Inspection Report
Deficiencies: 31
Jun 20, 2024
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State-compiled facility profile showing 24 inspections from 2021-08-01 to 2025-07-31 with deficiency history and enforcement summary.
Findings
Across 24 inspections, the facility had 34 total violations with 15 inspections resulting in no violations. Deficiencies covered admission standards, food service, personnel, environmental standards, resident protections, and resident services. No enforcement actions were reported during the period.
Deficiencies (31)
| Description |
|---|
| 487.4 (c)(12) — Admission standards: Engages in alcohol or drug use resulting in aggressive or destructive behavior |
| 487.4 (k) — Admission standards: Medical and mental health evaluations required within 30 days prior to admission and annually |
| 487.8 (b) — Food service: Provide three meals a day and nutritious evening snack |
| 487.8 (c) — Food service: Resident dietary regimen and allergies information available in food service area |
| 487.8 (d) (3) — Food service: Water, milk, coffee, tea, and hot decaffeinated beverage offered at each meal |
| 487.8 (d) (4,8,10-11) — Food service: Menus planned, recorded, available, and kept on file for six months |
| 487.8 (d) (9) — Food service: Menus posted in public area with daily changes or substitutions |
| 487.8 (e) (1) — Food service: Compliance with sanitation, safety, and health regulations |
| 487.8 (e) (3) — Food service: Food purchases and preparation based on planned menus and recipes |
| 487.8 (e) (12-13) — Food service: Appropriate tableware used; disposable plates and utensils not regularly used |
| 487.9 (a) (15) — Personnel: At least one individual qualified to administer basic first aid on duty at all times |
| 487.9 (j) (3-4) — Personnel: Qualified dietitian retained as dietary consultant with written agreement |
| 487.11 (a) — Environmental standards: Facility maintained in good repair and sanitation |
| 487.11 (f) (7) — Environmental standards: Smoke barriers with one hour fire-resistive rating installed |
| 487.11 (f) (12) — Environmental standards: Exit doors meet height, hardware, and accessibility requirements |
| 487.11 (f) (19) — Environmental standards: Prohibited fire hazards including smoking, heaters, combustible materials |
| 487.11 (k) (1-3) — Environmental standards: Continued maintenance of facility, clean and orderly building and grounds |
| 487.11 (k) (4) — Environmental standards: Walls and ceilings free of cracks, peeling, missing or cracked tiles |
| 487.11 (k) (6) — Environmental standards: Electrical systems maintained in good working order |
| 487.5 (f) (10-11) — Resident protections: Proper termination of admission agreements with notice |
| 487.7 (f) (5) — Resident services: System for medication administration and observation |
| 487.7 (d) (1) (v) — Resident services: Surveillance of grounds, facility, and activities to protect residents |
| 487.7 (d) (11) — Resident services: Incident reporting requirements for various resident events |
| 487.10 (c) (1-3) — Records and reports: Maintain complete, accurate, current resident records with privacy |
| 487.11 (f) (16) — Environmental standards: Emergency lighting installed in exit hallways, stairwells, public areas |
| 487.11 (k) (8) — Environmental standards: Ventilation, air conditioning, and air changing systems maintained |
| 487.12 (j) — Disaster and emergency planning: Department notification of emergencies or service interruptions |
| 487.6 (a) (4) — Resident funds and valuables: Personal allowance accounts kept separate and distinct |
| 487.6 (e) — Resident funds and valuables: Inventory and security of resident property held in custody |
| 487.4 (e) — Admission standards: Pre-admission screening for serious mental illness required |
| 485.11 (b) — Records and reports: Provide access to information and records as determined by department |
Report Facts
Inspections on page: 24
Total violations: 34
No-violation inspections: 15
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