Inspection Report
Complaint Investigation
Deficiencies: 17
Apr 8, 2025
Visit Reason
State-compiled facility profile showing 20 inspections from August 1, 2021 through July 31, 2025 with deficiency history and enforcement actions.
Findings
Across 20 inspections, the facility had 37 total violations with multiple inspections resulting in no violations. Deficiencies covered resident services, environmental standards, personnel, records and reports, and disaster planning. Enforcement actions were issued in 2024 and 2025.
Complaint Details
Multiple inspections classified as Complaint Surveys are included, with some resulting in violations and others with no violations.
Deficiencies (17)
| Description |
|---|
| 487.7 (d) (1) (iv) — Resident services: monitoring and guidance to assist residents in performing basic activities of daily living |
| 487.7 (f) (5) — Resident services: system for staff to provide proper dosage of medication and observe resident taking medication |
| 487.4 (c)(11)(i) — Admission standards: equipment presents no safety hazard |
| 487.5 (d) (6) — Resident protections: admission agreement requirements |
| 487.11 (f) (19) — Environmental standards: prohibited fire hazards including smoking and space heaters |
| 487.11 (h) (5) — Environmental standards: residents shall not have access to storage areas with dangerous materials |
| 487.12 (a-b) — Disaster and emergency planning: written plan for protection of residents and staff |
| 487.12 (f) — Disaster and emergency planning: monthly fire drills for staff and volunteers |
| 487.7 (d) (12-13) — Resident services: incident report requirements and resident's version inclusion |
| 487.9 (a) (8) — Personnel: health impairment and TB risk assessment requirements |
| 487.11 (k) (1-3) — Environmental standards: maintenance of facility, building, grounds, equipment and furnishings |
| 487.7 (g) (1) (ii-xiv) — Resident services: case management services including orientation, adjustment, and discharge planning |
| 487.9 (a) (15) — Personnel: qualified individual for basic first aid on duty at all times |
| 487.10 (d) (5) — Records and reports: maintenance of various resident and facility records |
| 485.11 (b) — Records and reports: supply and provide access to information and records as required |
| 487.4 (c)(12) — Admission standards: prohibition of alcohol or drug use resulting in aggressive or destructive behavior |
| 487.10 (e) (2) — Records and reports: submission of quarterly statistical information report |
Report Facts
Inspections on page: 20
Total violations: 37
No-violation inspections: 9
Enforcement actions: 3
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