Inspection Report
Renewal
Capacity: 110
Deficiencies: 20
Apr 1, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2021 to 2025 with deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility demonstrated repeated deficiencies in kitchen sanitation, administrative oversight, resident service plans, reporting and investigating abuse, medication administration, staffing tool implementation, and building maintenance. Several deficiencies remained uncorrected as of the most recent inspections.
Complaint Details
The 3/28/2024 inspection was a complaint investigation related to licensure complaints.
Deficiencies (20)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules, including unclean kitchen areas and improper food storage. |
| C0150 - Facility Administration: Operation: Failed to provide effective administrative oversight to ensure quality of care and services rendered. |
| C0154 - Facility Administration: Policy & Procedure: Failed to have effective methods of responding to and resolving resident complaints. |
| C0200 - Resident Rights and Protection - General: Failed to ensure residents were treated with dignity and respect related to meal service differences between dining room and apartment delivery. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report injuries of unknown cause and suspected abuse to local SPD office and conduct timely investigations. |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' needs, provided clear direction to staff, and were implemented. |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service plans were developed by a service planning team including required members. |
| C0270 - Change of Condition and Monitoring: Failed to evaluate significant changes of condition, refer to RN, update service plans, and communicate interventions. |
| C0280 - Resident Health Services: Failed to ensure RN assessments were completed and interventions developed for significant changes of condition. |
| C0303 - Systems: Treatment Orders: Failed to ensure written, signed physician orders were documented and carried out as prescribed. |
| C0310 - Systems: Medication Administration: Failed to maintain accurate MARs with medication-specific instructions and resident-specific parameters for PRN medications. |
| C0361 - Acuity Based Staffing Tool - Elements: Failed to fully implement an approved ABST that addressed all required care elements and staffing time. |
| C0370 - Staffing Requirements and Training – Pre-service: Failed to ensure all staff completed department-approved LGBTQIA2S+ training by required date. |
| C0613 - General Building: Doors-Walls, Cleanable: Failed to keep all interior materials and surfaces clean and in good repair. |
| C0645 - Plumbing Systems: Failed to maintain hot water temperatures in residents’ units within required range of 110 - 120 degrees Fahrenheit. |
| C0160 - Reasonable Precautions: Failed to ensure staff wore masks properly during COVID-19 related site visit. |
| C0155 - Facility Administration: Records: Failed to maintain complete and accurate records for sampled residents. |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN psychotropic medications had written, resident-specific parameters and non-pharmacological interventions. |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure residents received required fire and life safety instruction and documentation. |
| C0615 - Resident Units: Failed to ensure operable windows had locking mechanisms to prevent accidental falls on second floor. |
Report Facts
Inspections on page: 7
Total deficiencies: 34
Licensing violations: 10
Notices: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator / Executive Director | Named in multiple findings including kitchen sanitation, complaint resolution, abuse reporting, and facility oversight |
| Staff 2 | District Director of Operations | Named in multiple findings including kitchen sanitation, complaint resolution, abuse reporting, and facility oversight |
| Staff 3 | District Director of Clinical Operations / RN | Named in findings related to abuse reporting, medication administration, and resident health services |
| Staff 4 | Area Nurse Manager / RN | Named in findings related to abuse reporting, service plans, change of condition, and resident health services |
| Staff 5 | Health and Wellness Director / LPN | Named in medication administration findings |
| Staff 6 | Maintenance Manager / Director | Named in findings related to building maintenance and plumbing systems |
| Staff 9 | Med Tech | Named in training deficiency related to LGBTQIA2S+ training |
| Staff 14 | Medication Technician | Named in medication administration findings |
| Staff 15 | Resident Care Coordinator | Named in abuse reporting and medication administration findings |
| Staff 19 | Caregiver | Named in medication administration findings |
| Staff 20 | Medication Technician | Named in medication administration findings |
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