Inspection Report
Standard
Deficiencies: 0
Mar 13, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2015 to 2025 with deficiency history and inspection statuses.
Findings
The facility has undergone numerous inspections including initial licensure, monitoring, complaints, and standard surveys with a mix of no deficiencies, deficiencies cited, and deficiencies corrected across the years.
Report Facts
Inspections on page: 52
Inspection Report
Routine
Deficiencies: 43
Jan 16, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2015 to 2025 including standard, complaint, monitor, and expansion inspections with deficiency history and enforcement data.
Findings
Across all inspections, the facility has multiple deficiencies primarily related to resident care supervision, medication management, staff training, and background screening, with severity levels mostly Class 3 and some Class 4 violations. Several complaint investigations and monitoring visits found no deficiencies.
Complaint Details
Multiple complaint investigations were conducted between 2017 and 2025, with deficiencies cited primarily in resident care supervision, medication management, and resident rights. Some complaints found no deficiencies.
Severity Breakdown
Class 3: 38
Class 4: 4
2: 1
Unclassified: 1
Deficiencies (43)
| Description | Severity |
|---|---|
| A0025 — RESIDENT CARE - SUPERVISION | 2 |
| A0054 — MEDICATION - RECORDS | Class 3 |
| A0057 — MEDICATION - OVER THE COUNTER (OTC) PRODUCTS | Class 3 |
| A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES | Class 3 |
| CZ821 — REPORTING REQUIREMENTS; ELECTRONIC SUBMISSION | Unclassified |
| A0008 — ADMISSIONS - HEALTH ASSESSMENT | Class 3 |
| A0032 — RESIDENT CARE - ELOPEMENT STANDARDS | Class 3 |
| A0010 — ADMISSIONS - CONTINUED RESIDENCY | Class 3 |
| A0056 — MEDICATION - LABELING AND ORDERS | Class 3 |
| A0200 — EMERGENCY ENVIRONMENTAL CONTROL | Class 3 |
| A0081 — TRAINING - STAFF IN-SERVICE | Class 3 |
| A0165 — RISK MGMT & QA; ADVERSE INCIDENT REPORT | Class 3 |
| A0078 — STAFFING STANDARDS - STAFF | Class 3 |
| A0086 — TRAINING - ADRD | Class 3 |
| A0090 — TRAINING - DO NOT RESUSCITATE ORDERS | Class 3 |
| A0161 — RECORDS - STAFF | Class 3 |
| AE210 — ECC - TRAINING | Class 3 |
| CZ815 — BACKGROUND SCREENING; PROHIBITED OFFENSES | Class 4 |
| CZ816 — BACKGROUND SCREENING-COMPLIANCE ATTESTATION | Class 4 |
| A0030 — RESIDENT CARE - RIGHTS & FACILITY PROCEDURES | Class 3 |
| A0025 — RESIDENT CARE - SUPERVISION | Class 3 |
| A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN | Class 3 |
| A0054 — MEDICATION - RECORDS | Class 3 |
| A0056 — MEDICATION - LABELING AND ORDERS | Class 3 |
| A0078 — STAFFING STANDARDS - STAFF | Class 3 |
| A0025 — RESIDENT CARE - SUPERVISION | Class 3 |
| A0081 — TRAINING - STAFF IN-SERVICE | Class 3 |
| A0090 — TRAINING - DO NOT RESUSCITATE ORDERS | Class 3 |
| AE207 — ECC - SERVICES | Class 3 |
| CZ821 — REPORTING REQUIREMENTS; ELECTRONIC SUBMISSION | Class 4 |
| A0078 — STAFFING STANDARDS - STAFF | Class 3 |
| A0081 — TRAINING - STAFF IN-SERVICE | Class 3 |
| A0090 — TRAINING - DO NOT RESUSCITATE ORDERS | Class 3 |
| AE206 — ECC - SERVICE PLANS | Class 3 |
| AE207 — ECC - SERVICES | Class 3 |
| A0078 — STAFFING STANDARDS - STAFF | Class 3 |
| A0081 — TRAINING - STAFF IN-SERVICE | Class 3 |
| A0082 — TRAINING - HIV/AIDS | Class 3 |
| A0090 — TRAINING - DO NOT RESUSCITATE ORDERS | Class 3 |
| A0161 — RECORDS - STAFF | Class 4 |
| AE203 — ECC - STAFFING REQUIREMENTS | Class 3 |
| A0008 — ADMISSIONS - HEALTH ASSESSMENT | Class 3 |
| A0025 — RESIDENT CARE - SUPERVISION | Class 3 |
Report Facts
Inspections on page: 52
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