Inspection Report
Complaint Investigation
Census: 102
Capacity: 120
Deficiencies: 9
Apr 28, 2025
Visit Reason
State-compiled facility profile showing 24 inspections from 2023-01 to 2025-04 with deficiency history
Findings
Across multiple complaint investigations from 2023 to 2025, the facility had several deficiencies related to abuse investigations, resident supervision, accident prevention, and life safety code violations. Most inspections found no deficiencies, but some complaint investigations cited multiple deficiencies involving resident safety and abuse prevention.
Complaint Details
Multiple complaint investigations were conducted between 2023 and 2025, investigating numerous intake numbers related to abuse, neglect, and resident safety. Several complaint inspections found no deficiencies, while others cited multiple deficiencies related to abuse investigations and accident prevention.
Deficiencies (9)
| Description |
|---|
| R9-10-403.F.5.d. — Failed to complete a thorough investigation to rule out abuse regarding an injury of unknown origin for resident #118 |
| §483.12(a)(1) — Failed to ensure residents were free from abuse by visitors and other residents, including incidents involving residents #57, #116, #117, #126, #112, #134, and #118 |
| §483.12(c)(2)(3)(4) — Failed to thoroughly investigate allegations of abuse and prevent further abuse during investigation for resident #118 |
| §483.25(d)(1)(2) — Failed to ensure resident environment was free of accident hazards and provide adequate supervision to prevent accidents, including elopement of resident #129 |
| R9-10-410.B.3.a. — Failed to prevent abuse between residents #134 and #135 resulting in injury |
| R9-10-425.A.1.b. — Failed to ensure premises were free from conditions causing physical injury; inadequate supervision to prevent wandering and elopement for residents #57, #116, and #129 |
| Doors with Self-Closing Devices — Failed to keep a rated door to the kitchen closed, allowing it to be held open with a plate rack |
| Electrical Equipment - Power Cords and Extension Cords — Improper use of extension cords and power strips in resident rooms and offices creating fire hazard |
| §483.25(d)(1)(2) — Failed to provide adequate supervision and fall prevention measures for resident #8, resulting in multiple falls and injuries |
Report Facts
Inspections on page: 24
Total deficiencies: 10
Complaint inspections: 22
Facility capacity: 120
Resident census: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| FRANCISCO RODRIGUEZ MARTINEZ | Administrator | Named in abuse investigation findings regarding resident #118 |
| staff #34 | Administrator | Interviewed regarding abuse investigation and supervision failures |
| staff #9 | Staff | Witnessed resident altercation involving residents #116 and #117 |
| staff #12 | Certified Nursing Assistant (CNA) | Interviewed about resident wandering and supervision |
| staff #65 | Registered Nurse (RN) | Interviewed about resident wandering and supervision |
| staff #100 | Lead CNA | Interviewed about resident wandering and supervision |
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