Inspection Report — Mar 7, 2025
Certification/complaint
Citations: 23
Date: Mar 7, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2022 to 2025 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 85 complaints about this facility; 5 led to on-site inspections.
Findings
Across 5 inspections, 35 citations were issued including 23 standard health and 12 Life Safety Code citations. The facility had 85 complaints with 5 on-site inspections and 2 enforcement actions totaling $20,000 in fines.
Citations (23)
Accuracy Of Assessments: Failed to ensure accurate resident assessments during multiple inspections.
Infection Control: Deficiencies noted in infection prevention and control practices.
Physical Environment: Violations of Life Safety Code related to the physical environment.
Sprinkler System - Installation: Life Safety Code violations in sprinkler system installation.
Subdivision Of Building Spaces - Smoke Barrier: Life Safety Code violation regarding smoke barrier subdivision.
Residents Are Free Of Significant Med Errors: Failure to ensure residents were free from significant medication errors.
Bowel/bladder Incontinence, Catheter, Uti: Deficiencies in managing incontinence and urinary tract infections.
Care Plan Timing And Revision: Care plans were not timely revised or updated as required.
Drug Regimen Is Free From Unnecessary Drugs: Failure to ensure drug regimens were free from unnecessary medications.
Drug Regimen Review, Report Irregular, Act On: Deficiencies in reviewing and acting on irregular drug regimen reports.
Encoding/transmitting Resident Assessments: Issues with encoding and transmitting resident assessments accurately.
Free From Unnec Psychotropic Meds/prn Use: Failure to prevent unnecessary psychotropic medication use.
Notify Of Changes (injury/decline/room, Etc.): Failure to notify appropriate parties of resident changes.
Resident Rights/exercise Of Rights: Deficiencies in protecting and exercising resident rights.
Doors With Self-closing Devices: Life Safety Code violation regarding doors with self-closing devices.
Egress Doors: Violations related to egress doors under Life Safety Code.
Hazardous Areas - Enclosure: Life Safety Code violations in enclosure of hazardous areas.
Illumination Of Means Of Egress: Inadequate illumination of egress paths violating Life Safety Code.
Means Of Egress - General: General deficiencies in means of egress compliance with Life Safety Code.
Other Laws, Codes, Rules And Regulations: Violations of other applicable Life Safety Code regulations.
Develop/implement Comprehensive Care Plan: Failure to develop and implement comprehensive care plans.
Free Of Accident Hazards/supervision/devices: Failure to keep residents free from accident hazards, supervision, or device issues.
Reporting Of Alleged Violations: Deficiencies in reporting alleged violations as required.
Report Facts
Inspections on page: 5
Total violations/deficiencies cited: 35
Inspections with violations: 4
Inspections without violations: 1
Plan of correction counts: Not explicitly stated
Total fines: 20000
Number of enforcement actions: 2
Total complaints: 85
On-site complaint inspections: 5
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