Inspection Report Summary
The most recent inspection on February 7, 2025, identified multiple deficiencies during the facility’s initial licensure survey. Earlier inspections are not available for comparison, so this report provides the first detailed look at compliance. Inspectors cited issues related to medication storage, behavioral health management, staff training, and safety measures such as unsecured toxic chemicals. There were no complaint investigations or enforcement actions listed in the available report. Since this is the initial survey, no trend can yet be determined.
Deficiencies (last 1 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
| Description |
|---|
| The facility did not provide a written response to complainants within 30 days. |
| The facility did not maintain medication refrigerator temperatures between 38 and 45 degrees F, with documented out-of-range temperatures and no corrective action. |
| Psychotropic medication reviews for residents #5, #8, and #10 lacked updated behavioral data. |
| Toxic chemicals were stored in unlocked areas accessible to cognitively impaired residents. |
| The facility did not evaluate residents exhibiting maladaptive behaviors such as elopement, aggression, and sexual advancements. |
| Behavior management plans were not reviewed or adjusted to ensure effectiveness for residents with behavioral issues. |
| Three of ten staff did not have documentation of 16 hours of orientation training completed within 30 days of hire. |
| Ten of ten staff did not document completion of mental illness training. |
| Name | Title | Context |
|---|---|---|
| Heath Braverman | Administrator | Named in relation to unawareness of complaint response requirements and behavioral update requirements |
| Torrey Bollinger | Survey Team Leader | Survey team leader for the initial licensure inspection |
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