Inspection Report Summary
The most recent inspection on September 17, 2025, found no deficiencies. Earlier inspections showed a pattern of deficiencies related primarily to fire and safety compliance, cleanliness and maintenance, medication orders, and resident rights, with some issues also involving employee screening and training. Complaint investigations were mostly unsubstantiated, except for a substantiated case in April 2024 where the facility denied visitation rights to a resident’s visitor and had fire drill and medication order deficiencies. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows improvement over time, with recent inspections free of cited violations.
Deficiencies (last 9 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Inspection Report
RoutineInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding fire drills, cleaning practices, medication administration, and visitation denial. | |
| AA | Visitor denied access to Resident #3; provided interview about visitation denial and police involvement. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed multiple times regarding deficiencies including TB screening, facility repairs, temperature awareness, and background checks. | |
| Staff B | Interviewed regarding lack of sanitizing items in bathroom. | |
| Staff C | Employee hired 7/25/22 with no tuberculosis screening documentation. | |
| Staff D | Employee hired 6/28/23 with no criminal background check documentation. |
Inspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Staff B | Direct care staff hired 2/12/19 without required criminal background check | |
| Staff A | Interviewed staff who did not complete the required criminal background check on Staff B |
Inspection Report
Follow-UpInspection Report
Routine| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to fire and disaster drills, training hours, physical exam documentation, and proxy caregiver training | |
| Staff D | Named in findings related to training hours and proxy caregiver training |
Inspection Report
Follow-Up| Name | Title | Context |
|---|---|---|
| Staff A | Unlicensed staff who performed specialized tasks of medication administration and had not completed medication training. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff A | Named in medication container labeling deficiency and medication competency skills checklist deficiency | |
| Staff B | Named in medication competency skills checklist deficiency | |
| Staff C | Named in medication competency skills checklist deficiency |
Inspection Report
Follow-UpInspection Report
Follow-UpInspection Report
Annual InspectionInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding Resident #1's absence and notification failures |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff A was on duty the day of the incident and reported the call bells were not working. | ||
| Resident #2 found Resident #1 on the floor and called 911. |
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