Inspection Report
Complaint Investigation
Deficiencies: 19
Jan 7, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2022 to 2025 with complaint surveys, citations, and enforcement actions.
Findings
Across all inspections, the facility received multiple deficiencies primarily related to quality of care and life safety code issues, mostly at Level 2 severity, with one Level 3 deficiency indicating actual harm. Most deficiencies were corrected within a few months.
Complaint Details
Facility received 15 complaints from November 1, 2021 to October 31, 2025, with 39 complaint-related on-site inspections and 20 complaint-related citations during this period.
Severity Breakdown
Level 3: 1
Level 2: 18
Deficiencies (19)
| Description | Severity |
|---|---|
| Treatment/svcs to prevent/heal pressure ulcer: Standard Health Inspection Citation pertaining to quality of care. | Level 3 |
| Bowel/bladder incontinence, catheter, uti: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Infection prevention & control: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Services provided meet professional standards: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Fire alarm system - testing and maintenance: Standard Life Safety Code Citation pertaining to life safety code requirements. | Level 2 |
| Gas equipment - cylinder and container storag: Standard Life Safety Code Citation pertaining to life safety code requirements. | Level 2 |
| Subdivision of building spaces - smoke barrie: Standard Life Safety Code Citation pertaining to life safety code requirements. | Level 2 |
| Reporting - national health safety network: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Baseline care plan: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Develop/implement abuse/neglect policies: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Free of accident hazards/supervision/devices: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| License/comply w/ fed/state/locl law/prof std: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Cooking facilities: Standard Life Safety Code Citation pertaining to life safety code requirements. | Level 2 |
| Corridor - doors: Standard Life Safety Code Citation pertaining to life safety code requirements. | Level 2 |
| Egress doors: Standard Life Safety Code Citation pertaining to life safety code requirements. | Level 2 |
| Electrical systems - essential electric syste: Standard Life Safety Code Citation pertaining to life safety code requirements. | Level 2 |
| Portable fire extinguishers: Standard Life Safety Code Citation pertaining to life safety code requirements. | Level 2 |
| Free from abuse and neglect: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
| Reporting of alleged violations: Standard Health Inspection Citation pertaining to quality of care. | Level 2 |
Report Facts
Inspections on page: 13
Total citations: 47
Total complaints: 15
Complaint-related inspections: 39
Complaint-related citations: 20
Fine amount: 12000
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