Deficiencies per Year
24
18
12
6
0
Unclassified
Inspection Report
Renewal
Census: 71
Capacity: 84
Deficiencies: 23
Apr 3, 2025
Visit Reason
State-compiled facility profile showing 4 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 administrative oversight, resident service plans, change of condition evaluations, coordination with outside providers, staffing adequacy, fire and life safety training, and kitchen sanitation. Some deficiencies were corrected over time, but several were repeated or remained uncorrected at the latest visits.
Deficiencies (23)
| Description |
|---|
| C0000 - Comment: General comments and findings related to inspections and compliance. |
| C0150 - Facility Administration: Operation: Failed to provide effective administrative oversight to ensure quality of care and services rendered. |
| C0155 - Facility Administration: Records: Failed to ensure preparation, completeness, and accuracy of documentation or records for sampled residents. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report injuries of unknown cause for which abuse was not reasonably ruled out. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules; kitchen was unclean and in disrepair. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements for sampled residents. |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' needs, provided clear direction, and were updated following significant changes. |
| C0270 - Change of Condition and Monitoring: Failed to evaluate significant changes of condition, determine needed actions, and document progress until resolution. |
| C0280 - Resident Health Services: Failed to ensure RN assessments were conducted for significant changes of condition and documented interventions. |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to coordinate care with outside providers and ensure staff were informed of new interventions. |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when resident refused medication. |
| C0310 - Systems: Medication Administration: Failed to ensure MARs were accurate and included medication-specific instructions. |
| C0325 - Systems: Self-Administration of Meds: Failed to evaluate resident's ability to self-administer medications and obtain physician's order. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient direct care staff to meet residents' needs and fire safety evacuation standards during night shift. |
| C0361 - Acuity-Based Staffing Tool: Failed to update ABST quarterly and ensure appropriate staffing levels based on resident needs. |
| C0363 - Acuity Based Staffing Tool - Updates & Plan: Failed to update ABST following significant change of condition and consistently staff according to posted plan. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired staff had documented competency within 30 days of hire. |
| C0420 - Fire and Life Safety: Safety: Failed to ensure fire drills and instruction were conducted and recorded as required. |
| C0422 - Fire and Life Safety: Training For Residents: Failed to instruct residents on fire safety upon admission and annually; failed to use alternate exit routes during drills. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department. |
| C0613 - General Building: Doors-Walls, Cleanable: Failed to keep interior areas clean and in good repair including laundry rooms and carpets. |
| C0640 - Heating and Ventilation: Failed to ensure wall heaters and heating elements did not exceed 120 degrees Fahrenheit in areas subject to incidental contact. |
| C0655 - Call System: Failed to ensure exit doors were equipped with alarms or acceptable systems to alert staff when residents exited. |
Report Facts
Inspections on page: 4
Total deficiencies: 29
Total surveys: 4
Licensing violations: 20
Abuse violations: 0
Notices: 1
Licensed beds: 84
Resident census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director (ED) | Named in multiple findings related to administrative oversight and acknowledgment of deficiencies |
| Staff 2 | Health Services Administrator | Named in multiple findings related to health services, staffing, and plan of correction oversight |
| Staff 4 | Resident Services Coordinator | Named in findings related to resident records, service plans, and coordination |
| Staff 6 | Registered Nurse (RN) | Named in findings related to nursing assessments and care planning |
| Staff 7 | Regional RN | Named in findings related to nursing assessments and acknowledgment of deficiencies |
| Staff 8 | Health Services Quality Coordinator | Named in findings related to quality oversight and acknowledgment of deficiencies |
| Staff 9 | Regional Director | Named in findings related to oversight and acknowledgment of deficiencies |
| Staff 11 | Director of Resident Relations | Named in findings related to resident relations and acknowledgment of deficiencies |
| Staff 3 | Plant Operations | Named in findings related to facility maintenance and cleanliness |
| Staff 32 | Staffing Coordinator | Named in findings related to staffing schedules and adequacy |
| Staff 33 | Resident Services Coordinator first floor, MC Coordinator | Named in findings related to resident care coordination |
| Staff 34 | Staffing Coordinator | Named in findings related to staffing and plan of correction |
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