2 Reports
Inspection Report — Mar 23, 2026
Annual Inspection
Date: Mar 23, 2026
Visit Reason
Annual Licensure Survey: deficiencies 295.2060a)b)1)2) and 295.8000 a)1) cited
Findings
The establishment failed to have a quality assurance program in place and did not ensure all dietary staff received food handler training within 30 days of employment. The Executive Director committed to adding food handling training to orientation and ensuring all dietary staff complete ServSafe training.
Deficiencies (2)
A2060 (295.2060 Quality Improvement Program) - The establishment failed to have a quality assurance committee or program in place to detect issues, implement action, and resolve problems, creating a substantial probability of harm to residents.
A8000 (295.8000 Food Service) - The establishment failed to ensure all dietary staff received or obtained training in basic food handling principles within 30 days after employment, affecting all residents.
Report Facts
Staff lacking training: 21
Total dietary staff: 25
Inspection Report — Jun 3, 2025
Annual Inspection
Date: Jun 3, 2025
Visit Reason
Annual Licensure Survey Conducted with violations cited in Sections 295.2040 Disaster Preparedness h), 295.2050 Incident and Accident Reporting a)b)c), and 295.3040 Health Care Worker Background Check.
Findings
The establishment failed to identify residents who received assistance during evacuation drills, failed to report serious incidents/accidents to the Department, and did not comply with Health Care Worker Background Check requirements including registry searches and employment verifications.
Deficiencies (3)
A2040 (295.2040 Disaster Preparedness) - The establishment failed to identify residents who received assistance for evacuation in the written drill evaluations for multiple fire and tornado drills.
A2050 (295.2050 Incident and Accident Reporting) - The establishment failed to report serious incidents/accidents that resulted in physical harm or injury for one resident, including multiple falls and injuries.
A3040 (295.3040 Health Care Worker Background Check) - The establishment did not have documentation showing required registry searches prior to hiring and failed to provide annual employment verification for certain employees.
Report Facts
Residents reviewed: 5
Residents affected: 1
Employees reviewed: 9
Employees affected: 3
Employees with late registry check: 1
Employees with outdated verification: 2
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