Inspection Report
Capacity: 23
Deficiencies: 26
Oct 31, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from 2021 to 2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited repeated deficiencies including failure to maintain kitchen sanitation, incomplete or inaccurate service plans, inadequate infection prevention and control, staffing and training issues, environmental maintenance problems, and failure to comply with licensing and administrative requirements.
Complaint Details
Complaint investigations conducted on 1/13/2023 and 7/26/2022 identified deficiencies including failure to exercise reasonable precautions and compliance with applicable laws and regulations.
Deficiencies (26)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner with repeated findings of food spills, debris, poor staff hygiene, and equipment in need of repair. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure plan of correction for kitchen survey was implemented and satisfied the Department. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities, referencing multiple other citations. |
| C0260 - Service Plan: General: Service plans not reflective of residents' needs, lacked dated and initialed changes, and did not provide clear direction to staff for multiple residents. |
| C0270 - Change of Condition and Monitoring: Failed to ensure short term changes in condition had documented progress monitored at least weekly and provided clear resident-specific directions to staff. |
| C0295 - Infection Prevention & Control: Failed to maintain infection prevention and control protocols including hand hygiene and cleaning after incontinent episodes. |
| C0330 - Systems: Psychotropic Medication: PRN psychotropic medications lacked written, resident-specific parameters and documentation of non-pharmacological interventions prior to administration. |
| C0350 - Administrator Qualification and Requirements: Failed to employ a full-time administrator scheduled at least 40 hours per week. |
| C0362 - Acuity Based Staffing Tool - ABST Time: Failed to accurately capture care time and care elements provided to residents in ABST. |
| C0363 - Acuity Based Staffing Tool - Updates & Staffing Plan: Failed to complete ABST evaluation prior to move-in and update no less than quarterly with service plan updates. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain environment clean and in good repair with repeated findings of stains, odors, and damaged surfaces. |
| C0540 - Heating and Ventilation: Wall heaters exceeded 120 degrees Fahrenheit in resident areas subject to incidental contact. |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules, referencing multiple other citations. |
| Z0163 - Nutrition and Hydration: Failed to ensure individualized nutrition and hydration plans were developed and included in service plans for sampled residents. |
| C0010 - Licensing Complaint Investigation: Failed to operate and provide services in compliance with applicable laws and regulations as documented in complaint investigation. |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening resident health and safety, including toileting assistance. |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure sampled staff had current food handlers certificates at time of survey. |
| C0302 - Systems: Tracking Control Substances: Failed to have accurate system for tracking controlled substances administered to residents. |
| C0303 - Systems: Treatment Orders: Failed to ensure physician orders were available and carried out as prescribed for sampled residents. |
| C0340 - Restraints and Supportive Devices: Failed to complete thorough assessment for assistive devices with restraining qualities for sampled resident. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired direct care staff completed required First Aid and abdominal thrust training within 30 days. |
| C0420 - Fire and Life Safety: Safety: Failed to ensure fire and life safety documentation reflected all required fire drill components. |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure general fire and life safety requirements were met including use of alternate exit routes and staff awareness. |
| C0510 - General Building Exterior: Failed to maintain courtyard surfaces in good repair with multiple drop-offs along pathway edges. |
| H1518 - Individual Door Locks: Key Access: Failed to ensure residents had keys to their units per evaluated need with many rooms lacking locking door knobs. |
| Z0155 - Staff Training Requirements: Failed to ensure sampled newly hired staff completed all required pre-service and competency training and annual in-service training. |
Report Facts
Inspections on page: 8
Total deficiencies: 42
Total surveys: 8
Licensing violations: 10
Abuse violations: 0
Notices: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Assistant Executive Director | Named in multiple findings including administrator absence, infection control, and service plan issues |
| Staff 2 | Regional Director of Health Services | Named in multiple findings including infection control, service plan, and psychotropic medication issues |
| Staff 3 | Regional Director | Named in multiple findings including kitchen sanitation and administrative compliance |
| Staff 4 | Regional RN Consultant | Named in findings related to infection prevention and service plan compliance |
| Staff 14 | Regional Director of Operations | Acknowledged findings related to ABST, infection control, and environmental maintenance |
| Staff 10 | Medication Technician | Named in infection prevention finding related to incontinent episode |
| Staff 11 | Caregiver | Named in infection prevention finding related to cleaning after incontinent episode |
| Staff 12 | Maintenance | Named in heating and ventilation deficiency related to wall heater temperature checks |
| Staff 4 | Dietary Services Manager | Named in kitchen sanitation findings |
| Staff 5 | Regional Director of Operations | Named in kitchen sanitation and infection prevention findings |
| Staff 8 | Executive Director | Named in multiple findings including kitchen sanitation and staff training |
| Staff 15 | Registered Nurse | Named in training and restraint device assessment findings |
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