Deficiencies per Year
40
30
20
10
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Capacity: 44
Deficiencies: 37
Feb 5, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2021 to 2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited numerous deficiencies including failures in staffing, resident health services, infection control, medication administration, abuse reporting, and fire safety. Several deficiencies were repeat citations, with immediate plans of correction requested for serious risks to resident health and safety.
Complaint Details
The most recent inspection dated 2024-11-15 was a complaint investigation involving licensure complaints with findings of staffing deficiencies and multiple failures in resident care, abuse reporting, and infection control. Immediate plans of correction were requested for serious risks to resident health and safety.
Deficiencies (37)
| Description |
|---|
| C0360 - Staffing Requirements and Training: Staffing |
| C0000 - Comment |
| C0150 - Facility Administration: Operation |
| C0152 - Facility Administration: Required Postings |
| C0155 - Facility Administration: Records |
| C0156 - Facility Administration: Quality Improvement |
| C0231 - Reporting & Investigating Abuse-Other Action |
| C0260 - Service Plan: General |
| C0270 - Change of Condition and Monitoring |
| C0280 - Resident Health Services |
| C0282 - Rn Delegation and Teaching |
| C0295 - Infection Prevention & Control |
| C0300 - Systems: Medications and Treatments |
| C0303 - Systems: Treatment Orders |
| C0305 - Systems: Resident Right to Refuse |
| C0310 - Systems: Medication Administration |
| C0330 - Systems: Psychotropic Medication |
| C0361 - Acuity-Based Staffing Tool |
| C0372 - Training Within 30 Days: Direct Care Staff |
| C0420 - Fire and Life Safety: Safety |
| C0455 - Inspections and Investigation: Insp Interval |
| H1517 - Individual Privacy: Own Unit |
| H1518 - Individual Door Locks: Key Access |
| H1580 - Limitations: Threats to Health and Safety |
| Z0142 - Administration Compliance |
| Z0155 - Staff Training Requirements |
| Z0162 - Compliance With Rules Health Care |
| Z0163 - Nutrition and Hydration |
| Z0164 - Activities |
| Z0173 - Secure Outdoor Recreation Area |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable |
| C0240 - Resident Services Meals, Food Sanitation Rule |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable |
| C0158 - Disclosure & Notification to Potential Res |
| C0160 - Reasonable Precautions |
| C0252 - Resident Move-In and Eval: Res Evaluation |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc |
Report Facts
Inspections on page: 7
Total deficiencies: 49
Licensing violations: 10
Notices: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings related to administrative oversight, abuse reporting, and acknowledging deficiencies |
| Staff 3 | RN/Wellness Director | Named in findings related to nursing delegation, resident assessments, and acknowledging deficiencies |
| Staff 22 | Wellness Nurse, RN | Named in findings related to infection control, abuse reporting, and resident care oversight |
| Staff 27 | Executive Director | Named in findings related to fire safety, abuse reporting, and administrative oversight |
| Staff 36 | ALF Administrator | Named in findings related to staffing, abuse reporting, and administrative oversight |
| Staff 37 | Chief Wellness Officer | Named in findings related to quality improvement and infection control |
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