Deficiencies per Year
28
21
14
7
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Census: 28
Capacity: 40
Deficiencies: 25
Aug 6, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from 2022-2025 with deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility demonstrated repeated deficiencies including failure to implement and update acuity-based staffing tools, inadequate administrative oversight, failure to follow treatment orders, insufficient staff training, and issues with resident safety and service plans. Some deficiencies were corrected over time, but several remained uncorrected as of the most recent inspections.
Complaint Details
Complaint investigations documented for inspections dated 8/6/2025, 5/22/2024, 9/27/2023, and 8/2/2022 related to licensure complaints and acuity-based staffing tool implementation.
Deficiencies (25)
| Description |
|---|
| C0362 - Acuity Based Staffing Tool - Abst Time: Failure to fully implement and update an Acuity-Based Staffing Tool (ABST), including not evaluating all residents quarterly and not accurately capturing care needs and time reflected in service plans. |
| C0363 - Acuity Based Staffing Tool - Updates & Plan: Failure to fully implement and update an Acuity-Based Staffing Tool (ABST), including not evaluating all residents quarterly and not accurately capturing care needs and time reflected in service plans. |
| C0000 - Comment: Findings of re-licensure survey and revisit documented compliance and non-compliance with applicable regulations. |
| C0150 - Facility Administration: Operation: Failed to provide effective administrative oversight to ensure quality of services rendered; immediate plan of correction requested. |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening health, safety or welfare of residents, including inaccurate diet textures placing resident at risk. |
| C0242 - Resident Services: Activities: Failed to ensure daily program of social and recreational activities based on individual and group interests and needs. |
| C0303 - Systems: Treatment Orders: Failed to ensure medication and treatment orders were carried out as prescribed and documented for sampled residents. |
| C0374 - Annual and Biennial Inservice For All Staff: Failed to ensure long-term direct care staff completed required in-service training annually. |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and annually. |
| C0260 - Service Plan: General: Failed to implement service plans reflecting resident needs for sampled residents. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen and food storage in accordance with Food Sanitation Rules; multiple cleaning and repair issues noted. |
| C0010 - Licensing Complaint Investigation: Findings of licensing complaint investigation documented. |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed for sampled resident. |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update acuity-based staffing tool. |
| C0156 - Facility Administration: Quality Improvement: Failed to develop and conduct ongoing quality improvement programs evaluating services, resident outcomes and satisfaction. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to investigate and report injuries of unknown cause as suspected abuse. |
| C0302 - Systems: Tracking Control Substances: Failed to have system in place for accurately tracking controlled substances administered. |
| C0310 - Systems: Medication Administration: Failed to ensure MARs were accurate and provided clear instructions for PRN medications. |
| C0340 - Restraints and Supportive Devices: Failed to ensure supportive devices with restraining qualities were assessed and documented properly. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient number of caregivers to meet 24-hour scheduled and unscheduled needs. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired caregiving staff demonstrated satisfactory performance within 30 days of hire. |
| C0420 - Fire and Life Safety: Safety: Failed to ensure fire drills were conducted and documented every other month and staff received fire and life safety instruction on alternate months. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to ensure environment was kept clean and in good repair; multiple damages and maintenance issues noted. |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to ensure all exit doors were equipped with operational alarms or acceptable systems to alert staff. |
Report Facts
Inspections on page: 8
Total Surveys: 8
Total Deficiencies: 35
Abuse Violations: 0
Licensing Violations: 10
Notices: 3
Licensed Beds: 40
Current Census: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including acuity-based staffing tool, service plan implementation, medication administration, and administrative oversight |
| Staff 2 | RN / Wellness Director | Named in findings related to treatment orders, resident assessments, and medication administration |
| Staff 3 | Regional RN | Named in findings related to quality improvement and resident care oversight |
| Staff 6 | Activities | Named in findings related to resident activities program |
| Staff 8 | Caregiver | Named in findings related to in-service training and resident care |
| Staff 9 | Caregiver | Named in findings related to in-service training |
| Staff 10 | Caregiver | Named in findings related to staffing shortages and resident care |
| Staff 11 | Caregiver | Named in findings related to in-service training |
| Staff 14 | Medication Technician | Named in findings related to in-service training and resident diet observations |
| Staff 16 | Cook / Dietary Aide | Named in findings related to food preparation and sanitation |
| Staff 18 | Medication Technician | Named in findings related to resident diet and medication administration |
| Staff 4 | Business Office Manager | Named in findings related to staff training records |
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