Inspection Report
Kitchen
Census: 75
Capacity: 100
Deficiencies: 31
Dec 3, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from 2021-2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited repeated deficiencies including failure to maintain kitchen sanitation, inadequate staffing levels, failure to report abuse incidents timely, incomplete resident care plans, and insufficient emergency preparedness drills. Several deficiencies remained uncorrected at follow-up visits.
Complaint Details
Complaint investigations conducted on 4/14/2023, 2/13/2024, and 5/27/2025 identified multiple deficiencies including medication errors, failure to report abuse, and staffing issues.
Deficiencies (31)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner with multiple areas contaminated or in need of repair |
| C0362 - Acuity Based Staffing Tool - Abst Time: Failed to properly use Acuity Based Staffing Tool |
| C0363 - Acuity Based Staffing Tool - Updates & Plan: Failed to update and maintain posted staffing plan per ABST requirements |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report incidents of abuse or suspected abuse to local SPD office timely |
| C0360 - Staffing Requirements and Training: Staffing: Failed to ensure sufficient direct care staff to meet fire safety evacuation standards |
| C0422 - Fire and Life Safety: Training for Residents: Failed to instruct residents on fire and life safety procedures within required timeframes and maintain training records |
| C0435 - Emergency and Disaster Planning: Failed to conduct emergency preparedness drills at least twice a year as required |
| C0370 - Staffing Requirements and Training – Pre-service: Failed to ensure staff preparing and serving food had active food handler certificates |
| C0301 - Systems: Medication Administration: Failed to ensure staff visually observed resident take medication |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed |
| C0340 - Restraints and Supportive Devices: Failed to conduct thorough assessment before use of supportive devices with restraining qualities |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update Acuity Based Staffing Tool |
| C0000 - Comment: Various comments related to inspections and compliance |
| C0150 - Facility Administration: Operation: Failed to provide effective oversight to ensure quality of care and services |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening resident health and safety |
| C0200 - Resident Rights and Protection - General: Failed to ensure resident was treated with dignity and respect |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' current status and provided clear direction |
| C0270 - Change of Condition and Monitoring: Failed to evaluate and monitor changes of condition and communicate to staff |
| C0280 - Resident Health Services: Failed to ensure RN assessment completed for significant changes of condition |
| C0282 - RN Delegation and Teaching: Failed to ensure delegation and supervision of nursing care tasks per OSBN rules |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to coordinate care with outside providers and update service plans |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication system and adequate professional oversight |
| C0302 - Systems: Tracking Control Substances: Failed to maintain accurate controlled substances tracking system |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when resident refused medications |
| C0310 - Systems: Medication Administration: Failed to ensure MARs were accurate and included reasons for use and clear instructions |
| C0325 - Systems: Self-Administration of Meds: Failed to complete quarterly self-administration evaluations |
| C0330 - Systems: Psychotropic Medication: Failed to include non-pharmacological interventions and parameters for PRN psychotropic meds |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to document competency of newly hired direct care staff within 30 days |
| C0420 - Fire and Life Safety: Safety: Failed to provide documentation of required fire drill components and training |
| C0610 - General Building Exterior: Failed to maintain perimeter walkway surfaces in good repair |
| C0640 - Heating and Ventilation: Failed to ensure wall heater covers did not exceed 120 degrees Fahrenheit |
Report Facts
Inspections on page: 9
Total deficiencies: 46
Total licensing violations: 10
Total notices: 4
Licensed beds: 100
Resident census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Health Services Administrator – AL | Named in multiple findings related to abuse reporting and medication errors |
| Staff 2 | Resident Services Coordinator / Executive Director (ED) / Health Services Quality Coordinator | Named in multiple findings related to staffing, abuse reporting, and training |
| Staff 3 | Executive Chef / Business Office Manager | Named in kitchen sanitation and food handler certification findings |
| Staff 4 | Health Services Quality Coordinator / Executive Director | Named in findings related to abuse reporting and kitchen sanitation |
| Staff 5 | Regional Director of Operations | Acknowledged findings related to abuse reporting and staffing |
| Staff 6 | Medication Technician / Resident Services Coordinator | Named in findings related to emergency preparedness and abuse reporting |
| Staff 7 | Medication Technician / Resident Services Coordinator | Named in findings related to emergency preparedness and abuse reporting |
Loading inspection reports...
