Inspection Report
Complaint Investigation
Census: 40
Capacity: 40
Deficiencies: 26
Feb 6, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022 to 2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility demonstrated numerous deficiencies including failure to maintain sanitary kitchen conditions, inadequate administrative oversight, incomplete resident evaluations and service plans, failure to report and investigate abuse, insufficient infection control protocols, medication administration errors, inadequate staff training, and fire and life safety violations.
Complaint Details
Multiple complaint investigations conducted on 08/20/2024, 06/05/2024, 05/29/2024, 10/31/2023, 07/13/2023, 10/11/2022, and others documented with findings of failure to implement services, medication errors, staffing shortages, and failure to carry out orders as prescribed.
Deficiencies (26)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner with multiple areas of food spills, dirt, and needed repairs. |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for Residential Care and Assisted Living Facilities. |
| C0150 - Facility Administration: Operation: Failed to provide adequate administrative oversight and staff supervision. |
| C0154 - Facility Administration: Policy & Procedure: Failed to develop and implement written policies and procedures to respond to and resolve resident complaints. |
| C0156 - Facility Administration: Quality Improvement: Failed to develop and conduct ongoing quality improvement programs. |
| C0200 - Resident Rights and Protection - General: Failed to ensure residents received services protecting privacy and dignity and maintain confidentiality of medical records. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to immediately report and investigate resident-to-resident physical altercations and injuries of unknown cause. |
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to complete required move-in and quarterly resident evaluations. |
| C0260 - Service Plan: General: Failed to ensure service plans reflected residents’ needs, were available to staff, and implemented. |
| C0270 - Change of Condition and Monitoring: Failed to determine, document, communicate, and monitor resident-specific actions for changes of condition. |
| C0280 - Resident Health Services: Failed to ensure RN assessments were completed for significant changes of condition. |
| C0295 - Infection Prevention & Control: Failed to establish and maintain effective infection prevention and control protocols. |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication and treatment administration system. |
| C0303 - Systems: Treatment Orders: Failed to carry out physician orders as prescribed. |
| C0304 - Systems: Medication and Treatment Review: Failed to ensure pharmacist or RN reviewed medications and treatments every 90 days with documentation. |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when residents refused medications or treatments. |
| C0310 - Systems: Medication Administration: MARs lacked resident-specific parameters and reasons for use for PRN medications. |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN psychotropic medications had resident-specific parameters and documented non-pharmacological interventions. |
| C0340 - Restraints and Supportive Devices: Failed to complete required assessments, document alternatives, instruct staff, and include device use in service plan for side rails. |
| C0361 - Acuity Based Staffing Tool - Elements: Failed to use and update ABST quarterly to determine appropriate staffing levels. |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Failed to document competency in abdominal thrust training within 30 days for newly hired direct care staff. |
| C0420 - Fire and Life Safety: Safety: Failed to conduct and document unannounced fire drills every other month and provide fire safety instruction on alternate months. |
| C0422 - Fire and Life Safety: Training for Residents: Failed to instruct residents on fire safety procedures within 24 hours of admission and annually. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to keep interior materials and surfaces clean and in good repair. |
| H1517 - Individual Privacy: Own Unit: Failed to ensure residents’ rights of privacy in their own units. |
| H1518 - Individual Door Locks: Key Access: Failed to provide all residents with keys to their units. |
Report Facts
Inspections on page: 10
Total deficiencies: 46
Total surveys: 10
Licensing violations: 10
Notices: 4
Licensed beds: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jezeth Vaneza Zaragoza | Administrator | Named as facility administrator |
| Staff 1 | Executive Director | Named in multiple findings and interviews related to deficiencies and acknowledgements |
| Staff 2 | Assistant Executive Director/Business Office Manager | Named in multiple findings and interviews related to deficiencies and acknowledgements |
| Staff 3 | Culinary Director | Named in kitchen sanitation and food service deficiencies |
| Staff 6 | Medication Tech | Named in training and medication administration deficiencies |
| Staff 7 | Medication Tech | Named in psychotropic medication deficiencies |
| Staff 11 | Caregiver | Named in resident care and behavior observations |
| Staff 12 | Caregiver | Named in infection control and training deficiencies |
| Staff 15 | Caregiver | Named in training deficiencies |
| Staff 18 | Cook | Named in training deficiencies |
| Staff 19 | Cook | Named in training deficiencies |
| Staff 20 | Registered Nurse | Named in RN assessment and medication review deficiencies |
| Maintenance Director | Maintenance Director | Named in fire and life safety and facility maintenance deficiencies |
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