Inspection Report
Complaint Investigation
Capacity: 42
Deficiencies: 16
Sep 12, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from 2023-02 to 2025-09 with deficiency history and enforcement actions.
Findings
Across multiple complaint investigations and enforcement inspections, deficiencies were found related to failure to implement policies for resident behavior management, inadequate staff qualifications, incomplete or unsigned service plans, failure to notify emergency contacts promptly, and failure to document abuse investigations properly.
Complaint Details
The most recent enforcement inspection on 2025-09-12 was conducted as a complaint investigation covering complaints 00144654, 00144655, and 00141936 with multiple deficiencies found related to resident aggressive behavior incidents and staff response.
Deficiencies (16)
| Description |
|---|
| R9-10-803.C.1.g. Administration: Failed to implement policy on caregiver response to resident's sudden, intense, or out-of-control behavior to prevent harm. |
| R9-10-806.A.5.a-c. Personnel: Failed to ensure manager, caregivers, and assistant caregivers had necessary qualifications, experience, skills, and knowledge to meet resident needs and ensure safety. |
| R9-10-807.G.1. Residency and Residency Agreements: Failed to terminate residency in compliance with regulations for resident posing immediate threat to health and safety. |
| R9-10-819.D.1. Emergency and Safety Standards: Failed to immediately notify resident's emergency contact and primary care provider after accident or injury requiring medical services. |
| R9-10-808.C.1.a-g. Service Plans: Failed to ensure caregiver documented services provided in resident's medical record. |
| R9-10-810.B.1. Resident Rights: Failed to ensure resident was treated with dignity, respect, and consideration. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated at least once every three months for residents receiving directed care services. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and updated, is signed and dated by required parties. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 5. When initially developed and updated, is signed and dated by required parties (repeat citation). |
| E. A manager shall ensure documentation required by this Article is provided to the Department within two hours after a Department request. |
| J. A manager shall document and report suspected abuse, neglect, or exploitation and maintain documentation as required by law. |
| A. A manager shall ensure that before providing assisted living services, caregivers provide current documentation of first aid and CPR training. |
| C. A manager shall ensure personnel records include documentation of individual's license or certification if required. |
| C. A manager shall ensure a caregiver provides assisted living services as specified in the resident's service plan. |
| A. A manager shall ensure documentation of disaster plan review includes date, participants, critique, and recommendations. |
| B. A manager shall ensure individuals submit documentation dated within 90 days before acceptance including medical and behavioral health requirements. |
Report Facts
Inspections on page: 9
Total deficiencies: 17
Complaint inspections: 9
Total capacity: 42
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