Inspection Report
Complaint Investigation
Deficiencies: 12
May 15, 2025
Visit Reason
State-compiled facility profile showing 13 inspections from 2021-08-01 to 2025-07-31 with deficiency history and enforcement actions.
Findings
Across 13 inspections, the facility had 16 violations with 7 inspections resulting in no violations. Most inspections were complaint surveys with some other survey types, and enforcement actions were noted.
Complaint Details
Multiple complaint surveys are included, with violations noted in several complaint investigations between 2021 and 2025.
Deficiencies (12)
| Description |
|---|
| 487.4 (a) — Admission standards: An operator shall admit, retain and care for only those individuals who do not require services beyond those the operator is permitted by law and regulation to provide. |
| 1001.7 (k) (5) — Admission and retention standards: The Individualized Service Plan shall be reviewed and revised every six months and whenever ordered by the resident's physician or as frequently as necessary to reflect the changing care needs of the residents. |
| 487.7 (d) (1) (i) — Resident services: Supervision services shall include, but are not limited to: maintaining knowledge of general whereabouts of each resident. |
| 1001.10 (i) (5-8) — Resident services: Provide information and referral on an ongoing basis; coordinate with service providers; develop formal mechanisms to identify changes in behavior or appearance; maintain complete and accurate personal records. |
| 487.4 (c) (5) — Admission standards: An operator shall not accept nor retain any person who repeatedly behaves in a manner which directly impairs the well-being, care or safety of the resident or other residents, or which substantially interferes with the orderly operation of the facility. |
| 487.11 (k) (1-3) — Environmental standards: The operator shall insure continued maintenance of the facility; building and grounds maintained in clean, orderly condition and good repair; all equipment and furnishings maintained in clean, orderly condition and good working order. |
| 1001.10 (l)(1) — Medication management: Medication acquisition, storage and disposal, and assistance with self-administration of medication shall be performed in conformance with standards dictated by the facility's certification. |
| 1001.10 (l) (4-7) — Medication management: Medication orders for PRN reviewed with physician; physician's order identifies behaviors warranting medication; observation or consultation required for assistance; use of PRN medications for dementia limited. |
| 1001.11 (c) (2) (i-iv) — Personnel: Staff sufficient in number and qualified by training and experience; resident aides receive initial and ongoing training; records maintained; annual assessment conducted. |
| 487.8 (e) (1) — Food service: Operator shall comply with regulations relating to food service for sanitation, safety and health. |
| 487.11 (l) (1) — Environmental standards: Space in a facility shall be used exclusively for purposes set forth; requests for other uses must demonstrate no detriment and comply with codes. |
| 485.11 (b) — Records and reports: Operators shall supply and provide access to information and records as determined by the department. |
Report Facts
Inspections on page: 13
Total violations: 16
No-violation inspections: 7
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