Deficiencies per Year
4
3
2
1
0
Unclassified
Inspection Report
Follow-Up
Deficiencies: 2
Sep 25, 2025
Visit Reason
The visit was a health care licensure and follow-up inspection to verify compliance with prior cited deficiencies.
Findings
The facility failed to maintain medication refrigerator temperatures between 38 and 45 degrees F, with temperatures below 38 degrees for 84 days. Additionally, the fire suppression system's 5-year inspection and maintenance were overdue since the last inspection in 2019.
Deficiencies (2)
| Description |
|---|
| Medication refrigerator temperatures were not maintained between 38 and 45 degrees F, with temperatures below 38 degrees for 84 days. |
| Fire suppression system gauges and check valves had not been inspected, recalibrated, or replaced as required every 5 years. |
Report Facts
Days refrigerator temperature below 38 degrees: 84
Last fire suppression system inspection year: 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Webb | Administrator | Stated they were looking at purchasing a new medication refrigerator |
| Michael Oldfield | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Life Safety
Deficiencies: 2
Feb 8, 2023
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey for the facility.
Findings
The facility was found to have prohibited electrical applications with coffee pots plugged into relocatable power taps, and non-compliance with fire and life safety standards including failure to visually inspect fire extinguishers in January 2023.
Deficiencies (2)
| Description |
|---|
| Coffee pot was plugged into a Relocatable Power Tap (RPT) in both the office and the dining room, which is a prohibited use. |
| Fire extinguishers in the facility were not visually inspected in January of 2023, violating NFPA 10, 7.2.2. |
Inspection Report
Follow-Up
Deficiencies: 3
Dec 2, 2022
Visit Reason
The visit was a health care licensure and follow-up survey to assess compliance with licensing requirements and verify correction of previous deficiencies.
Findings
The facility was found to have three non-core issues including improper use of previous criminal history checks for an employee, failure to notify Licensing and Certification within one business day after a resident fall requiring hospital treatment, and inadequate monitoring and documentation of medication refrigerator temperatures.
Deficiencies (3)
| Description |
|---|
| Use of previous Criminal History and Background Check without completed state-only background check results; staff allowed to work alone without meeting conditions. |
| Failure to notify Licensing and Certification within one business day after Resident #1 fell and required hospital treatment. |
| Medication refrigerator temperatures containing insulin were not monitored and documented daily; only 8 days logged out of 30 days in November 2022. |
Report Facts
Days temperature logged: 8
Total days in month: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Webb | Administrator | Named in relation to failure to notify Licensing and Certification |
| Jenny Walker | Survey Team Leader | Led the health care licensure and follow-up survey |
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