Inspection Report
Re-Inspection
Capacity: 88
Deficiencies: 8
Nov 13, 2024
Visit Reason
State-compiled facility profile showing 5 inspections from 2021-2024 with deficiency history and licensing violations.
Findings
Across all inspections, the facility showed multiple deficiencies including failure to report suspected abuse timely, inaccurate acuity-based staffing tools, and maintenance issues with building cleanliness. Some deficiencies were corrected upon revisit, while others remained uncorrected.
Deficiencies (8)
| Description |
|---|
| C0000 - Comment: The findings of the re-licensure survey and revisit are documented with compliance determinations. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to notify SPD related to suspected abuse for 1 sampled resident. |
| C0361 - Acuity-Based Staffing Tool: Failed to update acuity-based staffing tool accurately for 2 sampled residents. |
| C0613 - General Building: Doors-Walls, Cleanable: Failed to ensure all interior materials and surfaces were kept clean and in good repair. |
| C0000 - Comment: The findings of the kitchen inspection documented substantial compliance. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in accordance with Food Sanitation Rules with multiple sanitation and food safety issues. |
| C0000 - Comment: The findings of the re-licensure survey and revisit are documented with compliance determinations. |
| C0655 - Call System: Failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. |
Report Facts
Inspections on page: 5
Total deficiencies: 5
Total licensing violations: 20
Total surveys: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in abuse reporting deficiency and call system deficiency |
| Staff 2 | Dietary Manager | Named in food sanitation deficiency |
| Staff 3 | Maintenance Director | Named in building cleanliness deficiency and call system monitoring |
| Staff 12 | Regional VP | Named in acuity-based staffing tool deficiency |
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