Inspection Report
Kitchen
Capacity: 75
Deficiencies: 19
Oct 30, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022-2025 with deficiency history and enforcement notices.
Findings
Across multiple inspections, the facility exhibited numerous deficiencies including failures in kitchen sanitation, resident service plans, medication administration, staffing adequacy, infection control, and fire and life safety. Several deficiencies remained uncorrected as of the latest visits.
Complaint Details
Multiple complaint investigations conducted, including on 11/1/2022 and 4/16/2025, identifying deficiencies in staffing, medication administration, and resident care.
Deficiencies (19)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen sanitation and food preparation in accordance with Food Sanitation Rules. |
| C0010 - Licensing Complaint Investigation: Various complaint investigations identifying regulatory non-compliance. |
| C0260 - Service Plan: General: Failed to ensure service plans reflected resident care needs and were followed. |
| C0262 - Service Plan: Service Planning Team: Deficiencies in service planning team processes. |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication and treatment systems and professional oversight. |
| C0303 - Systems: Treatment Orders: Deficiencies related to treatment orders. |
| C0360 - Staffing Requirements and Training: Staffing: Insufficient staffing to meet resident needs and incomplete staff training. |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to complete required pre-service orientation and training for new staff. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired direct care staff demonstrated required competencies within 30 days. |
| C0295 - Infection Prevention & Control: Failed to maintain infection prevention protocols during incontinence care. |
| C0310 - Systems: Medication Administration: MARs inaccurate and lacking resident-specific parameters and instructions. |
| C0330 - Systems: Psychotropic Medication: PRN psychotropic medications lacked resident-specific parameters and non-drug interventions. |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update acuity-based staffing tool. |
| C0420 - Fire and Life Safety: Safety: Failed to ensure unannounced fire drills included required components and staff received fire safety instruction. |
| C0613 - General Building: Doors-Walls, Cleanable: Facility environment not kept clean and in good repair. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to conduct thorough resident evaluations prior to move-in and after changes. |
| C0280 - Resident Health Services: Failed to assess significant changes of condition by RN. |
| C0282 - Rn Delegation and Teaching: Failed to ensure proper delegation and supervision of nursing tasks. |
| C0200 - Resident Rights and Protection - General: Failed to keep resident medical records confidential. |
Report Facts
Inspections on page: 10
Total deficiencies: 35
Licensing violations: 10
Notices: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director / Interim ED | Named in multiple findings including kitchen sanitation, medication administration, delegation, and service plan deficiencies. |
| Staff 2 | Dining Service Manager / LPN/Health Services Director | Named in kitchen sanitation and medication administration findings. |
| Staff 3 | Maintenance Director | Named in fire and life safety and general building deficiencies. |
| Staff 4 | Medication Technician (MT) | Named in delegation and medication administration deficiencies. |
| Staff 5 | Dietary Services Manager | Named in kitchen sanitation findings. |
| Staff 9 | Medication Technician (MT) | Named in infection prevention and medication administration deficiencies. |
| Staff 10 | Medication Technician (MT) | Named in delegation and medication administration deficiencies. |
| Staff 21 | Regional RN Support | Named in assessment and staffing tool deficiencies. |
| Staff 22 | Medication Technician (MT) | Named in delegation deficiencies. |
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