Inspection Report
Capacity: 30
Deficiencies: 25
May 30, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2021 to 2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited numerous deficiencies including failures in food sanitation, service plan accuracy, infection prevention, staff training, fire and life safety, housekeeping, medication administration, and abuse reporting. Some deficiencies were corrected over time, but several remained uncorrected as of the most recent inspections.
Complaint Details
Complaint investigation on 2/2/2021 found failure to ensure reasonable precautions against health threats including inconsistent COVID-19 screening and lack of eye protection.
Deficiencies (25)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Facility failed to ensure the kitchen was in good repair, clean and appropriate storage was maintained in accordance with Food Sanitation Rules. |
| Z0142 - Administration Compliance: Facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
| C0260 - Service Plan: General: Facility failed to ensure service plans reflected residents' current health status and needs and provided clear direction to staff. |
| C0270 - Change of Condition and Monitoring: Facility failed to determine and document needed actions or interventions for short term changes of condition and monitor changes until resolved. |
| C0295 - Infection Prevention & Control: Facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Facility failed to ensure newly hired direct care staff completed required first aid and abdominal thrust training within 30 days of hire. |
| C0420 - Fire and Life Safety: Safety: Facility failed to ensure life safety instruction to staff was provided on alternate months and fire drills were properly conducted and documented. |
| C0530 - Housekeeping and Laundry: Facility failed to ensure proper processing of soiled linens and separation from clean linens. |
| Z0155 - Staff Training Requirements: Facility failed to ensure staff completed all required pre-service orientation, dementia training, and annual training hours. |
| Z0162 - Compliance with Rules Health Care: Facility failed to provide health care services in accordance with licensing rules. |
| Z0163 - Nutrition and Hydration: Facility failed to ensure individualized nutrition and hydration plans were developed and documented for residents. |
| C0160 - Reasonable Precautions: Facility failed to ensure reasonable precautions against conditions threatening health and welfare, including inconsistent COVID-19 screening and lack of eye protection. |
| C0231 - Reporting & Investigating Abuse-Other Action: Facility failed to promptly investigate and report allegations of suspected abuse involving residents. |
| C0242 - Resident Services: Activities: Facility failed to provide an activity program based on individual and group interests and needs. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Facility failed to ensure move-in and quarterly evaluations addressed all required elements and reflected residents' status. |
| C0280 - Resident Health Services: Facility failed to ensure RN assessments and interventions were completed for residents with significant changes or weight changes. |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Facility failed to coordinate care with outside providers and implement recommendations. |
| C0302 - Systems: Tracking Control Substances: Facility failed to have accurate tracking system for controlled substances administered. |
| C0303 - Systems: Treatment Orders: Facility failed to ensure medication and treatment orders were carried out as prescribed. |
| C0310 - Systems: Medication Administration: Facility failed to ensure MARs were accurate and documented medication administration properly. |
| C0330 - Systems: Psychotropic Medication: Facility failed to ensure PRN psychoactive medications were given only for specific symptoms and after non-drug interventions. |
| C0340 - Restraints and Supportive Devices: Facility failed to ensure supportive devices were assessed and staff instructed on proper use. |
| Z0164 - Activities: Facility failed to consistently provide meaningful activities and individualized activity plans for residents. |
| Z0165 - Behavior: Facility failed to provide individualized service plans for behavioral symptoms impacting residents or others. |
| Z0173 - Secure Outdoor Recreation Area: Facility failed to provide access to secured outdoor space allowing residents independent entry and return. |
Report Facts
Inspections on page: 6
Total deficiencies: 39
Licensing violations: 8
Abuse violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RETA HOLDER | Administrator | Named in multiple findings and acknowledgments across inspections |
| Staff 1 | Executive Director | Named in multiple findings and acknowledgments across inspections |
| Staff 2 | Operations Director | Named in multiple findings and acknowledgments across inspections |
| Staff 3 | Lead Med Tech / RCC | Named in infection control and medication administration findings |
| Staff 5 | Maintenance Director / Cook | Named in kitchen and maintenance related findings |
| Staff 6 | Care Partner | Named in housekeeping and laundry findings |
Loading inspection reports...
