Inspection Report
Renewal
Deficiencies: 20
Apr 16, 2025
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State-compiled facility profile showing 16 inspections from 2021-08-01 through 2025-07-31 with deficiency history and enforcement summary.
Findings
Across 16 inspections, the facility had 23 violations with 9 inspections resulting in no violations. The most recent relicensure survey identified 12 violations with an approved plan of correction. No enforcement actions were reported during this period.
Complaint Details
Multiple complaint surveys are included with no violations found in most; some complaint surveys resulted in violations with approved plans of correction.
Deficiencies (20)
| Description |
|---|
| 488.7 (d) (1)(i-iii) — Resident services: Medication assistance requirements for resident self-administration and storage. |
| 488.7 (d) (3) — Resident services: System for staff to assist residents needing medication assistance. |
| 488.7 (d) (4) — Resident services: Recording for medications including maintaining medication regimen information. |
| 488.7 (d) (8) (iv) — Resident services: Medications must not be emptied from one container into another. |
| 488.7 (d) (8) (vii) — Resident services: Medications must be disposed of per physician or pharmacist instructions. |
| 488.11 (d) (1) — Environmental standards: Building must be in good repair and sanitation per laws. |
| 488.11 (e) (3) — Environmental standards: Storage of poisonous or dangerous materials separate from food storage. |
| 488.12 (h) — Disaster and emergency procedures: Annual fire drill with resident participation. |
| 1001.7 (k) (5) — Admission and retention standards: Individualized Service Plan review and revision requirements. |
| 1001.10 (l) (4-7) — Medication management: PRN medication orders and use limitations. |
| 1001.11 (l) (1-2) — Personnel: Immunization record requirements for direct care staff. |
| 1001.12 (c) (3) — Records and reports: Personnel record maintenance requirements. |
| 488.7 (a) — Resident services: Provision of resident services including supervision and care. |
| 488.7 (d) (8) (i-iii) — Resident services: Storage of medications by operators in locked cabinets and separation of medication types. |
| 488.11 (g) (11) — Environmental standards: Maintenance of entrances, exits, and walkways free from hazards. |
| 488.7 (b) (8) — Resident services: Actions required in event of resident death notification and reporting. |
| 488.7 (d) (7) — Resident services: Prohibition on staff changing medication dosage or schedule without physician authorization. |
| 485.11 (b) — Records and reports: Providing access to information and records to the department. |
| 488.10 (e) (4) — Records and reports: Quarterly statistical information report including census and deaths. |
| 488.5 (e) (3) — Resident protections: Conditions for termination of admission agreements and involuntary discharge. |
Report Facts
Inspections on page: 16
Total violations: 23
No-violation inspections: 9
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