Inspection Reports for Deer Ridge Memory Care Community
3901 5th St SE, Puyallup, WA 98374, United States, WA, 98374
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
87% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
42 residents
Based on a October 2025 inspection.
Census over time
Inspection Report
Follow-Up
Census: 42
Deficiencies: 2
Oct 15, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 10/15/2025 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, confirming that previously cited deficiencies related to investigations and preadmission assessments were corrected. Earlier complaint investigations identified failures in conducting investigations of abuse allegations and preadmission assessments for residents.
Complaint Details
The complaint investigations involved allegations of unexpected death, staff to resident incident, and staff to resident abuse. The investigations found failed provider practices including failure to investigate abuse allegations and implement interventions, and failure to conduct preadmission assessments. Substantiation status is not explicitly stated.
Deficiencies (2)
| Description |
|---|
| The Assisted Living Facility failed to conduct investigations to determine the circumstances of accidents and incidents, implement interventions to prevent recurrence, and protect residents for 5 of 5 sampled residents. |
| The facility failed to conduct a pre-admission assessment for 1 of 5 sampled residents, resulting in the resident not receiving appropriate services and a decline in health. |
Report Facts
Total residents: 42
Resident sample size: 4
Closed records sample size: 1
Number of residents with failed investigations: 5
Number of residents with failed preadmission assessment: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Conducted the complaint investigations and on-site verification |
| Laurie Anderson | Community Field Manager | Signed the follow-up inspection letter |
| Staff A | Administrator | Named in findings related to failure to investigate abuse allegations and preadmission assessment |
| Staff B | Director of Residential Services | Interviewed regarding findings on abuse investigations and resident falls |
| Staff C | Medication Technician | Involved in abuse allegation with resident R2 |
| Staff D | Active Living Director | Reported abuse allegation involving Staff C and resident R2 |
| Staff E | Active Living Staff | Reported abuse allegation involving Staff C and resident R2 |
Inspection Report
Follow-Up
Deficiencies: 0
Aug 21, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 08/21/2025 to verify correction of previously cited deficiencies related to continuing education training requirements for staff.
Findings
The follow-up inspection found no deficiencies; the previously cited deficiencies regarding continuing education training for staff were corrected.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Heinz | Long Term Care Surveyor | Department staff who did the On Site verification during the follow-up inspection. |
| Cory Cisneros | Nursing Home Allied Health Field Manager | Signed the follow-up inspection letter. |
Inspection Report
Follow-Up
Census: 46
Deficiencies: 1
Jul 7, 2025
Visit Reason
The Department of Social and Health Services completed a follow-up visit to Deer Ridge Memory Care Community to verify correction of previously cited deficiencies related to staff continuing education requirements.
Findings
The licensee failed to ensure four staff completed the required 12 hours of continuing education, resulting in an uncorrected deficiency that placed all 46 residents at risk of receiving care from unqualified caregivers. A civil fine of $400 was imposed based on this violation.
Deficiencies (1)
| Description |
|---|
| Failure to ensure four staff completed 12 hours of continuing education as required. |
Report Facts
Civil fine amount: 400
Residents at risk: 46
Staff not meeting CE requirements: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Manfay Chan | Field Manager | Contact person for submission of Statement of Deficiencies and inquiries. |
| Matt Hauser | Compliance Specialist | Author of the civil fine notice. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 18, 2025
Visit Reason
The Department of Social and Health Services completed a complaint investigation at Deer Ridge Memory Care Community on June 18, 2025, to assess allegations related to failure to conduct investigations of accidents and incidents.
Findings
The licensee failed to conduct investigations to determine the circumstances of accidents and incidents, implement interventions to prevent recurrence, and protect five residents, resulting in a civil fine of $1,500.00. This deficiency was recurring, previously cited on multiple occasions.
Complaint Details
The visit was complaint-related, and the deficiency was substantiated, resulting in a civil fine.
