Inspection Report
Complaint Investigation
Deficiencies: 13
Mar 21, 2024
Visit Reason
State-compiled facility profile showing multiple complaint surveys and inspections from 2021 to 2024 with deficiency and enforcement history.
Findings
Across multiple complaint surveys from 2022 and 2024, the facility had several Level 1 and Level 2 deficiencies related to quality of care and life safety code issues, all corrected. Enforcement actions included a fine related to quality of care.
Complaint Details
The facility received 8 complaints from November 1, 2021 to October 31, 2025, with 7 complaint-related on-site inspections during this period and 0 complaint-related citations.
Severity Breakdown
Level 1: 2
Level 2: 11
Deficiencies (13)
| 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 |
| 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 |
| Pasarr screening for md & id — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Right to survey results/advocate agency info — 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 1 |
| Stairways and smokeproof enclosures — 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 |
| Dispose garbage and refuse properly — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Infection prevention & control — Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Personal privacy/confidentiality of records — 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 |
| Fire drills — 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 1 |
| 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 |
| Smoking regulations — 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: 5
Total citations: 13
Total complaints: 8
Complaint-related inspections: 7
Complaint-related citations: 0
Total fines: 2000
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