Deficiencies per Year
28
21
14
7
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Kitchen
Capacity: 63
Deficiencies: 25
Jun 6, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from 2022-2025 with deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility demonstrated numerous deficiencies primarily related to food sanitation, medication administration, staffing, resident care plans, and complaint investigations. Several deficiencies remained uncorrected at the time of inspections, with ongoing issues in kitchen sanitation, medication tracking, and resident safety.
Complaint Details
Multiple complaint investigations were conducted, identifying deficiencies related to medication administration, treatment orders, staffing, and resident care. Several complaints remain uncorrected as of the latest inspections.
Deficiencies (25)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen and food service areas in accordance with Food Sanitation Rules including cleanliness, equipment repair, food storage, and staff knowledge. |
| C0360 - Staffing Requirements and Training: Staffing |
| C0362 - Acuity Based Staffing Tool - Abst Time |
| C0363 - Acuity Based Staffing Tool - Updates & Plan |
| C0000 - Comment |
| C0301 - Systems: Medication Administration |
| C0010 - Licensing Complaint Investigation |
| C0303 - Systems: Treatment Orders |
| C0000 - Comment |
| C0160 - Reasonable Precautions |
| C0200 - Resident Rights and Protection - General |
| C0231 - Reporting & Investigating Abuse-Other Action |
| C0260 - Service Plan: General |
| C0270 - Change of Condition and Monitoring |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc |
| C0300 - Systems: Medications and Treatments |
| C0302 - Systems: Tracking Control Substances |
| C0303 - Systems: Treatment Orders |
| C0310 - Systems: Medication Administration |
| C0374 - Annual and Biennial Inservice For All Staff |
| C0000 - Comment |
| C0240 - Resident Services Meals, Food Sanitation Rule |
| C0010 - Licensing Complaint Investigation |
| C0303 - Systems: Treatment Orders |
| C0365 - Staffing Rqmt and Training: Training Rqmts |
Report Facts
Inspections on page: 9
Total deficiencies: 22
Licensing violations: 10
Abuse violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Reeves | Administrator | Named as Administrator in facility information |
| Staff 1 | Executive Director | Named in multiple findings and plan of correction discussions |
| Staff 2 | Wellness Director/LPN or Dining Services Director | Named in multiple findings and plan of correction discussions related to kitchen and medication |
| Staff 3 | RN or Maintenance | Named in findings and plan of correction discussions |
| Staff 11 | Medication Technician | Named in training deficiency |
| Staff 13 | Caregiver/Medication Technician | Named in resident care plan deficiency |
| Staff 15 | Caregiver | Named in training deficiency |
| Staff 17 | Van Driver | Named in abuse investigation deficiency |
| Staff 4 | Regional RN | Named in medication administration deficiency |
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