Deficiencies (1)
| Description |
|---|
| Failure to conduct investigations to determine the circumstances of accidents and incidents, implement interventions to prevent recurrence, and protect residents for five residents. |
Report Facts
Civil fine amount: 1500
Number of residents affected: 5
Previous citation dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the imposition of civil fine letter |
| Manfay Chan | Field Manager | Contact person for plan of correction and inquiries |
Inspection Report
Follow-Up
Deficiencies: 3
Aug 9, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.
Complaint Details
The complaint investigation was conducted from 2024-02-22 through 2024-05-20 regarding allegations including untimely resident records, unsigned care plans, lack of personal care, facility pipe burst, and failure to notify resident representative of charge increases. The investigation found failed provider practices with citations written.
Deficiencies (3)
| Description |
|---|
| Failed to provide resident records timely to resident representatives. |
| Failed to ensure negotiated service agreements were agreed upon and signed by resident representatives for 3 of 3 sample residents. |
| Failed to notify resident’s representative in advance of an increase in service charges; facility reimbursed resident. |
Report Facts
Resident sample size: 3
Compliance Determination Completion Dates: 05/20/2024 and 08/09/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Conducted complaint investigation and follow-up inspection |
| Manfay Chan | Field Manager | Signed follow-up inspection report and enforcement correspondence |
| Staff B | Director of Residential Services | Interviewed regarding care plan signing practices |
| Staff A | Administrator | Interviewed regarding care plan signing practices |
Inspection Report
Follow-Up
Census: 8
Deficiencies: 3
Jun 25, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Previous deficiencies related to negotiated service agreements were corrected.
Deficiencies (3)
| Description |
|---|
| Failure to ensure residents received care and services as agreed upon in the negotiated service agreement for 6 of 8 sampled residents, placing residents at risk for wounds, infections, and decreased skin integrity. |
| Failure to ensure residents received care and services in a manner that enhances dignity and quality of life for 7 of 8 sampled residents, resulting in residents not receiving showers and decreased dignity and quality of life. |
| Failure to notify or consult with resident representatives when there was a significant change in resident's condition. |
Report Facts
Residents sampled: 8
Residents at risk: 6
Residents not receiving showers: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Department staff who conducted the on-site verification and inspection |
| Manfay Chan | Field Manager | Signed the follow-up inspection letter |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 24, 2024
Visit Reason
The Department of Social and Health Services conducted a complaint investigation at Deer Ridge Memory Care Community on May 24, 2024, due to concerns about failure to investigate incidents of resident falls and injuries.
Findings
The investigation found that the licensee failed to conduct proper investigations into falls and injuries of unknown source for three residents, contributing to serious harm including fractures requiring surgery and hospitalization, lack of preventative measures, and risk of abuse.
Complaint Details
The complaint investigation found recurring deficiencies related to failure to investigate resident falls and injuries, previously cited on May 19, 2023, October 5, 2022, September 9, 2022, and June 23, 2022.
Deficiencies (1)
| Description |
|---|
| Failure to conduct an investigation that determined the circumstances of events and institute measures to prevent future incidents when residents sustained falls and injuries of unknown source for three residents. |
Report Facts
Civil fine amount: 1500
Number of residents involved: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Manfay Chan | Field Manager | Contact person for submission of Statement of Deficiencies and inquiries |
| Matt Hauser | Compliance Specialist | Signed the letter imposing the civil fine |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 22, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations including a resident sustaining a fracture after a fall, injury of unknown source, failure to follow the current service plan regarding showering, fall not investigated, residents not receiving care due to COVID-19 isolation, and surfaces not cleaned properly.
Findings
The facility failed to thoroughly investigate resident falls and injuries of unknown origin for multiple residents, resulting in failed provider practice citations. The investigations lacked determination of circumstances and preventive measures. Some allegations related to COVID-19 isolation and cleaning were not substantiated due to insufficient information.
Complaint Details
The complaint investigation included allegations of a resident sustaining a fracture after a fall, injury of unknown source, failure to follow service plan for showering, fall not investigated, residents isolated due to COVID-19, and improper cleaning. The facility was found out of compliance with failed provider practice citations issued as documented in a Statement of Deficiencies dated 05/24/2024.
