Deficiencies per Year
24
18
12
6
0
Unclassified
Inspection Report
Deficiencies: 22
Jul 29, 2025
Visit Reason
State-compiled facility profile showing 14 inspections from 2021-08-01 through 2025-07-31 with deficiency history and enforcement actions.
Findings
Across 14 inspections, the facility had a total of 32 violations with 5 inspections resulting in no violations. Violations covered a range of regulatory codes including admission standards, resident services, medication management, personnel, and records and reports. Enforcement actions include a stipulation and order issued in June 2025.
Complaint Details
Includes complaint surveys with violations and no violations; specific complaint details not provided.
Deficiencies (22)
| Description |
|---|
| 485.11 (b) — Records and reports: Operators must supply and provide access to information and records as determined by the department. |
| 487.4 (a) — Admission standards: Operator shall admit, retain and care for only those individuals who do not require services beyond those permitted by law. |
| 487.4 (c) (5) — Admission standards: Operator shall not accept or retain persons who repeatedly behave in a manner impairing well-being or safety of residents or facility operation. |
| 487.7 (d) (11) — Resident services: Operator must prepare incident reports for specified resident incidents. |
| 487.7 (d) (12-13) — Resident services: Operator must maintain incident reports and submit copies to the department and Justice Center as applicable. |
| 487.7 (f) (11) (iii) — Resident services: Operator retaining controlled substance prescriptions must obtain a class 3a controlled substance license and follow storage standards. |
| 487.11 (k) (1-3) — Environmental standards: Operator must maintain facility, building, grounds, equipment, and furnishings in clean, orderly, and good repair condition. |
| 487.12 (f) — Disaster and emergency planning: Operator must conduct monthly fire drills for staff and volunteers under specified conditions. |
| 1001.8 (a) — Consumer and resident protections: Operator must provide considerate and respectful care promoting dignity and autonomy. |
| 1001.10 (i) (5-8) — Resident services: Operator must provide ongoing information and referral, coordinate services, develop mechanisms to identify changes in residents, and maintain accurate personal records. |
| 1001.10 (l)(1) — Medication management: Medication acquisition, storage, disposal, and assistance must conform to applicable standards. |
| 1001.11 (c) (2) (i-iv) — Personnel: Operator must provide sufficient qualified staff with required training and annual assessments. |
| 487.7 (d) (1) (x) — Resident services: Supervision services must include investigation of incidents involving resident endangerment or injury. |
| 1001.7 (k) (5) — Admission and retention standards: Individualized Service Plans must be reviewed and revised every six months or as needed. |
| 1001.10 (j) (1) — Resident services: Residents must be provided necessary personal care to maintain hygiene, health, and participation in activities. |
| 1001.7 (g)(1-3) — Admission and retention standards: Operator must conduct pre-admission evaluations within 30 days prior to admission. |
| 402.4(b)(2)(i) — General requirements: Provider must develop policies for criminal history checks and supervise temporary employees to protect resident safety. |
| 487.4 (c) (1) — Admission standards: Operator shall not accept or retain persons needing continual medical or nursing care beyond facility scope. |
| 487.8 (c) — Food service: Information on residents' dietary regimens and allergies must be available and used in meal planning. |
| 487.10 (d) (1-2) — Records and reports: Operator must maintain complete, accurate, and current facility operation and maintenance records available for inspection. |
| 487.10 (d) (5) — Records and reports: Operator must maintain various records including resident, program, food service, maintenance, staff, certificates, and quality assurance plans. |
| 1001.12 (b) (1-7) — Records and reports: Operator must maintain complete and accurate personal resident records including personal data, medical evaluations, service plans, medication records, and case management notes. |
Report Facts
Inspections on page: 14
Total violations: 32
No-violation inspections: 5
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