Deficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Census: 52
Capacity: 64
Deficiencies: 18
Nov 4, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2022-2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited numerous deficiencies including failures in kitchen sanitation, administration compliance, resident care and safety, infection control, staffing, service planning, and fire and life safety training. Many deficiencies were repeated across inspections and involved multiple residents and staff.
Complaint Details
Complaint investigations conducted on 10/18/2022 and 2/7/2024 revealed failures to immediately notify local Department offices of incidents of abuse or suspected abuse for multiple residents, failures in staff training, call system functionality, and service plan implementation.
Deficiencies (18)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules including cleaning, maintenance, and proper dishwashing temperatures |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for Residential Care and Assisted Living Facilities |
| C0150 - Facility Administration: Operation: Failed to provide effective oversight to ensure quality of care and services rendered |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions to protect resident health and safety including improper handling and call system failures |
| C0200 - Resident Rights and Protection - General: Failed to ensure residents were treated with dignity and respect and maintained a safe and homelike environment during care |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report incidents of abuse and injuries of unknown cause to local SPD office and conduct appropriate investigations |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' needs, provided clear direction, and were implemented |
| C0270 - Change of Condition and Monitoring: Failed to determine, document, communicate, and monitor actions or interventions for changes of condition |
| C0280 - Resident Health Services: Failed to ensure timely RN assessments and documentation for significant changes of condition |
| C0295 - Infection Prevention & Control: Failed to follow infection prevention and control protocols during incontinence care and handling of soiled items |
| C0340 - Restraints and Supportive Devices: Failed to ensure devices with restraining qualities were assessed quarterly for safety and least restrictive use |
| C0362 - Acuity Based Staffing Tool - ABST Time: Failed to accurately capture care time and care elements in staffing tool for residents |
| C0420 - Fire and Life Safety: Safety: Failed to provide fire and life safety instruction to staff on alternate months |
| C0422 - Fire and Life Safety: Training for Residents: Failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure plan of correction was implemented and satisfied the Department |
| C0513 - Doors, Walls, Elevators, Odors: Failed to keep interior and exterior materials and surfaces clean and in good repair |
| H1510 - Individual Rights Settings: Privacy, Dignity: Failed to ensure resident rights of privacy and dignity during ADL care |
| H1518 - Individual Door Locks: Key Access: Failed to ensure residents and only appropriate staff had keys to access units |
Report Facts
Inspections on page: 7
Total deficiencies: 47
Licensing violations: 10
Notices: 3
Licensed beds: 64
Census: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Campero | Administrator | Named as facility administrator in facility information |
| Staff 1 | Executive Director | Named in multiple findings related to administration, resident care, and compliance |
| Staff 2 | Health Services Director / LPN | Named in findings related to resident care and compliance |
| Staff 3 | Registered Nurse | Named in findings related to resident health services and assessments |
| Staff 4 | Regional Director of Health Services | Named in findings related to compliance and investigations |
| Staff 5 | Resident Care Coordinator | Named in findings related to resident care and compliance |
| Staff 6 | Resident Care Coordinator | Named in RN assessment completion |
| Staff 7 | Maintenance Director | Named in findings related to facility maintenance and fire safety |
| Staff 9 | Caregiver | Named in resident care and infection control findings |
| Staff 12 | Caregiver | Named in resident care and infection control findings |
| Staff 18 | Caregiver | Named in resident care and infection control findings |
| Staff 28 | Director of Health Services / LPN | Named in findings related to resident service plans and compliance |
| Staff 30 | Regional Director of Health Services | Named in findings related to resident safety and compliance |
| Staff 31 | Administrator | Named in findings related to resident safety and compliance |
| Staff 33 | Caregiver | Named in resident safety findings |
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