Deficiencies (1)
| Description |
|---|
| Failed to conduct investigations determining circumstances of falls and injuries of unknown source for 3 of 4 sampled residents, contributing to fractures and risk of harm. |
Report Facts
Resident sample size: 4
Compliance Determination Completion Date: May 24, 2024
Investigation Date Range: 2024-02-22 to 2024-05-24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Investigator who conducted the complaint investigation and on-site verification |
| Cory Cisneros | Field Manager | Field Manager who signed the follow-up inspection letter |
| Staff C | Resident Care Coordinator | Interviewed regarding resident falls and interventions |
| Staff B | Director of Residential Services | Interviewed regarding fall investigations and resident injuries |
| Staff A | Administrator | Interviewed regarding resident incidents and investigations |
Inspection Report
Enforcement
Deficiencies: 2
Feb 6, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Deer Ridge Memory Care Community to impose civil fines based on violations of state regulations and to enforce compliance with negotiated service agreements and resident rights.
Findings
The facility was found to have recurring deficiencies related to failure to provide care and services as agreed upon in negotiated service agreements for six residents, and failure to ensure dignity and quality of life for seven residents by not providing showers. These deficiencies placed residents at risk for wounds, infections, and decreased skin integrity and dignity.
Deficiencies (2)
| Description |
|---|
| Failure to ensure that residents received care and services as agreed upon in the negotiated service agreement for six residents, placing them at risk for wounds, infections, and decreased skin integrity. |
| Failure to ensure residents received care and services in a manner that enhances dignity and quality of life for seven residents, resulting in seven residents not receiving showers and being placed at risk for wounds, infections, and decreased dignity. |
Report Facts
Civil fine amount: 1000
Civil fine amount: 1000
Total civil fines: 2000
Number of residents affected: 6
Number of residents affected: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Manfay Chan | Field Manager | Contact person for submission of Statement of Deficiencies and inquiries |
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 2
Nov 21, 2023
Visit Reason
The Department of Social and Health Services completed a follow-up visit at Deer Ridge Memory Care Community to assess correction of previously cited deficiencies.
Findings
The facility failed to provide showers and adequate care to ten residents, resulting in decreased skin integrity and dignity. These deficiencies were uncorrected from a prior citation on May 4, 2023, leading to civil fines.
Deficiencies (2)
| Description |
|---|
| Failure to provide showers for ten residents, contributing to risk of skin infections and decreased skin integrity. |
| Failure to ensure residents received care and services in a manner that enhances dignity and quality of life for ten residents. |
Report Facts
Civil fine amount: 600
Civil fine amount: 600
Number of residents affected: 10
Total civil fines: 1200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Manfay Chan | Field Manager | Contact person for submission of Statement of Deficiencies and inquiries |
| Matt Hauser | Compliance Specialist | Signed the letter imposing civil fines |
Inspection Report
Follow-Up
Deficiencies: 3
Nov 1, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to compliance determinations 29660 and 20461.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies related to failure to investigate resident falls, failure to notify family and physician of falls, failure to assess and monitor residents after falls, and failure to train staff on incident reporting were corrected.
Complaint Details
The complaint investigation was triggered by allegations that the facility did not investigate a resident fall and did not notify the family of the resident fall. The investigation found failed facility practices and citations were written. The facility was out of compliance at the time of the complaint investigation.
Deficiencies (3)
| Description |
|---|
| Failed to investigate circumstances surrounding resident falls, including one resulting in a left clavicle fracture, contributing to recurring falls, hospitalization, pain, and decreased quality of life. |
| Failed to assess, evaluate, or monitor a resident’s change in physical function after sustaining falls, contributing to continued falls, hospitalization, and health decline. |
| Failed to train employees on policies and procedures for investigating incidents of abuse and neglect, resulting in staff not responding appropriately to a resident fall. |
Report Facts
Compliance Determination Completion Date: Nov 1, 2023
Compliance Determination Completion Date: May 19, 2023
Resident sample size: 1
Closed records sample size: 1
Number of falls documented for Resident 1: 3
Dates of prior citations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Conducted on-site verification and complaint investigation |
| Manfay Chan | Field Manager | Signed follow-up inspection letter and involved in investigation |
| Staff A | Administrator | Interviewed regarding fall investigations and staff training; did not know details of investigations or interventions |
| Staff B | Medication Technician | Interviewed about resident falls and interventions |
| Staff C | Licensed Nurse | Interviewed about training on incident management |
| Staff D | Licensed Nurse | Identified as lacking training on incident management |
| Staff E | Licensed Nurse | Identified as lacking training on incident management |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Sep 18, 2023
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation due to an allegation that the facility failed the fire and life safety inspection.
