile showing multiple inspections from 2017 to 2025 with deficiency history and inspection statuses.
Findings
The facility has undergone numerous inspections including complaint investigations, monitoring visits, and initial licensure with a mix of deficiencies cited, corrected, and some inspections with no deficiencies noted.
Multiple Class 3 deficiencies related to medication records, dietary standards, physical plant safety, records, emergency environmental control, and emergency management planning with correction dates mostly in June 2024 and one in September 2024.
Findings
Multiple Class 3 deficiencies related to medication records, dietary standards, physical plant safety, records, emergency environmental control, and emergency management planning with correction dates mostly in June 2024 and one in September 2024.
Severity Breakdown
Class 3: 7
Deficiencies (7)
Description
Severity
Tag A0054 — MEDICATION - RECORDS
Class 3
Tag A0093 — FOOD SERVICE - DIETARY STANDARDS
Class 3
Tag A0152 — PHYSICAL PLANT - SAFE LIVING ENVIRON/OTHER
Multiple Class 3 deficiencies related to medication records, emergency care, training, dietary standards, physical plant safety, records, and reporting requirements with correction dates in August 2023.
Findings
Multiple Class 3 deficiencies related to medication records, emergency care, training, dietary standards, physical plant safety, records, and reporting requirements with correction dates in August 2023.
Severity Breakdown
Class 3: 6Unclassified: 1
Deficiencies (7)
Description
Severity
Tag A0054 — MEDICATION - RECORDS
Class 3
Tag A0075 — USE OF PERSONNEL; EMERGENCY CARE (AED)
Class 3
Tag A0084 — TRAINING - ASSIS SELF-ADMIN MEDS & MED MGMT
Class 3
Tag A0093 — FOOD SERVICE - DIETARY STANDARDS
Class 3
Tag A0152 — PHYSICAL PLANT - SAFE LIVING ENVIRON/OTHER
Class 3
Tag A0160 — RECORDS - FACILITY
Class 3
Tag CZ821 — REPORTING REQUIREMENTS; ELECTRONIC SUBMISSION
Multiple Class 3 and unclassified deficiencies related to resident care supervision, training, and background screening with correction dates mostly in 2023 and 2025.
Findings
Multiple Class 3 and unclassified deficiencies related to resident care supervision, training, and background screening with correction dates mostly in 2023 and 2025.
Severity Breakdown
Class 3: 62: 1Unclassified: 1
Deficiencies (7)
Description
Severity
Tag A0025 — RESIDENT CARE - SUPERVISION
2
Tag A0081 — TRAINING - STAFF IN-SERVICE
Class 3
Tag A0082 — TRAINING - HIV/AIDS
Class 3
Tag A0083 — TRAINING - FIRST AID AND CPR
Class 3
Tag A0086 — TRAINING - ADRD
Class 3
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Class 3
Tag CZ813 — RESULTS OF SCREENING & NOTIFICATION IN FILE
Multiple Class 3 and unclassified deficiencies related to admissions, resident care supervision, elopement standards, physical restraints, staffing, training, emergency plan approval, and background screening with correction dates mostly in early 2022.
Findings
Multiple Class 3 and unclassified deficiencies related to admissions, resident care supervision, elopement standards, physical restraints, staffing, training, emergency plan approval, and background screening with correction dates mostly in early 2022.
