Deficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Census: 36
Capacity: 95
Deficiencies: 20
Aug 28, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2022-2025 with deficiency history and enforcement actions
Findings
Across all inspections, the facility exhibited multiple deficiencies including failure to maintain sanitary kitchen conditions, inadequate staffing levels, incomplete resident evaluations and service plans, medication administration errors, and insufficient fire and life safety training and documentation. Some deficiencies were corrected upon revisit, while others remained uncorrected.
Deficiencies (20)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen sanitation and food preparation in accordance with Food Sanitation Rules |
| C0000 - Comment: General comments related to compliance and survey findings |
| C0361 - Acuity-Based Staffing Tool: Failed to implement an acuity-based staffing tool including all required ADLs and staff time |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and annually |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening resident health and safety including emergency planning and staffing |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to complete required move-in and quarterly evaluations for sampled residents |
| C0260 - Service Plan: General: Service plans were not updated after significant changes or reflective of resident care needs |
| C0262 - Service Plan: Service Planning Team: Service plans were not developed by a proper service planning team including required participants |
| C0270 - Change of Condition and Monitoring: Failed to evaluate and monitor residents' conditions and document progress until resolution |
| C0280 - Resident Health Services: Failed to ensure RN assessment and appropriate interventions for resident with injury |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to coordinate care with outside providers and implement recommendations |
| 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 |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when resident refused medications |
| C0360 - Staffing Requirements and Training: Staffing: Insufficient number of caregivers during night shift to meet resident needs |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to document pre-service orientation and dementia training for new employees |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to document competency demonstration within 30 days for newly hired direct care staff |
| C0374 - Annual and Biennial Inservice For All Staff: Failed to ensure annual in-service training including dementia care for direct care staff |
| C0420 - Fire and Life Safety: Safety: Failed to document all required components of fire drills and provide fire safety instruction on alternate months |
Report Facts
Inspections on page: 4
Total deficiencies: 21
Licensing violations: 1
Abuse violations: 0
Licensed beds: 95
Resident census: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings and acknowledgements across inspections |
| Staff 2 | Director of Nursing Services/RN | Named in multiple findings and acknowledgements across inspections |
| Staff 13 | Maintenance Director | Named in fire and life safety and emergency planning findings |
| Staff 14 | Sales Director | Named in training documentation findings |
| Staff 16 | Resident Care Coordinator | Named in staffing and resident care findings |
| Staff 4 | Medication Technician | Named in medication administration and training findings |
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