Inspection Report
Complaint Investigation
Deficiencies: 12
Aug 22, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2021 to 2025 including complaint and standard inspections with deficiency history.
Findings
Across multiple inspections, the facility had several Class 3 deficiencies primarily related to staffing standards, staff training, and records. Several complaint investigations found no deficiencies, while some standard inspections cited multiple Class 3 deficiencies.
Complaint Details
Multiple complaint investigations were conducted on 2025-08-22, 2023-09-25, 2023-02-01, 2022-12-14, 2022-09-21, and 2022-06-24 with some resulting in no deficiencies and others citing Class 3 and Unclassified deficiencies.
Severity Breakdown
Class 3: 11
Unclassified: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| A0078 — STAFFING STANDARDS - STAFF | Class 3 |
| A0081 — TRAINING - STAFF IN-SERVICE | Class 3 |
| A0082 — TRAINING - HIV/AIDS | Class 3 |
| A0086 — TRAINING - ADRD | Class 3 |
| A0090 — TRAINING - DO NOT RESUSCITATE ORDERS | Class 3 |
| A0161 — RECORDS - STAFF | Class 3 |
| A0079 — STAFFING STANDARDS - LEVELS | Class 3 |
| A0160 — RECORDS - FACILITY | Class 3 |
| A0165 — RISK MGMT & QA | Class 3 |
| CZ813 — RESULTS OF SCREENING & NOTIFICATION IN FILE | Unclassified |
| CZ814 — BACKGROUND SCREENING CLEARINGHOUSE | Unclassified |
| CZ816 — BACKGROUND SCREENING-COMPLIANCE ATTESTATION | Unclassified |
Report Facts
Inspections on page: 18
Plan of correction dates: 11
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 22, 2025
Visit Reason
State-compiled facility profile showing 11 inspections from 2021-06-15 to 2025-08-22 with deficiency history
Findings
Across multiple inspections, most complaint and standard inspections found no deficiencies, with a few inspections citing deficiencies that were later corrected.
Report Facts
Inspections on page: 11
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