Inspection Report
Complaint Investigation
Deficiencies: 19
Mar 20, 2025
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State-compiled facility profile showing multiple inspections from 2020 to 2025 with deficiency history and enforcement details.
Findings
Across all inspections, the facility had multiple Class 3 deficiencies primarily related to staffing, training, medication management, records, and emergency planning. Several complaint investigations found no deficiencies, while others cited Class 3 violations with corrective actions noted.
Complaint Details
Multiple complaint investigations are included, some with no deficiencies found and others citing Class 3 deficiencies related to medication, records, emergency planning, and staff training.
Severity Breakdown
Class 3: 18
2: 1
Deficiencies (19)
| Description | Severity |
|---|---|
| A0078 — STAFFING STANDARDS - STAFF | Class 3 |
| A0081 — TRAINING - STAFF IN-SERVICE | Class 3 |
| A0082 — TRAINING - HIV/AIDS | Class 3 |
| A0090 — TRAINING - DO NOT RESUSCITATE ORDERS | Class 3 |
| A0161 — RECORDS - STAFF | Class 3 |
| A0181 — EMERGENCY PLAN APPROVAL | Class 3 |
| A0200 — EMERGENCY ENVIRONMENTAL CONTROL | Class 3 |
| A0055 — MEDICATION - STORAGE AND DISPOSAL | Class 3 |
| A0081 — TRAINING - STAFF IN-SERVICE | Class 3 |
| A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN | Class 3 |
| A0054 — MEDICATION - RECORDS | Class 3 |
| A0056 — MEDICATION - LABELING AND ORDERS | Class 3 |
| A0160 — RECORDS - FACILITY | Class 3 |
| A0083 — TRAINING - FIRST AID AND CPR | Class 3 |
| A0162 — RECORDS - RESIDENT | Class 3 |
| A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES | 2 |
| A0162 — RECORDS - RESIDENT | Class 3 |
| AN277 — LNS - RESIDENT CARE STANDARDS | Class 3 |
| A0081 — TRAINING - STAFF IN-SERVICE | Class 3 |
Report Facts
Inspections on page: 21
Inspection Report
Complaint Investigation
Deficiencies: 23
Mar 20, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2020 to 2025 with deficiency history and inspection statuses.
Findings
The facility underwent numerous inspections including complaint investigations, monitoring, and expansions with a mix of deficiency citations, corrections, and some inspections reporting no deficiencies.
Deficiencies (23)
| Description |
|---|
| Initial Licensure — No Deficiencies |
| Complaint — Deficiencies Cited |
| Monitor — Deficiencies Cited |
| Follow-up — Deficiencies Corrected |
| Complaint — Deficiencies Corrected |
| Complaint — Deficiencies Cited |
| Complaint — Deficiencies Corrected |
| Complaint — No Deficiencies |
| Expansion — Deficiencies Cited |
| Complaint — Deficiencies Cited |
| Expansion — Deficiencies Cited |
| Expansion — Deficiencies Corrected |
| Complaint — Deficiencies Corrected |
| Standard — Deficiencies Cited |
| Standard — Deficiencies Corrected |
| Complaint — Deficiencies Cited |
| Complaint — Deficiencies Corrected |
| Complaint — No Deficiencies |
| Standard — Deficiencies Cited |
| Standard — Deficiencies Cited |
| Standard — Deficiencies Corrected |
| Complaint — No Deficiencies |
| Complaint — No Deficiencies |
Report Facts
Inspections on page: 23
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