Inspection Report Summary
The most recent inspection on June 18, 2025, found no deficiencies. Earlier inspections showed a pattern of deficiencies related mainly to staffing issues, including inadequate nurse presence in the memory care unit and insufficient trained caregiver coverage, as well as failures in incident reporting and infection control practices. Complaint investigations mostly resulted in unsubstantiated findings, except for a citation regarding failure to report a serious incident within 24 hours and some staffing and supervision concerns. Enforcement actions such as fines or license suspensions were not listed in the available reports. The trend suggests improvement over time, with the most recent inspections showing no deficiencies after a period of multiple citations.
Deficiencies (last 5 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Inspection Report
Original LicensingInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint InvestigationInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff D | Certified Medication Aide (CMA) | Interviewed and observed working on 1st floor Assisted Living Unit and going back and forth between AL and Memory Care unit. |
| Staff E | Licensed Practical Nurse (LPN) | Interviewed and stated helping to cover 1st floor Assisted Living Unit and noted Staff C was not a CMA or licensed caregiver. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding staffing, care plans, memory care certificate, and pharmacist reviews | |
| Staff C | Caregiver on first floor and certified medication aide without quarterly pharmacist review | |
| Staff D | Assigned to second floor but was on lunch break during inspection | |
| Staff F | Certified medication aide without quarterly pharmacist review | |
| Staff G | Scheduled to work in ALF 7:00 a.m. to 3:00 p.m. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Staff C | Observed Resident #1 outside the neighboring library and provided interview details about the elopement | |
| Staff F | Held the door open allowing Resident #1 to exit the memory care unit; was new and unaware of the incident | |
| Staff D | Observed not wearing a mask while providing care to residents, violating infection control policies | |
| Staff I | Reviewed security camera footage of the elopement incident | |
| Staff B | Provided information about Staff F and the elopement incident | |
| Staff A | Provided interview regarding video footage and facility mask policy | |
| Staff G | On-duty staff at the memory care unit during the elopement incident |
Inspection Report
Complaint InvestigationInspection Report
Original LicensingLoading inspection reports...



