Inspection Report
Capacity: 23
Deficiencies: 16
Feb 20, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2022-2025 with deficiency history and enforcement notices
Findings
Across multiple inspections, the facility demonstrated numerous deficiencies including failure to properly monitor and document resident changes of condition, inadequate medication administration and tracking, insufficient staff training, and issues with privacy and kitchen sanitation. Some deficiencies were corrected in follow-up visits, but several remained uncorrected as of the most recent inspection.
Deficiencies (16)
| Description |
|---|
| C0270 - Change of Condition and Monitoring: Failed to ensure residents with short term changes had resident-specific instructions and weekly progress documented until resolution |
| C0280 - Resident Health Services: Failed to ensure timely RN assessment and documentation for residents with significant changes of condition |
| C0302 - Systems: Tracking Control Substances: Failed to have an approved system for tracking controlled substances and disposal |
| C0310 - Systems: Medication Administration: Failed to ensure accuracy of MARs including resident specific parameters for PRN medications |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN psychotropic medications had written resident-specific parameters and documented non-drug interventions |
| C0372 - Training within 30 days: Direct Care Staff: Failed to ensure newly hired direct care staff had documented First Aid and abdominal thrust training within 30 days |
| H1517 - Individual Privacy: Own Unit: Failed to ensure residents' privacy as shared bathroom doors were not lockable |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for the facility |
| Z0155 - Staff Training Requirements: Failed to ensure staff completed required pre-service orientation, dementia training, competency demonstration, and annual in-service training |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules |
| C0000 - Comment: Kitchen inspection findings documented; facility in substantial compliance on revisit |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen and kitchenette in good repair and sanitary manner with multiple sanitation and repair issues |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure initial move-in evaluations included all required elements |
| C0361 - Acuity-Based Staffing Tool: Failed to use results of ABST to develop and update staffing plan |
| C0420 - Fire and Life Safety: Safety: Failed to conduct and document fire drills and provide fire and life safety instruction as required |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
Report Facts
Inspections on page: 4
Total deficiencies: 18
Total surveys: 4
Notices: 1
Licensed beds: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Memory Care Executive Director / MCC ED/LPN | Named in multiple findings related to change of condition, medication administration, and staff training |
| Staff 2 | Resident Care Coordinator / Executive Chef | Named in findings related to medication tracking and kitchen sanitation |
| Witness 1 | Consultant Operations Specialist | Acknowledged findings during inspections |
| Staff 20 | Business Office Manager | Named in staff training record reviews |
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