Deficiencies per Year
24
18
12
6
0
Unclassified
Inspection Report
Follow-Up
Deficiencies: 22
Oct 8, 2025
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to assess compliance with state regulations and verify correction of previous deficiencies.
Findings
The facility failed to provide necessary resources and support, resulting in multiple repeat non-core deficiencies including unsecured toxic chemicals, incomplete medication administration, lack of resident assessments after health changes, failure to monitor medication refrigerator temperatures, incomplete psychotropic medication reviews, outdated service agreements, inadequate behavior documentation, infection control lapses, failed kitchen inspection, insufficient staffing, and lack of current staff certifications.
Deficiencies (22)
| Description |
|---|
| Failed to provide necessary resources leading to multiple repeat non-core deficiencies including unsecured toxic chemicals, incomplete assessments, medication errors, and infection control failures. |
| Toxic chemicals stored in unlocked cabinets accessible to cognitively impaired residents. |
| Residents' medications were not available or given as ordered for multiple residents. |
| Facility nurse did not assess residents after changes in mental or physical health status. |
| Medication refrigerator temperatures were not monitored or documented daily. |
| No record or documentation of drug disposals; accumulation of expired medications. |
| Psychotropic medication reviews not completed for residents on long-term psychotropic medications. |
| Residents' Negotiated Service Agreements (NSAs) did not reflect needs or services accurately and were not updated. |
| Facility did not evaluate or document interventions for residents' maladaptive behaviors. |
| Staff files lacked documentation of orientation and continued training hours. |
| Medication technicians administered medications without hand hygiene; staff not wearing aprons during meal prep. |
| Missing kitchen hood suppression semi-annual inspection and cleaning report. |
| Failed kitchen inspection; no Certified Food Protection Manager on site. |
| Buildings left unattended due to insufficient staffing during night shifts. |
| Five of eight employees lacked current First Aid and CPR certifications. |
| Staff passing medications were not delegated by a current facility nurse. |
| Facility nurse did not conduct required initial or quarterly assessments for multiple residents. |
| Facility nurse did not implement all residents' orders; orders implemented only when nurse unavailable. |
| Facility did not complete investigations of incidents and accidents involving residents. |
| Administrator did not immediately implement corrective actions to prevent recurrence of incidents. |
| Facility failed to notify licensing agency within one business day of reportable incidents. |
| Facility staff documentation was incomplete; medication technicians charted for caregivers. |
Report Facts
Missed medication doses: 45
Resident falls: 5
Staff without current First Aid and CPR certifications: 5
Staff files lacking orientation training documentation: 4
Staff files lacking job-related continued training documentation: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Scroggin | Administrator | Administrator stated he was hired a few weeks ago and was still getting to know residents and systems |
| Melvin Lu | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 19, 2024
Visit Reason
The inspection was conducted as a health care complaint investigation regarding the facility's handling of Resident #5's behaviors.
Findings
The facility failed to adequately evaluate and track Resident #5's maladaptive behaviors, including physical aggression, intrusive wandering, and refusals of care, as acknowledged by the facility administrator.
Complaint Details
The visit was triggered by a health care complaint investigation concerning inadequate evaluation and tracking of Resident #5's maladaptive behaviors.
Deficiencies (2)
| Description |
|---|
| The facility did not evaluate Resident #5's behaviors of physical aggression, intrusive wandering, and refusals of care. |
| The facility did not track ongoing behaviors or the effectiveness of interventions after Resident #5 engaged in maladaptive behaviors. |
Inspection Report
Life Safety
Deficiencies: 5
Oct 10, 2024
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to evaluate compliance with fire safety standards and emergency procedures.
Findings
The facility was found deficient in documenting the emergency assembly area in the emergency plan, had multiple fire suppression system issues including non-sprinklered combustible overhangs and obstructed or corroded fire suppression pendants, non-operational emergency lighting, unsafe walking surfaces, and inadequate emergency egress and relocation drills that did not include actual evacuation or performance evaluation.
