Inspection Report
Kitchen
Capacity: 52
Deficiencies: 30
Oct 23, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2023-2025 with deficiency history and enforcement notices
Findings
Across multiple inspections from 2023 to 2025, Fircrest Senior Living demonstrated repeated deficiencies in kitchen sanitation, resident care plans, infection control, medication administration, and administrative compliance. Several deficiencies were repeated across revisits, with some corrected and others remaining uncorrected as of the latest inspections.
Complaint Details
Complaint investigation conducted on 06/05/2024 found multiple failures including failure to refer sexual assault victims timely, failure to monitor residents with 1-on-1 supervision, and failure to notify RN of nursing needs. Safety plans were requested and accepted. Findings were acknowledged by multiple staff and conditions placed on facility.
Deficiencies (30)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules, including unclean kitchen areas and improper food storage |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| C0200 - Resident Rights and Protection - General: Failed to ensure residents' right to dignity, respect, and privacy during meal assistance and ADL care |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report and investigate incidents of abuse promptly |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff |
| C0295 - Infection Prevention & Control: Failed to maintain infection prevention and control protocols during ADL care and meal service |
| C0302 - Systems: Tracking Control Substances: Failed to ensure a system was in place to track controlled substances accurately |
| C0310 - Systems: Medication Administration: Failed to ensure accurate MARs with resident-specific parameters and documentation |
| C0420 - Fire and Life Safety: Safety: Failed to document all required elements for fire drills and provide fire and life safety instruction to staff |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure plan of correction was implemented and satisfied the Department |
| C0000 - Comment: General comments related to inspections and findings |
| C0010 - Licensing Complaint Investigation: Findings from complaint investigation |
| C0154 - Facility Administration: Policy & Procedure: Failed to implement policy for referral of residents who may be victims of acute sexual assault within required timeframe |
| C0270 - Change of Condition and Monitoring: Failed to monitor resident consistent with evaluated needs and service plan |
| C0280 - Resident Health Services: Failed to notify facility RN of nursing needs for a resident |
| Z0140 - Administration Responsibilities: Failed to provide effective administrative oversight over Memory Care Community |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening health, safety or welfare of residents |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service plans were developed by a Service Planning Team including required members |
| C0303 - Systems: Treatment Orders: Failed to ensure written, signed physician orders for all medications and treatments |
| C0330 - Systems: Psychotropic Medication: Failed to ensure non-pharmacological interventions were attempted and documented prior to psychotropic medication administration |
| C0340 - Restraints and Supportive Devices: Failed to ensure assistive devices with restraining qualities were assessed and instructions provided |
| C0361 - Acuity-Based Staffing Tool: Failed to use an acuity-based staffing tool showing all residents with required care elements and staff time |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure residents were instructed on fire safety procedures upon admission and annually |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules |
| Z0163 - Nutrition and Hydration: Failed to ensure individualized nutrition and hydration plans were developed and included in service plans |
| Z0173 - Secure Outdoor Recreation Area: Failed to ensure secured outdoor courtyard door accessibility and policy for locking |
| Z0176 - Resident Rooms: Failed to ensure residents were not locked outside rooms and rooms had individualized identifiers |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired staff completed required pre-service dementia and infectious disease prevention training |
| C0010 - Licensing Complaint Investigation: Findings of complaint investigation conducted 02/01/22 |
Report Facts
Inspections on page: 6
Total deficiencies: 46
Total licensing violations: 10
Total notices: 3
Total licensed beds: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including kitchen sanitation, resident care, infection control, medication administration, complaint investigation, and administrative oversight |
| Staff 2 | LPN / Resident Services Coordinator | Named in multiple findings including kitchen sanitation, resident care, infection control, medication administration, complaint investigation, and administrative oversight |
| Staff 3 | Lead Med Tech / Lead MT | Named in multiple findings including kitchen sanitation, resident care, infection control, medication administration, complaint investigation, and administrative oversight |
| Staff 5 | ALF Administrator / Executive Chef | Named in kitchen sanitation findings |
| Staff 8 | Caregiver / CG | Named in resident care and infection control findings |
| Staff 9 | Caregiver / CG | Named in resident care and infection control findings |
| Staff 10 | RN | Named in complaint investigation findings |
| Staff 18 | LPN Resident Services Coordinator | Named in resident care and infection control findings |
| Staff 22 | Caregiver / CG | Named in resident care findings |
| Staff 24 | Caregiver / CG | Named in infection control findings |
| Staff 28 | Resident Services Coordinator | Named in medication administration findings |
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