The most recent inspection on March 6, 2025, identified two deficiencies related to personnel TB documentation and medication administration errors. Earlier inspections showed a pattern of issues mostly involving caregiver training, skills verification, and documentation, including a prior enforcement action in July 2023 that resulted in civil fines totaling $3,250 for similar training and certification deficiencies. Complaint investigations conducted in 2024 were generally unsubstantiated, with no deficiencies cited in those cases. The main themes across inspections involved caregiver training and documentation, medication administration, and some facility maintenance concerns. The facility’s record shows some improvement since the more extensive deficiencies and enforcement actions in mid-2023, though some issues persist.
Deficiencies (last 3 years)
Deficiencies (over 3 years)3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The enforcement resulted in civil fines totaling $3,250 for violations related to caregiver training, skills verification, and expired CPR and first aid certifications.
Fines & Penalties (3)
Amount
Reason
Status
$2,500.00
Five employees working as caregivers did not have caregiver training certificates.
—
$250.00
Five caregivers' skills and knowledge were not verified and documented before providing physical health services.
—
$500.00
One employee's CPR training and first aid training were expired.
Nine deficiencies found related to fall prevention training, caregiver training and verification, first aid documentation, resident admission, service plan documentation, disaster drills, resident orientation, and facility cleanliness.
Findings
Nine deficiencies found related to fall prevention training, caregiver training and verification, first aid documentation, resident admission, service plan documentation, disaster drills, resident orientation, and facility cleanliness.
Deficiencies (9)
Description
36-420.01 — Fall prevention training program
Caregiver training documentation incomplete
Caregiver skills verification missing
First aid training documentation missing
Resident admission requirements not met
Directed care service plan documentation incomplete
Disaster drill documentation missing
Resident orientation to exits missing
Premises and equipment cleaning inadequate
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