Inspection Report
Deficiencies: 23
Mar 18, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2021-08-01 to 2025-07-31 with deficiency history and enforcement summary.
Findings
Across 7 inspections from August 2021 through July 2025, the facility had 24 violations in total, with 4 inspections resulting in no violations. The most recent inspections include a relicensure and complaint survey with 17 violations under review and an other survey with 1 violation approved. No enforcement actions were recorded during this period.
Complaint Details
Complaint surveys are included among the inspections, with some resulting in violations and others with no violations.
Deficiencies (23)
| Description |
|---|
| 485.5 (g) — Operating certificates: No operator shall change or modify a facility, or the services originally approved and stipulated by the operating certificate, without the prior written approval of the department. |
| 488.3 (f) (2) — General provisions: An operator must request and receive written approval from the department prior to instituting any alternative to the requirements of this Part. |
| 488.4 (c) (11) (vi) — Admission and retention standards: Each required medical evaluation attests to the individual's ability to use and maintain the equipment. |
| 488.7 (b) (1) (i) — Resident services: Supervision includes knowledge of the general whereabouts of each resident. |
| 488.7 (b) (1) (iv) — Resident services: Investigation of incidents involving resident health, safety, injury or death. |
| 488.7 (c) (6) — Resident services: Physical restraints must not be used if the resident is unable to remove them. |
| 488.11 (d) (1) — Environmental standards: The building must be in good state of repair and sanitation and comply with applicable laws. |
| 488.11 (f) (1) — Environmental standards: Furnishings and equipment must support daily activities and not endanger residents. |
| 488.11 (g) (6) — Environmental standards: Electrical systems must be maintained in good working order. |
| 488.11 (g) (14) — Environmental standards: Smoke and fire protection equipment must be maintained per manufacturer's specifications. |
| 1001.7 (k) (2) — Admission and retention standards: Individualized Service Plan must be developed with resident and representatives and documented consultation with physician. |
| 1001.10 (g) (1)-(2) (i-ii) — Resident services: Operator shall designate sufficient staff responsible for monitoring residents on-site at all times. |
| 1001.10 (i) (5-8) — Resident services: Case management services including information, coordination, formal mechanisms for identifying changes, and maintaining records. |
| 1001.10 (k) (4) (i-iii) — Resident services: Hospice services permitted with conditions for safe care and coordination. |
| 1001.10 (l)(1) — Medication management: Medication acquisition, storage, disposal, and assistance with self-administration must conform to standards. |
| 1001.11 (c) (2) (i-iv) — Personnel: Operator shall provide sufficient qualified staff with required training and assessments. |
| 1001.13 (b)(1)(i-iii)(2)(3)(4)(iv-vi) — Structural and environmental standards: Building must comply with fire safety features including sprinkler systems, smoke detection, fire protection, handrails, and emergency call systems. |
| 485.11 (b) — Records and reports: Operators must supply and provide access to information and records as determined by the department. |
| 485.5 (f) — Operating certificates: No operator shall change or modify a facility, or the services originally approved and stipulated by the operating certificate, without prior written approval. |
| 488.7 (b) (1) (iii) — Resident services: Assistance and encouragement in basic activities of daily living including nutrition, hygiene, community participation, and money management. |
| 488.7 (c) (5) — Resident services: Residents must not be provided tray services except as necessary for short-term illness. |
| 1001.7 (e) (2) (i-iv) — Admission and retention standards: Procedures for discharge when resident requires 24-hour skilled nursing or medical care, with conditions for enhanced assisted living retention. |
| 1001.10 (l) (4-7) — Medication management: Requirements for PRN medication orders, review, observation, and limitations for persons with dementia. |
Report Facts
Inspections on page: 7
Total violations: 24
No-violation inspections: 4
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