Inspection Report
Complaint Investigation
Deficiencies: 14
Jun 23, 2025
Visit Reason
State-compiled facility profile showing 13 inspections from August 1, 2021 through July 31, 2025 with deficiency history and enforcement actions.
Findings
Across 13 inspections, the facility had 17 total violations with 9 inspections resulting in no violations. Deficiencies included environmental standards, admission standards, resident services, personnel, records and reports, and disaster planning. Enforcement actions include a stipulation and order issued in February 2025.
Complaint Details
Multiple complaint surveys are included, with some resulting in violations and plans of correction approved, indicating complaint investigations were conducted.
Deficiencies (14)
| Description |
|---|
| 487.11 (k) (13) — Environmental standards: Sprinkler systems shall be maintained in good repair and working order. |
| 487.11 (k) (14) — Environmental standards: Smoke and fire protection equipment, including fire extinguishers, shall be maintained in accord with manufacturer's specifications. |
| 487.4 (k) — Admission standards: Medical and mental health evaluations shall be conducted within 30 days prior to admission and annually or as condition changes warrant. |
| 487.4 (m) — Admission standards: Persistent efforts to secure alternative placement for residents who cannot be retained must be documented. |
| 487.7 (f) (5) — Resident services: System to provide proper medication dosage and observe resident taking medication. |
| 487.9 (a) (3) — Personnel: Initial orientation and in-service training including emergency procedures and reporting responsibilities. |
| 487.9 (a) (8) — Personnel: Employee health assessments including TB testing and physician statements. |
| 487.10 (c) (1-3) — Records and reports: Maintain complete, accurate, current resident records with privacy and accessibility. |
| 487.11 (k) (1-3) — Environmental standards: Continued maintenance of facility, building, grounds, equipment, and furnishings in good condition. |
| 487.11 (k) (15) — Environmental standards: Annual inspection/testing of smoke detection, fire alarm, sprinkler, fire extinguishers, heating, elevators, and water supply. |
| 487.12 (f) — Disaster and emergency planning: Monthly fire drills for staff and volunteers at varied times including full and partial evacuations. |
| 487.4 (c) (5) — Admission standards: Operator shall not accept or retain persons who repeatedly impair safety or orderly operation. |
| 487.7 (g) (1) (ii-xiv) — Resident services: Case management services including orientation, assistance, linkages, documentation, and grievance systems. |
| 487.9 (a) (15) — Personnel: At least one individual qualified to administer basic first aid on duty and onsite at all times. |
Report Facts
Inspections on page: 13
Total violations: 17
No-violation inspections: 9
Enforcement actions: 1
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