Findings
The facility failed to maintain compliance with fire and life safety codes, placing all 44 residents at risk for not receiving timely assistance in case of an emergency. The facility failed the annual fire and life safety inspection on 05/16/2023 and a follow-up inspection on 08/02/2023.
Complaint Details
The complaint investigation was triggered by an allegation that the facility failed the fire and life safety inspection. The investigation confirmed failed provider practice and citations were written.
Deficiencies (1)
| Description |
|---|
| Failed to maintain compliance with fire and safety codes as required, placing all 44 residents at risk for not receiving timely assistance in case of an emergency. |
Report Facts
Total residents: 44
Compliance Determination Completion Date: Completion dates mentioned are 09/20/2023 and 10/23/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Investigator who conducted the complaint investigation and off-site verification |
| Staff A | Administrator | Interviewed regarding fire drills and facility compliance |
| Staff B | Physical Plant Director | Interviewed regarding fire and life safety maintenance and documentation |
Inspection Report
Re-Inspection
Deficiencies: 6
Aug 2, 2023
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at Deer Ridge Memory Care Community to verify correction of previously noted violations.
Findings
The re-inspection found multiple violations that had not been corrected, including lack of documentation for fire sprinkler system testing, fire door inspections, fire-resistance-rated construction inventory, duct and air transfer opening maintenance, exit sign placement, and emergency power system testing.
Deficiencies (6)
| Description |
|---|
| Facility was unable to provide fire sprinkler system documentation showing that annual forward flow testing has been performed per NFPA 25, 13.7.2. |
| Unable to provide record showing that fire doors have been annually inspected, tested and repaired in the past 12 months. |
| Facility shall provide an inventory of all fire-resistance-rated construction and conduct annual inspections and maintain records. |
| Unable to provide test documentation showing that fire/smoke damper 1-year, post install, inspection and testing has been performed, per NFPA 80, 19.5.3. |
| Exterior exit sign required outside the Rose dining room pointing in the direction of egress travel; exit sign installed ±30 feet from north exit door, visible from main lobby direction, shall be rotated towards maintenance/activity office, with chevron arrow pointing to exit door. |
| Unable to provide documentation showing the emergency generator has received monthly load tests for the past 12 months. |
Report Facts
Next inspection scheduled date: Sep 4, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Signed as Deputy State Fire Marshal conducting the inspection. |
| Lucas Parker | Named as Owner or Owner's Representative signing the report. |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 19, 2023
Visit Reason
The Department of Social and Health Services completed a Complaint Investigation at Deer Ridge Memory Care Community on May 19, 2023, due to concerns about failure to investigate circumstances surrounding a resident's falls.
Findings
The licensee failed to investigate circumstances surrounding a resident’s falls, resulting in one fall causing a left clavicle fracture. This failure contributed to recurring falls, hospitalization, pain, and decreased quality of life. This deficiency was recurring and previously cited multiple times in 2022.
Complaint Details
The visit was complaint-related and substantiated by the finding that the licensee failed to investigate a resident's falls, leading to injury and recurring incidents.
Deficiencies (1)
| Description |
|---|
| Failure to investigate circumstances surrounding a resident’s falls, resulting in injury and recurring falls. |
Report Facts
Civil Fine Amount: 1000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter. |
| Manfay Chan | Field Manager | Contact person for plan of correction and appeals. |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 19, 2023
Visit Reason
The Department of Social and Health Services completed a complaint investigation at Deer Ridge Memory Care Community related to failure to investigate circumstances surrounding a resident's falls.
Findings
The licensee failed to investigate circumstances surrounding a resident’s falls, resulting in a left clavicle fracture and contributing to recurring falls, hospitalization, pain, and decreased quality of life. This deficiency was recurring and previously cited multiple times.
