Inspection Report
Kitchen
Census: 32
Capacity: 48
Deficiencies: 14
Aug 1, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from 2022-11 to 2025-08 with deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility showed repeated deficiencies related to kitchen sanitation, resident service plans, staffing and training, and fire and life safety. Some deficiencies were corrected over time, while others remained uncorrected as of the latest inspections.
Complaint Details
Complaint investigations conducted on 2025-03-04 and 2023-07-26 related to licensure complaints with deficiencies noted and not corrected.
Deficiencies (14)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner including food spills, improper dish machine sanitizing, and improper food handling. |
| C0303 - Systems: Treatment Orders |
| C0000 - Comment: Kitchen inspection findings documented with some substantial compliance noted on re-visit. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure initial evaluation addressed all required elements for sampled resident. |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of current status, reviewed quarterly, and provided to legal representatives. |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service planning team involvement in updating service plan for sampled resident. |
| C0270 - Change of Condition and Monitoring: Failed to evaluate, communicate, and monitor changes of condition for sampled resident. |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure newly hired staff completed required pre-service orientation and dementia training. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired staff demonstrated competency within 30 days of hire. |
| C0374 - Annual and Biennial Inservice For All Staff: Failed to ensure required annual in-service training hours were completed. |
| C0420 - Fire and Life Safety: Safety: Failed to provide fire and life safety instruction on alternate months, conduct unannounced fire drills on all shifts every other month, and document required elements. |
| C0613 - General Building: Doors-Walls, Cleanable: Failed to keep interior surfaces in good repair including laundry room walls. |
| C0010 - Licensing Complaint Investigation: Licensing complaint investigation findings documented. |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update Acuity Based Staffing Tool; census discrepancy noted. |
Report Facts
Inspections on page: 9
Total deficiencies: 13
Total surveys: 7
Licensing violations: 20
Notices: 2
Licensed beds: 48
Resident census: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director / Operations Director / Acting ED | Named in multiple findings including kitchen sanitation, staffing tool, and service plan deficiencies |
| Staff 2 | Dining Services Director / Cook / Person in Charge | Named in kitchen sanitation and food handling deficiencies |
| Staff 3 | Wellness Director | Named in service plan and change of condition deficiencies |
| Staff 9 | Business Office Manager | Named in staff training and competency deficiencies |
| Staff 5 | Vice President of Operations | Named in building repair deficiencies |
| Staff 6 | Med Aide | Named in pre-service training and competency deficiencies |
| Staff 10 | Care Associate | Named in pre-service training and competency deficiencies |
| Staff 11 | Med Aide / Care Associate | Named in competency deficiencies |
| Staff 12 | Care Associate / Med Tech | Named in annual in-service training deficiencies |
| Staff 13 | Care Associate | Named in annual in-service training deficiencies |
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