Inspection Report
Capacity: 90
Deficiencies: 14
Jul 8, 2024
Visit Reason
State-compiled facility profile showing 3 inspections from 2022 to 2024 with deficiency history and enforcement violations.
Findings
Across three inspections from 2022 to 2024, the facility showed multiple deficiencies primarily related to food sanitation, resident care plans, abuse investigations, and facility maintenance. Some deficiencies were corrected upon revisit, while others remained uncorrected.
Deficiencies (14)
| Description |
|---|
| C0000 - Comment: Findings of kitchen inspections and general comments documented. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Facility failed to maintain kitchen in good repair and sanitary manner including moldy food, improper refrigeration temperatures, and inadequate cleaning of water and ice dispensers. |
| C0295 - Infection Prevention & Control: Facility lacked policy and procedures for exclusion of food service workers when sick or ill with contagious food-related illness. |
| Z0142 - Administration Compliance: Facility failed to follow licensing rules for Residential Care and Assisted Living Facilities, referencing C240 and C295. |
| C0231 - Reporting & Investigating Abuse-Other Action: Facility failed to ensure prompt investigation and reporting of injuries and incidents to rule out abuse or neglect for sampled residents. |
| C0242 - Resident Services: Activities: Facility failed to ensure a daily program of social and recreational activities based on resident needs and interests. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Facility failed to ensure move-in evaluations addressed all required elements and were completed prior to admission for sampled residents. |
| C0260 - Service Plan: General: Facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction for delivery of services. |
| C0305 - Systems: Resident Right to Refuse: Facility failed to notify physician when a resident refused medication as ordered. |
| C0330 - Systems: Psychotropic Medication: Facility failed to document non-pharmacological interventions prior to administering PRN psychotropic medications. |
| C0361 - Acuity-Based Staffing Tool: Facility failed to ensure the Acuity-Based Staffing Tool was updated to accurately reflect resident care needs. |
| Z0142 - Administration Compliance: Facility failed to follow licensing rules referencing C231, C242 and C361. |
| Z0162 - Compliance With Rules Health Care: Facility failed to follow licensing rules referencing C252, C260, C305 and C330. |
| Z0173 - Secure Outdoor Recreation Area: Facility failed to ensure fences surrounding outdoor recreation area were at least six feet in height. |
Report Facts
Inspections on page: 3
Total deficiencies: 13
Total licensing violations: 18
Total surveys: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings including abuse investigation and food sanitation deficiencies |
| Staff 2 | Assistant Administrator / Head Cook / Person in Charge | Named in food sanitation and infection prevention findings |
| Staff 3 | Resident Care Coordinator (RCC) | Named in abuse investigation and medication refusal findings |
| Staff 5 | Licensed Practical Nurse (LPN) | Named in abuse investigation and medication refusal findings |
| Staff 6 | Licensed Practical Nurse (LPN) | Named in abuse investigation and medication refusal findings |
| Staff 23 | Activity Director | Named in activities program deficiency |
| Chief Operations Officer | Infection Control Specialist | Named in infection prevention plan of correction |
| Kitchen Coordinator | Kitchen Coordinator | Responsible for oversight of kitchen cleaning and audits in plan of correction |
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