Complaint Details
The visit was complaint-related and substantiated by the finding of failure to investigate falls leading to injury and recurring incidents.
Deficiencies (1)
| Description |
|---|
| Failure to investigate circumstances surrounding a resident’s falls resulting in injury and recurring falls. |
Report Facts
Civil fine amount: 1000
Previous deficiency citation dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the letter regarding the civil fine and complaint investigation |
| Manfay Chan | Field Manager | Contact person for plan of correction and appeals |
Inspection Report
Re-Inspection
Deficiencies: 13
May 16, 2023
Visit Reason
The Office of the State Fire Marshal conducted a re-inspection at the Deer Ridge Memory Care Community facility to verify correction of previously cited fire safety violations.
Findings
Multiple fire safety violations were found uncorrected, including lack of documentation for semi-annual kitchen hood cleanings, fire-resistance-rated construction inspections, fire door operability and inspection, fire/smoke damper testing, sprinkler system testing, suppression system servicing, unobstructed fire alarm pull stations, carbon monoxide alarm inspections, exit sign placements, emergency generator testing and servicing, and fire drill documentation.
Deficiencies (13)
| Description |
|---|
| Unable to provide reports showing that two semi-annual kitchen hood cleanings were performed in the past 12 months. |
| Facility shall provide an inventory of all fire-resistance-rated construction and conduct annual inspections with maintenance records. |
| Fire door to main boiler room made inoperable - door handle removed and tape on latch. |
| Ivy dining room fire door failed to close and latch when tested. |
| Unable to provide test documentation showing that fire/smoke damper 1-year post-install inspection and testing has been performed. |
| Unable to provide fire sprinkler system documentation including last annual confidence test, 3-year full flow trip test, 5-year inspection/test, and last annual forward flow test report. |
| Unable to provide reports showing that two semi-annual suppression system servicings were performed in the past 12 months. |
| Furniture found blocking manual fire alarm pull-station next to north hall exit door. |
| Unable to provide documentation showing monthly inspection of the facility's carbon monoxide alarms in the past 12 months. |
| Exit signs missing or improperly placed in Rose activity room, Rose exterior overhang, and near north exit door. |
| Unable to provide documentation showing emergency generator monthly load tests and annual servicing in the past 12 months. |
| Unable to provide record showing fire doors have been annually inspected, tested, and repaired in the past 12 months. |
| Unable to provide fire drill documentation for multiple shifts and quarters from 2022 to 2023. |
Report Facts
Semi-annual kitchen hood cleanings: 2
Suppression system servicings: 2
Fire drill documentation missing: 4
Exit sign placement distance: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lysandra Davis | Deputy State Fire Marshal | Signed the inspection report |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
May 2, 2023
Visit Reason
The investigation was initiated due to a family member's complaint alleging that a resident was isolated from the community and did not receive prescribed eye drops as ordered by the provider.
Findings
The investigation found that the resident was not isolated but was part of an elopement drill, so the isolation allegation was unsubstantiated. However, the facility failed to ensure the resident received the prescribed eye drop medication Latanoprost for glaucoma as ordered, placing the resident at risk. Staff had documented administration of the medication during periods when the medication was not available, indicating a failure in medication management and ordering procedures.
Complaint Details
Complaint alleged that a resident was isolated from the community and did not receive prescribed eye drops. The isolation allegation was unsubstantiated. The medication administration allegation was substantiated with findings of medication not being available yet marked as given.
Deficiencies (1)
| Description |
|---|
| Facility failed to receive and administer prescribed medications for 1 of 5 residents, placing the resident at risk by not receiving medications prescribed for glaucoma. |
Report Facts
Total residents: 50
Resident sample size: 7
Medication doses per vial: 50
Investigation date range: Investigation conducted from 2023-05-02 through 2023-05-11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marilyn Klotz | Investigator | Investigator conducting the complaint investigation |
| Carol Gijima | Community Complaint Investigator (NCI) | Department staff who did the on-site verification |
| Manfay Chan | Field Manager | Signed the follow-up inspection letter |
| Staff C | Director of Resident Services | Interviewed regarding medication administration and ordering procedures |
| Staff D | Facility Director | Interviewed regarding medication refill procedures and staff instructions |
| Staff E | Certified Nursing Assistant/Medication Technician | Interviewed regarding medication administration and documentation procedures |
| Staff F | Medical Provider | Left a message for callback but did not respond |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 27, 2022
Visit Reason
The inspection was conducted in response to complaint #63321 regarding water flowing from multiple areas on two halls in the community.
