Inspection Report
Capacity: 140
Deficiencies: 4
Aug 27, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2023-10-30 to 2025-08-27 including complaint investigations and a modification inspection with deficiency history.
Findings
Across all inspections, no deficiencies were cited in complaint investigations or the modification inspection, but four deficiencies were found during the annual compliance inspection on October 30, 2023, related to resident acceptance, service plans, and opioid policy.
Complaint Details
Four complaint investigations were conducted on 2024-09-11, 2024-09-24, 2024-12-20, and 2025-01-10; no deficiencies were cited in any complaint inspections.
Deficiencies (4)
| Description |
|---|
| C. A manager shall not accept or retain an individual if: 1. The individual requires continuous: a. Medical services; - The manager accepted an individual requiring continuous medical services, which the facility cannot provide. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: b. The level of service the resident is expected to receive; - The manager failed to ensure service plans included the expected level of service for four residents. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): b. As follows: ii. At least once every six months for a resident receiving personal care services, and - The manager failed to ensure a service plan was reviewed and updated at least every six months for one resident. |
| R9-10-120. Opioid Prescribing and Treatment F. For a health care institution where opioids are administered as part of treatment or where a patient is provided assistance in the self-administration of medication for a prescribed opioid, a medical director, a manager, or a provider shall: 1. Establish, document, and implement policies and procedures for administering an opioid as part of treatment or providing assistance in the self-administration of medication for a prescribed opioid, to protect the health and safety of a patient, that: a-e. - The manager failed to establish, document, and implement required opioid administration policies and procedures. |
Report Facts
Inspections on page: 6
Total deficiencies: 4
Complaint inspections: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Interviewed and acknowledged issues related to service plans and opioid policy during the 2023-10-30 inspection | |
| E2 | Interviewed and acknowledged issues related to service plans during the 2023-10-30 inspection |
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