Deficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Original Licensing
Census: 43
Capacity: 48
Deficiencies: 24
Oct 29, 2025
Visit Reason
State-compiled facility profile showing 3 inspections from 2021 to 2025 with deficiency history and enforcement actions
Findings
Across all inspections, the facility was found to have multiple deficiencies including failure to ensure resident dignity and respect, inadequate reporting and investigation of abuse, incomplete and inaccurate service plans and medication administration, infection control lapses, staffing shortages, environmental safety issues, and failure to comply with fire and life safety requirements. Some deficiencies were repeated from prior inspections.
Deficiencies (24)
| Description |
|---|
| C0200 - Resident Rights and Protection - General: Failed to ensure residents were treated with dignity and respect during meal service |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report injuries of unknown cause to local SPD office when abuse could not be ruled out |
| C0260 - Service Plan: General: Failed to ensure service plans reflected current care needs and provided clear directions to staff |
| C0295 - Infection Prevention & Control: Failed to ensure infection prevention practices such as wearing barrier protection during meal service |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed |
| C0310 - Systems: Medication Administration: Failed to maintain accurate Medication Administration Records (MAR) |
| C0340 - Restraints and Supportive Devices: Failed to assess and instruct caregivers on use of supportive devices with restraining qualities |
| C0360 - Staffing Requirements and Training: Staffing: Failed to maintain adequate direct care staffing to meet resident needs |
| C0510 - General Building Exterior: Failed to store poisons, chemicals, and toxic materials in locked areas |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain facility environment clean and in good repair |
| H1510 - Individual Rights Settings: Privacy, Dignity: Failed to ensure privacy and dignity related to bathroom door locks |
| H1511 - Individual Rights Settings Right to Freedom: Failed to ensure right to freedom from restraints for residents using supportive devices |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for Residential Care and Assisted Living Facilities |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules |
| C0000 - Comment (2024 inspection): Facility was in substantial compliance with relevant OARs for Resident Services - Meals and Food Sanitation Rules |
| C0000 - Comment (2021 inspection): Documented findings of relicensure survey and re-visits with multiple deficiencies |
| C0231 - Reporting & Investigating Abuse-Other Action (2021): Failed to investigate and report injuries of unknown cause as suspected abuse |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen was in good repair, including broken tile floor near walk-in freezer |
| C0420 - Fire and Life Safety: Safety: Failed to ensure fire and life safety preparedness, instruction, and documentation |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure general fire and life safety requirements were met |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
| C0510 - General Building Exterior (2021): Failed to ensure courtyard pathway edges did not have drop offs creating trip hazards |
| C0540 - Heating and Ventilation: Failed to ensure wall heater covers did not exceed 120 degrees Fahrenheit |
| Z0142 - Administration Compliance (2021): Failed to follow licensing rules for Residential Care and Assisted Living Facilities (repeat citation) |
Report Facts
Inspections on page: 3
Total deficiencies: 22
Total surveys: 3
Notices: 1
Licensed beds: 48
Resident census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Regional Director of Operations | Named in multiple findings including dignity, abuse reporting, staffing, and infection control |
| Staff 2 | Regional Nurse Consultant, RN | Named in multiple findings including dignity, abuse reporting, staffing, and infection control |
| Staff 3 | Regional Nurse Consultant, LPN | Named in multiple findings including dignity, abuse reporting, staffing, and infection control |
| Staff 6 | RN | Named in multiple findings including dignity, abuse reporting, staffing, and infection control |
| Staff 10 | MA (Medication Aide) | Named in medication administration and treatment order findings |
| Staff 16 | Regional Maintenance Director | Named in environmental and privacy findings |
Loading inspection reports...