Severity Breakdown
Class 3: 10Unclassified: 2
Deficiencies (12)
Description
Severity
Tag A0010 — ADMISSIONS - CONTINUED RESIDENCY
Class 3
Tag A0025 — RESIDENT CARE - SUPERVISION
Class 3
Tag A0032 — RESIDENT CARE - ELOPEMENT STANDARDS
Class 3
Tag A0033 — PHYSICAL RESTRAINTS
Class 3
Tag A0078 — STAFFING STANDARDS - STAFF
Class 3
Tag A0081 — TRAINING - STAFF IN-SERVICE
Class 3
Tag A0083 — TRAINING - FIRST AID AND CPR
Class 3
Tag A0086 — TRAINING - ADRD
Class 3
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Class 3
Tag A0181 — EMERGENCY PLAN APPROVAL
Class 3
Tag CZ814 — BACKGROUND SCREENING CLEARINGHOUSE
Unclassified
Tag CZ816 — BACKGROUND SCREENING-COMPLIANCE ATTESTATION
Unclassified
Inspection Report Change Of OwnershipDeficiencies: 9Oct 1, 2020
Visit Reason
Multiple Class 3 and unclassified deficiencies related to admissions, medication storage, staffing, training, dietary standards, records, and background screening with correction dates mostly in late 2020 and early 2021.
Findings
Multiple Class 3 and unclassified deficiencies related to admissions, medication storage, staffing, training, dietary standards, records, and background screening with correction dates mostly in late 2020 and early 2021.
Severity Breakdown
Class 3: 8Unclassified: 1
Deficiencies (9)
Description
Severity
Tag A0010 — ADMISSIONS - CONTINUED RESIDENCY
Class 3
Tag A0055 — MEDICATION - STORAGE AND DISPOSAL
Class 3
Tag A0078 — STAFFING STANDARDS - STAFF
Class 3
Tag A0081 — TRAINING - STAFF IN-SERVICE
Class 3
Tag A0082 — TRAINING - HIV/AIDS
Class 3
Tag A0086 — TRAINING - ADRD
Class 3
Tag A0093 — FOOD SERVICE - DIETARY STANDARDS
Class 3
Tag A0160 — RECORDS - FACILITY
Class 3
Tag CZ816 — BACKGROUND SCREENING-COMPLIANCE ATTESTATION
Multiple Class 3 and Class 4 deficiencies related to resident care supervision, medication assistance, records, staffing, training, and documentation with correction dates mostly in mid-2019.
Findings
Multiple Class 3 and Class 4 deficiencies related to resident care supervision, medication assistance, records, staffing, training, and documentation with correction dates mostly in mid-2019.
Severity Breakdown
Class 3: 8Class 4: 1
Deficiencies (9)
Description
Severity
Tag A0025 — RESIDENT CARE - SUPERVISION
Class 3
Tag A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN
Class 3
Tag A0054 — MEDICATION - RECORDS
Class 3
Tag A0056 — MEDICATION - LABELING AND ORDERS
Class 3
Tag A0078 — STAFFING STANDARDS - STAFF
Class 3
Tag A0081 — TRAINING - STAFF IN-SERVICE
Class 3
Tag A0086 — TRAINING - ADRD
Class 3
Tag A0091 — TRAINING - DOCUMENTATION & MONITORING
Class 4
Tag A0163 — RECORDS - RESIDENT, PENALTIES FOR ALTERATION
Class 3 and Class 4 deficiencies related to admissions, staffing, training, HIV/AIDS, ADRD, DNROs, documentation, and staff records with correction dates mostly in early 2018.
Findings
Class 3 and Class 4 deficiencies related to admissions, staffing, training, HIV/AIDS, ADRD, DNROs, documentation, and staff records with correction dates mostly in early 2018.
Severity Breakdown
Class 3: 8Class 4: 2
Deficiencies (10)
Description
Severity
Tag A0010 — ADMISSIONS - CONTINUED RESIDENCY
Class 3
Tag A0077 — STAFFING STANDARDS - ADMINISTRATORS
Class 3
Tag A0078 — STAFFING STANDARDS - STAFF
Class 3
Tag A0081 — TRAINING - STAFF IN-SERVICE
Class 3
Tag A0082 — TRAINING - HIV/AIDS
Class 3
Tag A0084 — TRAINING - ASSIS SELF-ADMIN MEDS & MED MGMT
Class 3
Tag A0086 — TRAINING - ADRD
Class 3
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Class 3
Tag A0091 — TRAINING - DOCUMENTATION & MONITORING
Class 4
Tag A0161 — RECORDS - STAFF
Class 4
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