Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Re-Inspection
Capacity: 100
Deficiencies: 16
Nov 6, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2022-2025 with deficiency history and enforcement actions
Findings
Across multiple inspections, the facility demonstrated repeated deficiencies in resident rights, evaluations, service plans, health services, infection control, medication administration, staffing tools, fire and life safety, and building maintenance. Deficiencies were often not corrected at the time of visits and involved multiple residents and staff.
Complaint Details
Complaint investigation conducted on 1/24/2024 related to licensure complaint with deficiencies in meals and treatment orders
Deficiencies (16)
| Description |
|---|
| C0200 - Resident Rights and Protection - General: Failed to ensure residents were treated with dignity and respect, privacy was protected, and medical records kept confidential |
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements and were performed quarterly and relevant to residents' current conditions |
| C0260 - Service Plan: General: Failed to ensure service plans were completed quarterly, reflective of resident needs, provided clear instructions, implemented, and updated after significant changes |
| C0280 - Resident Health Services: Failed to ensure timely RN assessments for residents with significant changes of condition related to weight loss |
| C0295 - Infection Prevention & Control: Failed to maintain infection prevention protocols during ADL care and proper disposal of incontinence trash |
| C0303 - Systems: Treatment Orders: Failed to ensure medication and treatment orders were carried out as prescribed and properly documented |
| C0310 - Systems: Medication Administration: Failed to maintain accurate Medication Administration Records (MAR) for all medications including OTC |
| C0363 - Acuity Based Staffing Tool - Updates & Staffing Plan: Failed to complete and update ABST evaluations prior to admission, after significant changes, and quarterly |
| C0420 - Fire and Life Safety: Safety: Failed to ensure written fire drill records included all required elements |
| C0613 - General Building: Doors-Walls, Cleanable: Failed to ensure interior surfaces were clean and in good repair |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols met Food Sanitation Rules |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to provide three nutritious, palatable meals |
| C0303 - Systems: Treatment Orders: Failed to carry out medication orders as prescribed for a sampled resident |
| C0000 - Comment: Documented findings of kitchen inspections and revisits |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure staff completed required Infectious Disease Prevention training prior to 07/01/22 |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired staff completed abdominal thrust and First Aid training within 30 days |
Report Facts
Inspections on page: 5
Total deficiencies: 17
Total surveys: 5
Licensing violations: 10
Abuse violations: 0
Notices: 1
Licensed beds: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director (ED) | Named in multiple findings related to resident rights, evaluations, service plans, health services, infection control, medication administration, staffing, and fire safety |
| Staff 2 | Resident Care Coordinator (RCC) | Named in multiple findings related to resident evaluations, service plans, infection control, medication administration, and staffing |
| Staff 3 | Resident Care Coordinator (RCC) | Named in findings related to resident rights, infection control, medication administration, and evaluations |
| Staff 5 | Licensed Practical Nurse (LPN) | Named in findings related to resident rights, evaluations, service plans, infection control, medication administration, and health services |
| Witness 1 | RN Consultant | Named in multiple findings and interviews related to resident rights, evaluations, service plans, health services, infection control, medication administration, and staffing |
| Staff 6 | Plant Operations Tech | Named in fire and life safety and building maintenance findings |
| Staff 8 | Caregiver (CG) | Named in service plan deficiency observation |
| Staff 10 | Medication Technician / Caregiver (MT/CG) | Named in infection control and ostomy care findings |
| Staff 15 | Caregiver (CG) / Resident Assistant | Named in infection control and training deficiencies |
| Staff 20 | Caregiver (CG) | Named in infection control findings |
| Staff 2 | Administrator | Named in kitchen inspection findings |
| Staff 4 | Dishwasher/Dietary Aide | Named in kitchen inspection findings |
| Staff 6 | Sous Chef | Named in training deficiency |
| Staff 7 | Activities Director | Named in training deficiency |
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