The most recent inspection on April 3, 2024, found deficiencies related to medication refrigerator temperature monitoring, psychotropic medication reviews, and staff training for traumatic brain injury. Earlier inspections showed a pattern of issues including fire and life safety code compliance, emergency preparedness, nursing assessments, staff scheduling, and certification requirements. The main themes across reports involved medication management, staff training, and safety documentation. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports, and complaint investigations were not noted. The facility’s deficiencies appear consistent over time without a clear trend of improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 years)4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The inspection was a health care licensure and follow-up survey to assess compliance with regulatory requirements and verify correction of previous deficiencies.
Findings
The facility was found to have deficiencies including failure to monitor and document medication refrigerator temperatures containing insulin, lack of six-month psychotropic medication reviews for residents on such medications, and staff not having specialized training for traumatic brain injury despite admitting a resident with that diagnosis.
Deficiencies (3)
Description
Medication refrigerator temperatures were not monitored and documented daily for several months despite containing insulin.
Four residents on psychotropic medications for at least six months did not have required six-month medication reviews completed.
Five staff members lacked specialized training for traumatic brain injury, although the facility had a resident diagnosed with this condition.
Report Facts
Residents on psychotropic medications without six-month reviews: 4Staff without traumatic brain injury training: 5Survey date: Apr 3, 2024
Employees Mentioned
Name
Title
Context
Carry Avalos
Administrator
Stated facility had not been documenting medication refrigerator temperatures and confirmed admission of resident with traumatic brain injury
Bradley Perry
Survey Team Leader
Led the health care licensure and follow-up survey
Inspection Report Life SafetyCapacity: 16Deficiencies: 7Dec 12, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire and life safety standards for existing buildings licensed for three through sixteen residents.
Findings
The facility failed to maintain compliance with the 2018 edition of NFPA 101 Life Safety Code and related standards, including lack of documentation for emergency plan training, oxygen safety training, policies on flammable substances, monthly inspections of suppression systems, a resident room door that would not latch, unsecured exterior gates, and hot water temperature exceeding the allowed maximum.
Deficiencies (7)
Description
Lack of documentation for periodic emergency plan training and bi-monthly in-service training for staff.
No documentation showing staff are trained periodically on safety guidelines and oxygen use.
No policy for elimination of ignition sources and misuse of flammable substances.
No documentation of monthly visual inspections of wet suppression system gauges and secured control valves.
Resident room #2 door would not latch when fully closed.
Exterior yard gates are not secured by locks, only latching mechanisms.
Hot water temperature at plumbing fixtures was 125°F, exceeding the allowed maximum of 120°F.
Report Facts
Total licensed capacity: 16Hot water temperature: 125Fence height: 6Number of gates: 2
Inspection Report Life SafetyDeficiencies: 4Jun 4, 2021
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with applicable fire and life safety standards.
Findings
The facility had several non-core issues including an outdated relocation agreement, an emergency plan lacking a designated point of assembly, and improper use of relocatable power taps which were corrected on site during the inspection.
Deficiencies (4)
Description
Facility has one relocation agreement dated 2017; facility shall have two relocation agreements with two separate locations, reviewed not less than annually.
Facility emergency plan does not show point of assembly; drills shall be conducted at designated point of assembly per NFPA 101.
Relocatable power taps (RPTs) shall not be daisy-chained; RPTs were daisy-chained in main living room (corrected on site).
RPTs shall not be used for appliances; RPT used to supply power to an air purifier in main living room (corrected on site).
The inspection was a health care licensure and follow-up survey to assess compliance with nursing assessments, staff scheduling documentation, and food protection manager certification requirements.
Findings
The facility failed to consistently conduct nursing assessments for residents with changes in health status, did not maintain accurate as-worked staff schedules, and lacked an employee certified as a food protection manager at the time of the survey.
Deficiencies (3)
Description
Facility nurse did not consistently conduct nursing assessments when residents experienced changes in physical or mental health status.
Facility did not maintain as-worked schedules documenting personnel on duty at any given time.
Facility did not have an employee with certified food protection manager certification at the time of survey.
Report Facts
Facility License Number: RC-1059Survey Date: Dec 10, 2020Response Due Date: Jan 9, 2021
Employees Mentioned
Name
Title
Context
Carry Avalos
Administrator
Named as facility administrator
Stacey Brown
Survey Team Leader
Named as survey team leader
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