Inspection Report
Complaint Investigation
Deficiencies: 17
May 29, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2014 to 2025 including complaint investigations, monitoring visits, and standard surveys with deficiency history.
Findings
Across all inspections, the facility had multiple Class 3 deficiencies primarily related to emergency plan approval, admissions health assessments, resident refund policy, medication management, staff training, and records maintenance. Several inspections reported no deficiencies.
Complaint Details
Multiple complaint investigations are included with findings primarily of Class 3 deficiencies related to emergency plans, admissions, medication, and staff training.
Severity Breakdown
Class 3: 16
Class 4: 1
Unclassified: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| A0181 — EMERGENCY PLAN APPROVAL: The plan must be submitted for review and approval to the local emergency management agency. | Class 3 |
| A0008 — ADMISSIONS - HEALTH ASSESSMENT: Each resident must have been examined by a licensed practitioner within 60 days before or 30 days after admission. | Class 3 |
| A0170 — RESIDENT REFUND POLICY: Facility shall provide a refund within 45 days after transfer, discharge, or death of resident. | Class 3 |
| A0162 — RECORDS - RESIDENT: Resident records must be maintained on premises including demographic data and emergency contacts. | Class 3 |
| CZ815 — BACKGROUND SCREENING; PROHIBITED OFFENSES: Level 2 background screening must be conducted on specified employees. | Unclassified |
| CZ841 — IN-PERSON VISITATION: Compliance with visitation requirements for various licensed facilities. | Class 3 |
| A0055 — MEDICATION - STORAGE AND DISPOSAL: Residents may keep medications in possession if stored securely. | Class 3 |
| A0056 — MEDICATION - LABELING AND ORDERS: Prescription drugs must be properly labeled and dispensed according to regulations. | Class 3 |
| A0081 — TRAINING - STAFF IN-SERVICE: New employees must attend preservice orientation before interacting with residents. | Class 3 |
| A0180 — EMERGENCY MANAGEMENT: Facility must prepare a comprehensive emergency management plan. | Class 3 |
| A0200 — EMERGENCY ENVIRONMENTAL CONTROL: Facility must prepare a detailed plan for emergency environmental control including alternate power sources. | Class 3 |
| A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN: Unlicensed persons assisting with medication must be trained and meet requirements. | Class 3 |
| A0161 — RECORDS - STAFF: Personnel records must include background screening and training documentation. | Class 3 |
| A0091 — TRAINING - DOCUMENTATION & MONITORING: Certificates of training must be documented in personnel files. | Class 3 |
| A0093 — FOOD SERVICE - DIETARY STANDARDS: Meals must be planned based on USDA Dietary Guidelines and Dietary Reference Intakes. | Class 3 |
| AN278 — LNS - RECORDS: Records of residents receiving limited nursing services and nursing assessments must be maintained. | Class 3 |
| AZ815 — BACKGROUND SCREENING; PROHIBITED OFFENSES: Level 2 background screening required for specified employees. | Class 4 |
Report Facts
Inspections on page: 30
Inspection Report
Complaint Investigation
Deficiencies: 0
May 29, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2014 to 2025 with deficiency history and inspection statuses.
Findings
Across all inspections, the facility had a mix of no deficiencies, deficiencies cited, and deficiencies corrected statuses. The most recent inspections show no deficiencies cited.
Report Facts
Inspections on page: 38
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