Inspection Report
Complaint Investigation
Census: 38
Capacity: 65
Deficiencies: 14
Aug 28, 2024
Visit Reason
State-compiled facility profile showing 4 inspections from 2022 to 2024 with deficiency history and licensing violations.
Findings
Across four inspections, the facility showed multiple deficiencies primarily related to staffing tool implementation, resident evaluations, medication administration, service planning, and staff training. Some inspections found the facility in substantial compliance, while others identified numerous unresolved deficiencies.
Complaint Details
The most recent inspection dated 2024-08-28 was a Complaint Investigation related to licensure complaints.
Deficiencies (14)
| Description |
|---|
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update an Acuity Based Staffing Tool (ABST), including incomplete care needs entries for new residents and staffing not exceeding ABST requirements. |
| C0000 - Comment: Kitchen inspection found substantial compliance with relevant food sanitation rules. |
| C0000 - Comment: Change of ownership survey findings and re-visit documented; some deficiencies noted with multiple citations. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluation addressed all required elements for a sampled resident. |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service plans were developed by a Service Planning Team for sampled residents. |
| C0302 - Systems: Tracking Control Substances: Failed to have a system for accurately tracking controlled substances administered for a sampled resident. |
| C0303 - Systems: Treatment Orders: Failed to ensure orders were carried out as prescribed for medications and treatments for a sampled resident. |
| C0310 - Systems: Medication Administration: Failed to keep an accurate MAR of all medications administered for sampled residents, including inaccurate documentation and medication errors. |
| C0330 - Systems: Psychotropic Medication: Failed to document non-pharmacological interventions prior to administering PRN psychotropic medication for a sampled resident. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities; referral to other citations. |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired and long-term staff completed required orientation, competency, and annual training. |
| Z0162 - Compliance With Rules Health Care: Failed to follow licensing rules; referral to other citations. |
| Z0163 - Nutrition and Hydration: Failed to develop individualized nutrition and hydration plans for sampled residents. |
| Z0164 - Activities: Failed to evaluate required elements for activities and develop individualized activity plans for sampled residents. |
Report Facts
Inspections on page: 4
Total deficiencies: 12
Total surveys: 4
Licensing violations: 10
Abuse violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings and acknowledgments of deficiencies |
| Staff 2 | Regional Director of Operations | Named in multiple findings and acknowledgments of deficiencies |
| Staff 3 | RN | Named in multiple findings and acknowledgments of deficiencies |
| Staff 7 | Resident Care Manager | Named in medication administration and psychotropic medication findings |
| Staff 9 | Medication Aide (MA) | Named in staff training deficiencies |
| Staff 11 | Medication Aide (MA) | Named in staff training deficiencies |
| Staff 8 | Medication Aide (MA) | Named in staff training deficiencies |
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