Inspection Report
Deficiencies: 30
Apr 24, 2025
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State-compiled facility profile showing 23 inspections from 2021-08-01 to 2025-07-31 with deficiency history and enforcement actions.
Findings
Across 23 inspections, Brompton Heights had a total of 38 violations with multiple inspections resulting in no violations. Deficiencies covered a range of regulatory areas including operating certificates, resident services, environmental standards, medication management, and personnel.
Complaint Details
Multiple complaint surveys are included in the inspections, some with violations and some with none. Complaint investigations resulted in findings related to food service, resident supervision, medication management, and environmental standards.
Deficiencies (30)
| Description |
|---|
| 485.5 (g) — Operating certificates: No operator shall change or modify a facility or services without prior written approval. |
| 487.3 (g) (1-2) — General provisions: Waivers require written approval and must not adversely affect resident health and safety. |
| 487.4 (a) — Admission standards: Operator shall admit and care only for individuals within permitted service scope. |
| 487.7 (d) (1) (v) — Resident services: Surveillance of grounds, facility, and activities to protect residents. |
| 487.8 (e) (1) — Food service: Compliance with sanitation, safety, and health regulations. |
| 487.11 (f) (8) — Environmental standards: Smoke barriers must be smoketight, self-closing, maintained closed unless connected to detection systems, and open in direction of exit. |
| 487.11 (h) (11) — Environmental standards: Water temperature at faucets must be between 95°F and 110°F. |
| 487.11 (k) (1-3) — Environmental standards: Facility and equipment must be maintained clean, orderly, and in good repair. |
| 487.11 (k) (8) — Environmental standards: Ventilation and air conditioning systems maintained in good working order. |
| 487.11 (k) (13) — Environmental standards: Sprinkler systems maintained in good repair and working order. |
| 487.11 (k) (15) — Environmental standards: Annual inspection/testing of smoke detection, fire alarm, sprinkler, extinguishers, heating, elevators, and water supply systems. |
| 1001.7 (k) (5) — Admission and retention standards: Individualized Service Plan reviewed and revised every six months or as needed. |
| 1001.10 (l)(1) — Medication management: Medication acquisition, storage, disposal, and assistance must conform to standards. |
| 487.8 (e) (1) — Food service: Compliance with sanitation, safety, and health regulations. |
| 487.11 (b) (1-2) — Environmental standards: Plans for construction or renovation must be submitted and approved before implementation. |
| 487.7 (d) (11) — Resident services: Incident report required for various serious resident events. |
| 487.7 (d) (1) (i) — Resident services: Maintaining knowledge of general whereabouts of each resident. |
| 487.9 (a) (1) — Personnel: Staff sufficient in number and qualified by training and experience. |
| 1001.11 (c) (2) (i-iv) — Personnel: Resident aides must receive initial and ongoing training and annual performance assessments. |
| 487.5 (f) (3) — Resident protections: 30 days' written notice required to terminate admission agreement. |
| 487.5 (a) (3) (ix) — Resident protections: Residents may decorate rooms in compliance with fire and safety codes. |
| 1001.11 (b) — Personnel: Operator must ensure sufficient staff in number and qualifications. |
| 487.10 (e) (2) — Records and reports: Operator shall submit quarterly statistical information report. |
| 485.5 (f) — Operating certificates: No operator shall change or modify facility or services without prior written approval. |
| 487.3 (b) — General provisions: Operator shall maintain facility in compliance with regulations and statutes. |
| 487.7 (d) (1) (iv) — Resident services: Monitoring and guidance to assist residents in activities of daily living. |
| 487.7 (f) (8) — Resident services: Notify physician if resident refuses or unable to administer medications. |
| 1001.15 (f) (1) — Inspection and enforcement: Civil penalties up to $1,000 per day may be assessed. |
| 485.11 (b) — Records and reports: Operators must supply and provide access to information and records as determined by department. |
| 1001.10 (l) (4-7) — Medication management: PRN medication orders must be reviewed and limited for persons with dementia. |
Report Facts
Inspections on page: 23
Total violations: 38
No-violation inspections: 8
Enforcement actions: 1
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