Inspection Report
Monitoring
Capacity: 133
Deficiencies: 20
Oct 3, 2025
Visit Reason
State-compiled facility profile showing 18 inspections from 2023-01 to 2025-10 with deficiency history and enforcement actions.
Findings
Multiple inspections revealed numerous deficiencies related to service plan documentation, medication administration, staff qualifications, safety policies, and facility maintenance. Several enforcement actions and complaint investigations found repeated noncompliance issues posing risks to resident health and safety.
Complaint Details
Multiple complaint investigations were conducted between 2023 and 2025, with some resulting in substantiated allegations and deficiencies cited. Several investigations involved failure to report and document suspected abuse, neglect, or exploitation, and failure to maintain compliance with settlement agreement terms.
Deficiencies (20)
| Description |
|---|
| R9-10-808.A.5.a-d. Service Plans: Failed to ensure service plans were signed and dated by resident or representative and manager when initially developed or updated. |
| R9-10-808.C.1.g. Service Plans: Failed to ensure caregiver documented services provided in resident's medical record. |
| R9-10-808.A.4.b.ii. Service Plans: Failed to ensure service plan was reviewed and updated at least once every six months. |
| C. A manager shall ensure that policies and procedures are established and implemented to protect health and safety of residents including response to sudden, intense, or out-of-control behavior. |
| J. Reporting and investigation requirements for suspected abuse, neglect, or exploitation were not met including documentation and timely investigation. |
| 36-420.04. Emergency responders; failed to maintain documentation provided to emergency responders for two years. |
| C. A manager shall ensure resident medical records contain documentation of vaccination availability notification for influenza and pneumonia annually. |
| B. Medication Services: Failed to ensure medication administered in compliance with medication orders and properly documented. |
| H. Medication stored in resident's bedroom was not stored according to resident's service plan. |
| D. Documentation of accidents, emergencies, or injuries requiring medical services was incomplete or missing. |
| A. Premises and equipment were not cleaned or disinfected according to infection control policies. |
| A. Poisonous or toxic materials were not stored in locked areas inaccessible to residents. |
| A. Pets or animals allowed in the facility were not vaccinated against rabies. |
| E. Documentation required by this Article was not provided to the Department within two hours after request. |
| A. Caregiver skills and knowledge were not verified and documented before providing services. |
| A. Personnel records lacked required documentation including qualifications, certifications, and fingerprint clearance. |
| A. Failed to ensure resident service plans were signed and dated by required parties when developed or updated. |
| E. Failed to ensure mechanical means to alert employees to resident needs or emergencies were available and functional. |
| A. Heating and cooling systems failed to maintain facility temperature between 70°F and 84°F. |
| A. Equipment used at the facility was not maintained in working order. |
Report Facts
Inspections on page: 18
Total deficiencies: 41
Complaint inspections: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Named in multiple findings related to documentation, policy implementation, and interviews acknowledging deficiencies | |
| E2 | Care Specialist | Named in findings related to missing personnel records, training documentation, and service plan issues |
| E3 | Named in incident reports and findings related to abuse investigations and personnel record deficiencies | |
| E4 | Named in findings related to missing documentation and incident reports | |
| E5 | Named in abuse investigations and medication administration deficiencies | |
| E6 | Housekeeper | Named in findings related to fingerprint clearance and expired CPR/first aid certification |
| Peter DeMangus | Interim Executive Director | Named as person responsible in medication administration deficiency |
| Sam Brunner | Interim Director of Care | Named as person responsible in medication administration deficiency |
| Amy Sourathathone | Resident Care Coordinator | Named as person responsible in medication administration deficiency |
| Robert Dietterick | Administrator | Named in facility information but not linked to specific findings |
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