Inspection Report
Kitchen
Capacity: 23
Deficiencies: 29
Mar 13, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2022-09 to 2025-03 with deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility exhibited numerous deficiencies related to food sanitation, administration compliance, resident care evaluations, infection control, medication administration, staffing, training, and fire and life safety. Some deficiencies were corrected over time, while others remained uncorrected as of the latest inspections.
Complaint Details
Inspection dated 10/2/2023 identified 5 deficiencies related to licensing complaint investigation, service plan, medication administration, treatment orders, and staffing requirements; none were corrected as of 10/3/2023.
Deficiencies (29)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules including cleanliness, dishwasher operation, and food storage. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
| C0000 - Comment: Kitchen inspection findings documented; substantial compliance noted in follow-up. |
| C0010 - Licensing Complaint Investigation |
| C0260 - Service Plan: General: Failed to ensure resident service plans were reflective of needs and provided clear direction to staff. |
| C0301 - Systems: Medication Administration |
| C0303 - Systems: Treatment Orders |
| C0360 - Staffing Requirements and Training: Staffing |
| C0155 - Facility Administration: Records: Failed to maintain complete and accurate records for sampled residents. |
| C0160 - Reasonable Precautions: Failed to implement effective infection control methods. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to promptly investigate incidents and injuries of unknown origin. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure initial and quarterly evaluations were complete and reflective of resident needs. |
| C0270 - Change of Condition and Monitoring: Failed to evaluate, monitor, and refer significant changes of condition. |
| C0280 - Resident Health Services: Failed to ensure RN assessments for significant changes of condition. |
| C0282 - Rn Delegation and Teaching: Failed to ensure delegation and supervision of nursing tasks per OSBN rules. |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication system and professional oversight. |
| C0302 - Systems: Tracking Control Substances: Failed to accurately track controlled substances administered. |
| C0310 - Systems: Medication Administration: Failed to ensure accurate MAR documentation. |
| C0361 - Acuity-Based Staffing Tool: Failed to update ABST for resident significant changes of condition. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired direct care staff demonstrated competency within 30 days. |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills every other month and document required elements. |
| C0422 - Fire and Life Safety: Training For Residents: Failed to provide annual fire safety instruction for residents. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure relicensure survey plan of correction was implemented and satisfied the Department. |
| C0510 - General Building Exterior: Failed to ensure cleaning chemicals were labeled and safely stored in locked storage. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to ensure interior environment was clean and in good repair. |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired direct care staff completed required training and competency. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules. |
| Z0163 - Nutrition and Hydration: Failed to ensure individualized nutrition and hydration plans were developed and included in service plans. |
| Z0164 - Activities: Failed to ensure individualized activity plans were developed and meaningful activities provided. |
Report Facts
Inspections on page: 4
Total deficiencies: 31
Total surveys: 4
Licensing violations: 9
Abuse violations: 0
Notices: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including kitchen sanitation, administration compliance, resident care, medication oversight, and fire safety |
| Staff 2 | Site Manager / Area Manager | Named in multiple findings including kitchen sanitation, administration compliance, resident care, medication oversight, and fire safety |
| Staff 3 | Regional RN / Regional Dining Manager | Named in multiple findings including kitchen sanitation, administration compliance, resident care, medication oversight, and fire safety |
| Staff 4 | RN / Maintenance Director | Named in findings related to medication documentation and kitchen sanitation |
| Staff 5 | Activity Director | Named in findings related to medication delegation and staff training |
| Staff 6 | Maintenance Director | Named in fire and life safety findings |
| Staff 8 | Med Tech | Named in resident care findings |
| Staff 9 | Med Tech | Named in medication administration and staff training findings |
| Staff 13 | Med Tech | Named in medication delegation findings |
| Staff 14 | Med Tech | Named in findings related to bowel monitoring |
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