Inspection Report
Complaint Investigation
Capacity: 48
Deficiencies: 16
Apr 24, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2023-02 to 2025-04 with deficiency history and compliance findings.
Findings
Across multiple inspections, the facility exhibited deficiencies primarily related to staffing, service planning, infection prevention, training, and compliance with licensing rules. Some deficiencies were corrected upon revisit, while others remained uncorrected as of the latest inspection.
Complaint Details
Multiple inspections identified complaint investigations related to licensure complaints and acuity-based staffing tool deficiencies, with findings documented from on-site investigations conducted in May and April 2025.
Deficiencies (16)
| Description |
|---|
| C0360 - Staffing Requirements and Training: Staffing |
| C0361 - Acuity-Based Staffing Tool |
| C0363 - Acuity Based Staffing Tool - Updates & Plan |
| C0000 - Comment |
| C0252 - Resident Move-In and Eval: Res Evaluation |
| C0260 - Service Plan: General |
| C0262 - Service Plan: Service Planning Team |
| C0270 - Change of Condition and Monitoring |
| C0295 - Infection Prevention & Control |
| C0372 - Training Within 30 Days: Direct Care Staff |
| Z0142 - Administration Compliance |
| Z0155 - Staff Training Requirements |
| Z0162 - Compliance With Rules Health Care |
| C0303 - Systems: Treatment Orders |
| C0310 - Systems: Medication Administration |
| C0010 - Licensing Complaint Investigation |
Report Facts
Inspections on page: 6
Total deficiencies: 15
Total licensing violations: 10
Total abuse violations: 0
Total notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings related to staffing, infection control, training, and service plan deficiencies |
| Staff 2 | Corporate RN | Named in findings related to service plan and infection control deficiencies |
| Staff 3 | Resident Care Coordinator | Named in findings related to service plan and monitoring deficiencies |
| Staff 14 | Caregiver | Named in findings related to training deficiencies |
| Staff 15 | Caregiver | Named in findings related to training deficiencies |
| Staff 17 | RCF caregiver | Named in infection control observation deficiency |
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