Inspection Report
Re-Inspection
Capacity: 28
Deficiencies: 25
Nov 19, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2022-2025 with deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility demonstrated numerous deficiencies including failure to monitor and document changes of condition, inadequate tracking of controlled substances, incomplete staff training, failure to notify authorities of abuse incidents timely, and deficiencies in resident care plans and facility maintenance. Some deficiencies were corrected in follow-up visits, but many remained uncorrected as of the latest inspection.
Complaint Details
The complaint investigation conducted 05/15/24 to 05/16/24 found the facility failed to immediately notify the local Department office or AAA of abuse or suspected abuse incidents, with delays in reporting to Adult Protective Services documented for multiple incidents.
Deficiencies (25)
| Description |
|---|
| C0270 - Change of Condition and Monitoring: Failed to determine actions or interventions needed, communicate to staff, and monitor changes through resolution for residents with short-term changes of condition. |
| C0302 - Systems: Tracking Control Substances: Failed to have a system in place for accurately tracking controlled substances administered by the facility. |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Failed to ensure newly hired direct care staff demonstrated competency in first aid and abdominal thrust within 30 days of hire. |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for Residential Care and Assisted Living Facilities. |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules. |
| C0000 - Comment: Kitchen inspection findings documented; facility found in substantial compliance on re-visit. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols met Food Sanitation Rules; cleaning deficiencies observed. |
| Z0142 - Administration Compliance: Failed to follow licensing rules; referred to C240. |
| C0010 - Licensing Complaint Investigation: Findings documented from on-site investigation for compliance with OARs. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to immediately notify local Department or AAA of abuse or suspected abuse incidents. |
| C0260 - Service Plan: General: Failed to include written description in service plans of who provides services and details of service delivery for sampled residents. |
| C0310 - Systems: Medication Administration: Citation noted but no detailed findings provided. |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update an acuity-based staffing tool. |
| Z0163 - Nutrition and Hydration: Failed to ensure individualized nutrition and hydration plans were developed for sampled residents. |
| Z0164 - Activities: Failed to provide a daily program of social and recreational activities based on individual and group interests and needs. |
| C0270 - Change of Condition and Monitoring: Failed to evaluate changes of condition, implement interventions, provide staff directions, monitor conditions, and notify RN for sampled residents. |
| C0280 - Resident Health Services: Failed to ensure RN significant change of condition assessment was completed following severe weight loss for a sampled resident. |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to ensure outside service providers left written documentation and coordinate care for sampled residents. |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when resident refused medication orders. |
| C0330 - Systems: Psychotropic Medication: Failed to ensure documented non-pharmacological interventions prior to PRN psychotropic administration and complete documentation of PRN administrations. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired staff completed abdominal thrust and First Aid training within 30 days. |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills and provide fire and life safety instruction to staff on alternating months as required. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain building in good repair; observed paint chipping, gouges, missing plaster, and worn baseboards. |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired staff completed all required pre-service orientation and demonstrated competency in assigned duties within 30 days. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules; referred to multiple citations. |
Report Facts
Inspections on page: 5
Total deficiencies: 25
Total surveys: 5
Abuse violations: 0
Licensing violations: 20
Notices: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including abuse reporting, acuity-based staffing, and training deficiencies |
| Staff 2 | Resident Services Coordinator/RN | Named in findings related to change of condition monitoring and abuse reporting |
| Staff 3 | Memory Care Coordinator/LPN | Named in findings related to change of condition monitoring and controlled substances tracking |
| Staff 4 | Behavioral Support Specialist | Named in findings related to change of condition monitoring |
| Staff 5 | Environmental Services Director | Named in findings related to facility maintenance |
| Staff 9 | Universal Worker | Named in training deficiencies |
| Staff 10 | Caregiver | Named in training deficiencies |
| Staff 11 | Caregiver/Universal Worker | Named in training deficiencies |
| Staff 7 | Universal Worker | Named in training deficiencies |
| Staff 4 | Activities Director | Named in findings related to activities program deficiencies |
| Staff 1 | Dietary Manager/Cook | Named in kitchen sanitation deficiencies |
| Staff 3 | Regional Director of Operations | Named in multiple findings and acknowledgments |
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