Inspection Report Summary
The most recent inspection on May 22, 2025, identified deficiencies related to employee orientation, training, health evaluations, background checks, tuberculosis testing, and Alzheimer’s and dementia care education. Earlier reports showed similar issues with staff documentation and training requirements. Complaint investigations during this period were unsubstantiated. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The pattern of deficiencies suggests ongoing challenges with staff compliance and documentation, with no clear indication of improvement yet.
Deficiencies (last 1 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| E2 | Director of Health and Wellness | Missing initial health evaluation and background check. |
| E4 | Director of Memory Care | Missing required continuing education and training for Alzheimer's/Dementia care. |
| E5 | Care Associate Assisted Living | Missing orientation documentation, background check, and tuberculosis vaccination records. |
| E6 | Certified Nursing Assistant Assisted Living | Missing orientation documentation, background check, and tuberculosis vaccination records. |
| E7 | Care Associate Memory Care | Missing orientation documentation, initial health evaluation, background check, and tuberculosis vaccination records. |
| E8 | Certified Nursing Assistant Memory Care | Missing orientation documentation, background check, and tuberculosis vaccination records. |
| E9 | Certified Nursing Assistant Assisted Living | Missing orientation documentation and background check. |
| E11 | Business Office Manager | Unable to produce documentation for staff orientation, training, background checks, and tuberculosis vaccination records. |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Tammy DeCounter | Executive Director | Signed the Plan of Correction letter. |
| E2 | Director of Health and Wellness | Named in findings related to missing initial health evaluation and background checks. |
| E11 | Business Office Manager | Interviewed by surveyor and responsible for staff requirement log sheet and background check process. |
| E4 | Director of Memory Care | Named in findings related to incomplete dementia training documentation. |
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