Inspection Report
Capacity: 60
Deficiencies: 15
Oct 23, 2025
Visit Reason
State-compiled facility profile showing 3 inspections from 2023-2025 with deficiency history related to kitchen, licensure, and re-licensure surveys.
Findings
Across all inspections, the facility exhibited multiple deficiencies primarily related to kitchen sanitation and maintenance, resident service plans, staff training, medication delegation, and fire and life safety documentation. Some deficiencies were corrected upon revisit, while others remained uncorrected as of the latest inspections.
Deficiencies (15)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner including unwrapped silverware, damaged baseboards, stained sinks, grease build-up, undated food items, and improper food storage. |
| C0000 - Comment: Findings of kitchen inspection and revisit documented with substantial compliance noted on revisit. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Kitchen not maintained per Food Sanitation Rules with multiple areas needing cleaning and repair including unlabeled/undated food, damaged equipment, and uncleanable surfaces. |
| C0000 - Comment: Findings of re-licensure survey and revisit documented with substantial compliance noted on revisit. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Kitchen needed cleaning and repair including food spills, debris, damaged equipment, and uncleanable surfaces. |
| C0260 - Service Plan: General: Service plans not reflective or updated quarterly for sampled residents, lacking clear instructions for mobility and care needs. |
| C0262 - Service Plan: Service Planning Team: Service plans not developed by required service planning team for sampled residents. |
| C0270 - Change of Condition and Monitoring: Failed to develop, communicate, and monitor interventions for residents with changes of condition. |
| C0282 - Rn Delegation and Teaching: Failed to ensure delegation and supervision of nursing tasks per OSBN Division 47 rules for insulin administration by unlicensed staff. |
| C0325 - Systems: Self-Administration of Meds: Resident self-administered medications without physician's order approval. |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure pre-service orientation and dementia care training completed for new staff. |
| C0374 - Annual and Biennial Inservice For All Staff: Lacked documented evidence of required annual in-service training including dementia care for long-term staff. |
| C0420 - Fire and Life Safety: Safety: Fire drill records lacked documentation of required components including problems encountered, evacuation time, and number of occupants evacuated. |
| C0422 - Fire and Life Safety: Training For Residents: Failed to provide annual fire and life safety instruction to residents with documentation. |
| C0613 - General Building: Doors-Walls, Cleanable: Interior materials and surfaces not kept clean and in good repair including gouges, scratches, stains, and debris in multiple areas. |
Report Facts
Inspections on page: 3
Total deficiencies: 13
Total licensing violations: 6
Total surveys: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings discussions and acknowledgments |
| Staff 2 | Dietary Service Director | Named in kitchen inspection findings and acknowledgments |
| Staff 3 | Wellness Director | Named in service plan, change of condition, and training findings |
| Staff 4 | Wellness Coordinator | Named in RN delegation findings |
| Staff 5 | Maintenance Director | Named in fire and life safety and building maintenance findings |
| Staff 6 | Dining Services Director | Named in kitchen inspection findings |
| Staff 12 | MT | Named in RN delegation findings |
| Staff 13 | CG | Named in pre-service training findings |
| Staff 14 | MT | Named in annual in-service training findings |
| Staff 15 | MT | Named in annual in-service training findings |
| Staff 16 | MT | Named in pre-service training findings |
| Staff 17 | Business Office Director | Named in training record reviews |
| Staff 2 | RN | Named in RN delegation findings |
| Staff 3 | Wellness Director | Named in RN delegation findings |
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