Inspection Report
Change Of Owner
Census: 40
Capacity: 56
Deficiencies: 30
Oct 10, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2023-2025 with deficiency history and enforcement notices
Findings
Across multiple inspections from 2023 to 2025, the facility exhibited numerous deficiencies including failures in quality improvement programs, abuse reporting, resident evaluations, service plan availability and accuracy, change of condition monitoring, infection prevention, medication administration, staffing adequacy, training, and resident privacy. Immediate risks were addressed during the most recent change of ownership survey.
Complaint Details
Complaint investigation conducted on 2024-07-17 found failures in service plan implementation and acuity-based staffing tool documentation; verbal plan of correction provided.
Deficiencies (30)
| Description |
|---|
| C0156 - Facility Administration: Quality Improvement: Failed to conduct ongoing quality improvement programs evaluating services, resident outcomes, and satisfaction |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report injuries of unknown cause as suspected abuse and failed to investigate promptly |
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to ensure all required elements were addressed in initial resident evaluations |
| C0260 - Service Plan: General: Failed to ensure service plans were available, reflective of current needs, and provided clear directions to staff |
| C0270 - Change of Condition and Monitoring: Failed to evaluate, document, communicate, and monitor residents' changes of condition appropriately |
| C0280 - Resident Health Services: Failed to ensure RN assessments included documented findings, resident status, and interventions for significant changes |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to coordinate on-site health services with outside providers and update service plans accordingly |
| C0295 - Infection Prevention & Control: Failed to follow infection prevention and control protocols to ensure a safe, sanitary environment |
| C0302 - Systems: Tracking Control Substances: Failed to have an effective system for tracking controlled substances administered |
| C0310 - Systems: Medication Administration: Failed to maintain accurate MARs including resident-specific parameters and instructions |
| C0330 - Systems: Psychotropic Medication: Failed to ensure psychotropic medications had resident-specific parameters and documented non-pharmacological interventions |
| C0360 - Staffing Requirements and Training: Staffing: Failed to ensure minimum two direct care staff scheduled and available when two-person assist needed |
| C0361 - Acuity Based Staffing Tool - Elements: Failed to adopt an ABST that addressed and documented all required individual care elements |
| C0362 - Acuity Based Staffing Tool - ABST Time: Failed to ensure ABST reports reflected distinct areas and accurately captured care time and elements |
| C0363 - Acuity Based Staffing Tool - Updates & Staffing Plan: Failed to update and review ABST evaluation after significant change of condition |
| C0370 - Staffing Requirements and Training – Pre-service: Failed to ensure newly hired direct care staff demonstrated competency in first aid and abdominal thrust training within 30 days |
| 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 training within 30 days |
| C0422 - Fire and Life Safety: Training for Residents: Failed to instruct residents on fire and life safety procedures within 24 hours of admission and annually |
| H1510 - Individual Rights Settings: Privacy, Dignity: Failed to ensure privacy, dignity, and respect for residents; service plans accessible in common areas |
| H1517 - Individual Privacy: Own Unit: Failed to ensure privacy in own unit for residents sharing bathrooms and during ADL care |
| L0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements including pronouns and gender identity |
| Z0140 - Administration Responsibilities: Failed to provide effective oversight for facility operation and quality of services |
| Z0142 - Administration Compliance: Failed to provide effective oversight for facility operation and quality of services |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired staff completed required pre-service orientation and dementia training topics and demonstrated competency |
| Z0162 - Compliance with Rules Health Care: Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| Z0163 - Nutrition and Hydration: Failed to ensure individualized nutrition and hydration plans were developed and included in service plans |
| Z0164 - Activities: Failed to evaluate residents for activities addressing all required elements and develop individualized activity plans |
| C0000 - Comment: Kitchen inspections documented findings related to food sanitation and compliance with OARs |
| C0160 - Reasonable Precautions: Failed to implement effective infection control and exercise reasonable precautions against health threats |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure food was prepared and kitchen maintained in accordance with Food Sanitation Rules |
Report Facts
Inspections on page: 4
Total deficiencies: 36
Total licensing violations: 10
Total notices: 2
Facility licensed beds: 56
Facility census: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings including abuse reporting, change of condition, infection control, medication administration, staffing, and administrative oversight |
| Staff 2 | Resident Care Coordinator (RCC) | Named in multiple findings including abuse reporting, infection control, medication administration, staffing, and administrative oversight |
| Staff 20 | Regional Director of Operations | Acknowledged multiple findings during interviews |
| Staff 17 | Health Services Director / RN | Named in findings related to RN assessments and controlled substances tracking |
| Staff 4 | Medication Technician (MT) | Named in findings related to medication administration and psychotropic medication parameters |
| Staff 3 | Medication Technician (MT) | Named in findings related to psychotropic medication parameters |
| Staff 6 | Caregiver (CG) | Named in infection prevention and control observations |
| Staff 12 | Caregiver (CG) | Named in infection prevention and control observations |
| Staff 14 | Operations & Administration Director | Named in findings related to staff training and competency |
| Staff 10 | Caregiver (CG) | Named as newly hired direct care staff lacking required training and competency |
| Staff 13 | Medication Technician (MT) | Named as newly hired direct care staff lacking required training and competency |
| Staff 16 | Caregiver (CG) | Named as newly hired direct care staff lacking required training and competency |
| Staff 18 | Maintenance Manager | Named in fire and life safety training deficiency |
| Staff 19 | Caregiver (CG) | Named in staff training competency deficiency |
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