Findings
The Executive Director responded to the call about water flowing from multiple ceiling areas. The staff turned off the water and the fire department was called. Fire Systems West indicated that pipes may have been thawing causing the leak. The system was restored and a fire watch was done.
Complaint Details
Complaint #63321 involved water flowing from multiple ceiling areas. No fire occurred, sprinklers were not activated, no evacuation or injuries occurred, and the fire department responded. The complaint was investigated and addressed with no further issues noted.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shamera Gregory | Executive Director | Responded to the complaint about water flowing from multiple ceiling areas. |
| Cozetta Christian | Deputy State Fire Marshal | Conducted the inspection and signed the report. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 9, 2022
Visit Reason
The complaint investigation was conducted due to allegations including unauthorized medication changes, medication changes leading to a fall and death, unauthorized hospital transfer, missing items, and soiled bedding.
Findings
The facility failed to develop and implement a safe medication system, resulting in medication errors that placed a resident at risk of medical and physical decline. The investigation found a medication error and failure to investigate it properly, constituting failed provider practice with citations written.
Complaint Details
The complaint investigation was based on allegations of unauthorized medication changes, medication changes leading to a fall and death, unauthorized hospital transfer, missing items, and soiled bedding. The investigation substantiated failed provider practice related to medication errors but found insufficient information to support other allegations.
Deficiencies (2)
| Description |
|---|
| Failed to develop and implement a safe medication system to ensure medications were given as prescribed for one resident. |
| Failed to investigate, document, and institute measures to prevent recurrence of a medication error for one resident. |
Report Facts
Investigation Date Range: 04/26/2022 through 09/09/2022
Closed records sample size: 1
Medication administration days with errors: 14
Correction completion date: Plan/Attestation Statement dated 2022-10-28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Investigator who conducted the complaint investigation and on-site verification |
| Manfay Chan | Field Manager | Field Manager who signed enforcement and notification letters |
Inspection Report
Complaint Investigation
Deficiencies: 3
Jun 23, 2022
Visit Reason
The inspection was conducted as a complaint investigation following allegations that residents did not receive care services, no activities were provided, and staff were not giving residents snacks.
Findings
The facility failed to investigate allegations of neglect for several residents, failed to obtain required background checks for staff, and failed to report neglect allegations to the Complaint Resolution Unit. These failures placed residents at risk of harm. Some allegations could not be substantiated due to insufficient information.
Complaint Details
The complaint investigation was based on allegations that residents did not receive care services, no activities were provided, and staff were not giving residents snacks. The investigation found failed provider practices related to neglect investigations, background checks, and reporting to the Complaint Resolution Unit.
Deficiencies (3)
| Description |
|---|
| Failed to investigate and document investigative actions and findings for alleged or suspected abuse, neglect, or incidents jeopardizing resident health or life. |
| Failed to obtain required background checks for staff working with vulnerable residents. |
| Failed to report allegations of neglect to the Complaint Resolution Unit when staff were notified. |
Report Facts
Resident sample size: 2
Closed records sample size: 1
Sample residents with failed neglect investigation: 3
Sample staff missing background checks: 4
Sample residents at risk due to failure to report neglect: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Investigator who conducted the complaint investigation and follow-up inspection |
| Jody Just | Field Manager | Field Manager who signed enforcement and deficiency letters |
| Shaneka G. | Administrator or Representative | Administrator who signed Plan of Correction documents |
| Staff A | Administrator | Interviewed regarding neglect allegations and background checks |
| Staff B | Director of Residential Services | Interviewed regarding neglect allegations and background checks |
Loading inspection reports...



