Deficiencies per Year
32
24
16
8
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 31
May 27, 2025
Visit Reason
State-compiled facility profile showing 22 inspections from 2021-08-01 to 2025-07-31 with deficiency history and enforcement summary.
Findings
Across 22 inspections, the facility had 36 violations with multiple complaint and other surveys reporting deficiencies. Several plans or notices of correction were under review or approved, and no enforcement actions were recorded during the period.
Deficiencies (31)
| Description |
|---|
| 487.6 (f) (1) — Resident funds and valuables: At discharge, operator must provide final accounting, refund, and return property. |
| 487.6 (f) (2) — Resident funds and valuables: Operator shall refund advance payments on a per diem basis. |
| 487.7 (d) (11) — Resident services: Operator must prepare incident reports for various resident incidents. |
| 485.11 (b) — Records and reports: Operators must supply and provide access to information and records as required. |
| 487.4 (k) — Admission standards: Medical and mental health evaluations must be conducted within 30 days prior to admission and annually or as condition changes. |
| 487.10 (c) (1-3) — Records and reports: Maintain complete, accurate, current resident records accessible to staff and inspectors. |
| 487.10(e)(3) — Records and reports: Quarterly statistical information report requirements for facilities with 80+ beds and serious mental illness residents. |
| 487.13 (c) — Transitional adult homes: Submit compliance plan to reduce mental health census under 25% over time. |
| 402.4(b)(2)(iv) — General requirements: Policies for criminal history checks and supervision of temporary employees. |
| 487.4 (i) — Admission standards: Mental health evaluation by qualified professional documented on prescribed form. |
| 487.7 (f) (1-4) — Resident services: Medication management and self-administration protocols. |
| 487.7 (f) (5) — Resident services: System for staff to provide and observe medication administration. |
| 487.7 (f) (11) (iii) — Resident services: Controlled substance storage requirements and licensing. |
| 487.7 (g) (1) (i) — Resident services: Case management evaluations at least annually. |
| 487.8 (e) (3) — Food service: Food purchasing and preparation based on planned menus and tested recipes. |
| 487.9 (a) (8) — Personnel: Health assessments and TB testing requirements for employees. |
| 487.11 (f) (19) — Environmental standards: Prohibited fire hazards including smoking and space heaters. |
| 487.11 (i) (11-12) — Environmental standards: Windows in resident areas must have curtains and screens. |
| 487.11 (j) (1-3) — Environmental standards: Clean and comfortable environment free of vermin and odors. |
| 487.11 (k) (1-3) — Environmental standards: Maintenance of building, grounds, equipment, and furnishings. |
| 487.11 (k) (4) — Environmental standards: Walls and ceilings free of cracks, peeling, or missing tiles. |
| 487.12 (a-b) — Disaster and emergency planning: Written plan for emergencies including evacuation and drills. |
| 487.12 (i) — Disaster and emergency planning: Maintain records of fire drills including participation. |
| 487.5 (f) (10-11) — Resident protections: Termination of admission agreements and notice requirements. |
| 487.4 (e) — Admission standards: Pre-admission screening for serious mental illness and related procedures. |
| 487.7 (a) — Resident services: Provision of room, board, housekeeping, supervision, personal care, case management, and activities. |
| 487.7 (d) (4) — Resident services: Procedures for missing residents and notification requirements. |
| 487.5 (b) (2) — Resident protections: Resident organizations must meet, be chaired by residents, and have staff liaison. |
| 487.11 (f) (12) — Environmental standards: Exit doors must meet height, hardware, and accessibility requirements. |
| 487.12 (d) — Disaster and emergency planning: Evacuation procedures posted conspicuously on every floor and wing. |
| 487.12 (j) — Disaster and emergency planning: Notification requirements for emergencies and system failures. |
Report Facts
Inspections on page: 22
Total violations: 36
No-violation inspections: 10
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