Inspection Report
Capacity: 15
Deficiencies: 30
Dec 10, 2024
Visit Reason
State-compiled facility profile showing 5 inspections from 2021 to 2024 with deficiency history and enforcement notices
Findings
Across multiple inspections from 2021 to 2024, the facility exhibited numerous deficiencies including food sanitation violations, medication administration and tracking issues, failure to report abuse, inadequate staff training, and building safety concerns. Some deficiencies were corrected over time, while others remained uncorrected as of the latest inspections.
Deficiencies (30)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure food was handled and kitchen maintained in accordance with Food Sanitation Rules including undated/unlabeled foods, expired foods, improper storage, and lack of temperature monitoring |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| C0000 - Comment: Findings of re-licensure and other surveys documented |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report resident altercations to local SPD |
| C0302 - Systems: Tracking Control Substances: Failed to have system for accurately tracking controlled substances for sampled residents |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when resident refused medications |
| C0545 - Plumbing Systems: Hot water temperatures exceeded 120 degrees Fahrenheit in residents' units and common areas |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules |
| Z0173 - Secure Outdoor Recreation Area: Fences surrounding outdoor recreation area were below required six feet height |
| C0150 - Facility Administration: Operation: Failed to provide effective oversight to ensure quality of care and services |
| C0152 - Facility Administration: Required Postings: Failed to ensure required postings were displayed accessibly and conspicuously |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening health, safety or welfare including infection control lapses |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure quarterly evaluations were completed and reflective of residents' current status |
| C0260 - Service Plan: General: Failed to ensure service plans reflected residents' current care needs and provided clear direction |
| C0270 - Change of Condition and Monitoring: Failed to determine and document needed actions for residents following changes of condition and monitor until resolved |
| C0280 - Resident Health Services: Failed to ensure RN assessment was completed for significant changes of condition |
| C0282 - Rn Delegation and Teaching: Failed to ensure delegation and supervision of nursing tasks in accordance with OSBN rules |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication system and adequate professional oversight |
| C0303 - Systems: Treatment Orders: Failed to ensure medication orders were carried out as prescribed and signed physician orders documented |
| C0310 - Systems: Medication Administration: Failed to ensure resident MARs included resident specific parameters and instructions for PRN medications |
| C0350 - Administrator Qualification and Requirements: Failed to ensure qualified administrator employed to work 40 hours per week |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure pre-service orientation and dementia training completed prior to providing services |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired caregiving staff demonstrated competency and certification within 30 days |
| C0374 - Annual and Biennial Inservice For All Staff: Failed to have documented evidence of required annual in-service training for staff |
| C0420 - Fire and Life Safety: Safety: Failed to ensure fire drills conducted/documented every other month and staff received fire safety instruction on alternate months |
| C0422 - Fire and Life Safety: Training For Residents: Failed to instruct residents on fire safety within 24 hours of admission and annually, and keep written records |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
| C0510 - General Building Exterior: Failed to ensure courtyard pathways did not have drop offs and walkways were maintained to prevent tripping hazards |
| C0513 - Doors, Walls, Elevators, Odors: Failed to provide lever type door handles on all doors used by residents |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to ensure all exit doors had operational alarms or acceptable alert systems |
Report Facts
Inspections on page: 5
Total deficiencies: 32
Licensing violations: 6
Notices: 1
Licensed beds: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Bell | Administrator | Named as facility administrator in facility information |
| Staff 1 | Regional Director of Operations | Named in multiple inspection findings and acknowledgements |
| Staff 2 | Vice President of Operations | Named in inspection findings and acknowledgements |
| Staff 3 | Regional RN | Named in inspection findings and acknowledgements |
| Staff 4 | Assistant Administrator/Universal Worker | Named in medication error and delegation findings |
| Staff 5 | Universal Worker | Named in medication error and delegation findings |
| Staff 6 | Universal Worker | Named in medication error and delegation findings |
| Staff 7 | Assistant Administrator/Universal Worker of another facility | Named in medication error and delegation findings |
| Witness 1 | Consultant | Named in inspection findings and acknowledgements |
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