Deficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Deficiencies: 18
Nov 4, 2024
Visit Reason
State-compiled facility profile showing 3 inspections from 2021-08-01 to 2025-07-31 with deficiency history
Findings
Across three inspections from August 2021 through November 2024, a total of 19 violations were identified, primarily related to records and reports, medication management, environmental standards, and disaster planning. No enforcement actions were taken during this period.
Deficiencies (18)
| Description |
|---|
| 485.11 (b) — Records and reports: Operators shall supply and provide access to information and records as determined by the department. |
| 487.7 (f) (11) (iii) — Resident services: Storage of medications requires a class 3a controlled substance license as an institutional Dispenser, Limited. |
| 487.7 (f) (12) (ii) — Resident services: Recording for medications must maintain detailed resident medication information. |
| 487.10 (d) (5) — Records and reports: Facility records must include individual resident records, census reports, incident reports, and quality assurance plans. |
| 487.10 (f) — Records and reports: Mandated forms including Personal Data Sheet, Daily Census Record, Incident Report, Medical Evaluation, and Inventory of Resident Property must be used. |
| 487.11 (f) (7) — Environmental standards: Smoke barriers with at least one hour fire-resistive rating must be installed at vertical shafts or stairways. |
| 487.11 (f) (8) — Environmental standards: Smoke barriers must be smoketight, self-closing, maintained closed unless connected to smoke detection, and open in direction of exit. |
| 487.11 (f) (17) — Environmental standards: Fire extinguishers must meet NFPA standards, be accessible, wall-hung, and properly charged. |
| 487.11 (h) (8) — Environmental standards: All corridors and stairways must have handrails on both sides. |
| 487.11 (i) (4) (iii-v) — Environmental standards: Minimum bedroom equipment includes a table, lamp, and lockable storage for personal articles and medications. |
| 487.11 (i) (6) — Environmental standards: Beds with side rails or over 36 inches high shall not be used except in sick bays. |
| 487.11 (k) (1-3) — Environmental standards: Facility and equipment must be maintained clean, orderly, and in good repair and working order. |
| 487.11 (k) (8) — Environmental standards: Ventilation, air conditioning, and air changing systems must be maintained in good working order. |
| 487.12 (a-b) — Disaster and emergency planning: Written plan required for protection of residents and staff during emergencies including evacuation and fire drills. |
| 487.12 (d) — Disaster and emergency planning: Evacuation procedures must be posted conspicuously on every floor and wing. |
| 487.12 (f) — Disaster and emergency planning: Monthly fire drills for staff and volunteers must be conducted at varied times including full and partial evacuations. |
| 1001.7 (k) (2) — Admission and retention standards: Individualized Service Plan must be developed with resident, representatives, and approved staff. |
| 1001.10 (l) (3) — Medication management: Medication assistance record must include diagnoses, medications, indications, allergies, and resident identification. |
Report Facts
Inspections on page: 3
Total violations: 19
No-violation inspections: 0
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