Inspection Report
Capacity: 80
Deficiencies: 18
Oct 16, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2022-2025 with deficiency history and enforcement actions
Findings
Across multiple inspections, the facility demonstrated numerous deficiencies including failure to perform timely resident evaluations and service plan updates, inadequate infection prevention practices, incomplete medication and treatment order documentation, insufficient staff training and competency documentation, and deficiencies in fire and life safety procedures and building maintenance.
Complaint Details
Complaint investigations conducted on 12/7/2022 and 4/2/2025 substantiated failures including medication and treatment order compliance and licensing compliance issues.
Deficiencies (18)
| Description |
|---|
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to ensure resident evaluations were performed quarterly for sampled residents |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' needs, provided clear direction, and were consistently implemented |
| C0270 - Change of Condition and Monitoring: Failed to ensure residents with short term changes had resident-specific instructions, communication to staff, and weekly progress documentation until resolution |
| C0295 - Infection Prevention & Control: Failed to ensure kitchen staff used proper infection control measures while serving residents |
| C0302 - Systems: Tracking Control Substances: Failed to have a system for accurately tracking controlled substances administered by the facility |
| C0303 - Systems: Treatment Orders: Failed to ensure medication and treatment orders were carried out as prescribed and documented with signed physician orders |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician/practitioner when residents refused to consent to orders |
| C0370 - Staffing Requirements and Training – Pre-service: Failed to ensure newly hired direct care staff completed all required pre-service orientation and dementia training within required timeframes |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Failed to ensure newly hired staff demonstrated competency in all required areas within 30 days of hire |
| C0374 - Annual and Biennial Inservice for All Staff: Failed to ensure long-term direct care staff completed required annual in-service training including dementia care |
| C0420 - Fire and Life Safety: Safety: Failed to ensure all required components of fire drills were documented |
| C0422 - Fire and Life Safety: Training for Residents: Failed to provide fire and life safety training for residents at least annually with documented records |
| C0613 - General Building: Doors-Walls, Cleanable: Failed to keep all interior surfaces clean and in good repair |
| C0303 - Systems: Treatment Orders (Complaint Investigation 4/2/2025): Failed to carry out medication and treatment orders as prescribed for a sampled resident |
| C0010 - Licensing Complaint Investigation: Assisted Living and Residential Care Facilities must operate in compliance with applicable laws and regulations |
| C0640 - Heating and Ventilation: Failed to provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen was maintained in accordance with Food Sanitation Rules, including cleanliness and glove use |
| C0361 - Acuity-Based Staffing Tool: Failed to ensure ABST was updated quarterly and accurately reflected resident care needs |
Report Facts
Inspections on page: 7
Total deficiencies: 18
Total surveys: 7
Abuse violations: 0
Licensing violations: 10
Notices: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alisha Rocha-Hills | Administrator | Named in multiple findings acknowledgments and responsible for corrections |
| Staff 1 | Administrator | Named in multiple findings acknowledgments and discussions |
| Staff 4 | Registered Nurse (RN) | Named in multiple findings acknowledgments and discussions |
| Staff 5 | Licensed Practical Nurse (LPN) | Named in multiple findings acknowledgments and discussions |
| Staff 2 | Resident Care Coordinator (RCC) | Named in medication error finding and interview |
| Staff 8 | Maintenance Assistant | Named in building maintenance findings |
| Staff 16 | Caregiver (CG) | Named in training and competency findings |
| Staff 14 | Caregiver (CG) | Named in training and competency findings |
| Staff 19 | Caregiver (CG) | Named in training and competency findings |
| Staff 20 | Caregiver (CG) | Named in annual in-service training findings |
| Staff 24 | Caregiver (CG) | Named in annual in-service training findings |
| Staff 29 | Caregiver (CG) | Named in annual in-service training findings |
| Staff 28 | Business Office Manager | Reported lack of system for staff training monitoring |
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