Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Kitchen
Capacity: 85
Deficiencies: 10
Jul 31, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2022-2025 with deficiency history and enforcement notices
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited repeated deficiencies related to kitchen sanitation, food handling, administration compliance, fire and life safety, and staff training. Several deficiencies were noted as not corrected, with plans of correction documented for each.
Complaint Details
Complaint investigation conducted on 2024-05-15 related to staffing requirements and training; deficiency not corrected
Deficiencies (10)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner; issues with food storage, pest entry, hand hygiene, and meal presentation |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| C0000 - Comment: Kitchen inspection findings documented; substantial compliance noted on revisit |
| C0360 - Staffing Requirements and Training: Staffing |
| C0420 - Fire and Life Safety: Safety: Failed to provide fire and life safety instruction to staff on alternating months |
| C0422 - Fire and Life Safety: Training For Residents: Failed to provide annual fire and life safety instruction to residents |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
| C0510 - General Building Exterior: Failed to ensure chemicals were properly labeled and locked; exterior pathways had trip hazards |
| C0540 - Heating and Ventilation: Failed to ensure heating elements did not exceed safe temperatures |
| Z0155 - Staff Training Requirements: Failed to ensure sampled direct care staff completed required annual training hours |
Report Facts
Inspections on page: 5
Total deficiencies: 14
Total surveys: 5
Licensing violations: 10
Abuse violations: 0
Notices: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings and acknowledged deficiencies |
| Staff 2 | Executive Chef / Maintenance Director / Person in Charge | Named in kitchen sanitation and administration compliance findings |
| Staff 3 | Maintenance Director | Named in kitchen sanitation findings and repairs |
| Staff 4 | Director of Plant Operations | Named in fire and life safety findings |
| Staff 5 | Maintenance Assistant | Named in fire and life safety findings |
| Staff 6 | Caregiver | Named in staff training deficiency |
| Staff 7 | Medication Technician | Named in staff training deficiency |
| Staff 8 | Caregiver | Named in staff training deficiency |
| Staff 13 | Caregiver | Named in staff training deficiency |
| Staff 19 | Business Office Manager | Named in staff training deficiency |
Loading inspection reports...
