Inspection Report
Complaint Investigation
Deficiencies: 31
Feb 28, 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 2021 to 2024, the facility received numerous deficiencies primarily related to quality of care and life safety code issues, mostly at Level 2 severity with isolated or patterned scope. Enforcement actions included fines totaling $14,000 for quality of care deficiencies.
Complaint Details
Facility received 22 complaints from November 1, 2021 to October 31, 2025, with 13 complaint-related on-site inspections and 6 complaint-related citations during this period.
Severity Breakdown
Level 1: 5
Level 2: 33
Level 3: 1
Deficiencies (31)
| Description | Severity |
|---|---|
| Accounting and records of personal funds: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Activities meet interest/needs each resident: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Develop/implement comprehensive care plan: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Free from unnec psychotropic meds/prn use: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Investigate/prevent/correct alleged violation: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Reasonable accommodations needs/preferences: Standard Health Inspection Citation pertaining 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 pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Corridor - doors: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Elevators: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 1 |
| Exit signage: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Fire alarm system - testing and maintenance: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 1 |
| Gas equipment - cylinder and container storag: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Gas equipment - testing and maintenance requi: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 1 |
| Hvac: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 1 |
| Illumination of means of egress: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Sprinkler system - installation: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Sprinkler system - maintenance and testing: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Stairways and smokeproof enclosures: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Free of accident hazards/supervision/devices: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 3 |
| Quality of care: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Care plan timing and revision: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Dispose garbage and refuse properly: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Food procurement,store/prepare/serve-sanitary: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Infection prevention & control: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Physician visits-frequency/timeliness/alt npp: Standard Health Inspection Citation pertaining to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping. | Level 2 |
| Doors with self-closing devices: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Egress doors: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Electrical systems - essential electric syste: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Electrical systems - other: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Emergency lighting: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
| Hazardous areas - enclosure: Standard Life Safety Code Citation pertaining to life safety code requirements established by NFPA. | Level 2 |
Report Facts
Inspections on page: 8
Date range of inspections: January 12, 2022 to February 28, 2024
Total fines: 14000
Total complaints: 22
Total citations: 23
Loading inspection reports...
