Inspection Report Summary
The most recent inspection on March 17, 2025, found no deficiencies during the Medicare recertification survey under the Life Safety Code 2012. Earlier inspections showed a mix of results, with some surveys citing deficiencies related primarily to infection control, administrator policies, emergency preparedness, and resident protection. Inspectors noted issues such as infection control program oversight, drug labeling, abuse prevention, and staff training in several reports. Complaint investigations were mostly unsubstantiated, with no fines or enforcement actions listed in the available reports. The inspection history suggests some improvement, as the latest survey was clean following prior citations.
Deficiencies per Year
8
6
4
2
0
Unclassified
Inspection Report
Capacity: 24
Deficiencies: 0
Mar 17, 2025
Visit Reason
Recertification survey for Medicare under Life Safety Code 2012 found no deficiencies.
Findings
Recertification survey for Medicare under Life Safety Code 2012 found no deficiencies.
Inspection Report
Complaint Investigation
Capacity: 24
Deficiencies: 5
Mar 13, 2025
Visit Reason
State compliance survey conducted in conjunction with multiple complaint investigations citing 5 deficiencies related to administrator policies, automated data processing, drug labeling, infection control, and infection control program oversight.
Findings
State compliance survey conducted in conjunction with multiple complaint investigations citing 5 deficiencies related to administrator policies, automated data processing, drug labeling, infection control, and infection control program oversight.
Deficiencies (5)
| Description |
|---|
| R9-10-403.C — Administrator policies and procedures for physical and behavioral health services |
| §483.20(f) — Automated data processing requirement |
| §483.45(g) — Labeling of Drugs and Biologicals |
| §483.80 — Infection Control program requirements |
| R9-10-422 — Infection control program under qualified individual |
Inspection Report
Complaint Investigation
Capacity: 24
Deficiencies: 0
Aug 20, 2024
Visit Reason
Onsite complaint survey with no deficiencies cited.
Findings
Onsite complaint survey with no deficiencies cited.
Inspection Report
Capacity: 24
Deficiencies: 2
Dec 1, 2023
Visit Reason
Recertification survey with acceptance of plan of correction; cited 2 deficiencies related to emergency preparedness training and medical gas personnel qualifications.
Findings
Recertification survey with acceptance of plan of correction; cited 2 deficiencies related to emergency preparedness training and medical gas personnel qualifications.
Deficiencies (2)
| Description |
|---|
| (1) Training program — Emergency preparedness plan staff review documentation |
| Gas Equipment — Qualifications and Training of Personnel handling medical gases |
Inspection Report
Complaint Investigation
Capacity: 24
Deficiencies: 2
Nov 29, 2023
Visit Reason
State compliance survey conducted with complaint investigations citing 2 deficiencies related to abuse prevention and resident protection.
Findings
State compliance survey conducted with complaint investigations citing 2 deficiencies related to abuse prevention and resident protection.
Deficiencies (2)
| Description |
|---|
| §483.12 — Freedom from Abuse, Neglect, and Exploitation |
| R9-10-410.B — Abuse prevention and resident protection |
Inspection Report
Capacity: 24
Deficiencies: 2
Aug 2, 2023
Visit Reason
Focused infection control survey citing 2 deficiencies related to administrator policies and infection control program.
Findings
Focused infection control survey citing 2 deficiencies related to administrator policies and infection control program.
Deficiencies (2)
| Description |
|---|
| R9-10-403.C — Administrator policies and procedures for physical and behavioral health services |
| §483.80 — Infection Control program requirements |
Inspection Report
Complaint Investigation
Capacity: 24
Deficiencies: 0
Feb 27, 2023
Visit Reason
Complaint survey with no deficiencies cited.
Findings
Complaint survey with no deficiencies cited.
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