Deficiencies (5)
| Description |
|---|
| Emergency plan did not document or provide the location of the area of assembly for resident evacuation. |
| Non-sprinklered combustible overhangs exceeding four feet in depth without fire suppression; fire suppression system pendants obstructed, painted, corroded, or loaded with grease and lint; widespread and systemic condition requiring remedy. |
| Emergency lighting non-operational at emergency light abutting boiler in Building 3. |
| Walking surfaces not maintained; large section of concrete missing at front door area of Building 1 creating a tripping hazard. |
| Emergency egress and relocation drills did not identify the location of the area of assembly, did not actually evacuate residents, and were not evaluated for performance or areas of improvement. |
Report Facts
Facility License Number: RC-1283
Survey Date: 10/10/2024
Response Due Date: 11/09/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janel Manning | Administrator | Named as facility administrator |
| Sam Burbank | Survey Team Leader | Conducted fire life safety and sanitation licensure survey |
| Maintenance Director | Interviewed regarding emergency drills and evacuation |
Inspection Report
Original Licensing
Deficiencies: 19
Jan 12, 2024
Visit Reason
The inspection was conducted as a health care initial licensure survey combined with a complaint investigation.
Findings
The facility was found to have multiple deficiencies including failure to complete criminal background checks for employees, lack of consistent activities for residents, failure to conduct timely investigations of resident falls, inadequate corrective actions, incomplete admission agreements after ownership change, poor housekeeping and maintenance, unsafe storage of toxic chemicals, failure of the RN to perform required assessments, medication administration errors, incomplete nursing assessments, improper medication refrigerator monitoring, missing psychotropic medication reviews, inadequate resident service agreements, lack of behavior plans, infection control breaches, failure to meet food safety standards, and insufficient staffing and delegation issues.
Complaint Details
The visit included a complaint investigation component, addressing allegations related to resident care, medication administration, staffing, and facility maintenance.
Deficiencies (19)
| Description |
|---|
| Three of seven employees did not have Department Criminal History and Background Checks completed. |
| No activities were offered in memory care unit and inconsistent activities in other houses. |
| Administrator did not conduct investigations within 30 days for multiple resident falls. |
| Administrator did not implement corrective actions to prevent recurrence of falls and injuries. |
| Residents did not receive new admission agreements after change of ownership. |
| Facility was not maintained in a clean, safe, and orderly manner with damaged and dirty areas. |
| Toxic chemicals stored in unlocked areas accessible to cognitively impaired residents. |
| Registered Nurse did not perform quarterly assessments for six of nine sampled residents. |
| Residents did not consistently receive medications and treatments as ordered. |
| Nursing assessments were not conducted when residents experienced changes in health status. |
| Medication refrigerator temperatures were not monitored and documented accurately daily. |
| Psychotropic medication reviews were not completed for residents on long-term psychotropic medications. |
| Residents' service agreements did not reflect needs or describe services accurately. |
| No behavior plan developed for resident refusing meals despite repeated refusals. |
| Facility did not follow correct infection control procedures including glove use and medication handling. |
| Facility failed kitchen inspection and lacked Certified Food Protection Manager. |
| Insufficient staff scheduled, especially on night shift, leading to unsupervised buildings and delayed care. |
| Five of six employees lacked current first aid and CPR certification. |
| Medication technicians were not properly delegated by the current facility nurse. |
Report Facts
Employees without background checks: 3
Residents without new admission agreements: 6
Residents with missed quarterly assessments: 6
Days medication not received: 8
Medication refrigerator days below 37°F: 5
Resident #6 missed meals: 18
Staff without current CPR training: 5
Medication technicians not delegated: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janel Manning | Administrator | Named as facility administrator responsible for oversight and cited for multiple deficiencies. |
| Bradley Perry | Survey Team Leader | Led the health care initial licensure and complaint investigation survey. |
| RN | Registered Nurse | Did not perform required quarterly assessments and did not delegate medication technicians. |
| LPN | Licensed Practical Nurse | Stated psychotropic medication reviews were not completed and confirmed lack of behavior plans and delegation issues. |
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