Inspection Reports for Ponderosa Retirement Center

The complaint investigation was substantiated, identifying failed provider practice related to fire safety violations found during the second Fire Marshal re-inspection.

The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. However, a prior complaint investigation found the facility failed their second Fire Marshal re-inspection and identified failed practices related to fire safety codes.

The facility failed to provide documentation of the fire alarm system annual maintenance inspection with the date completed missing. Deficiencies requiring repair were noted, with parts ordered and awaiting arrival. All items were corrected as of 05/15/2025.

Complaint investigation included complaint numbers 162956, 163022, 164883, 164275. The complaint was substantiated as the facility failed to meet Assisted Living Facility requirements related to billing.

The investigation found that the facility billed the named resident beyond their daily rate for cares, constituting a failed provider practice. However, the named resident's assessment was accurate and agreed upon by both the facility and the resident, with no failed practice identified in that regard.

The inspection found multiple fire safety violations including lack of documentation for fire sprinkler testing, fire alarm system maintenance, and hydrostatic testing. Several physical violations were noted such as combustible storage issues, unfused multi-plug adapters, doors failing to close properly, and missing emergency lighting. Many deficiencies were corrected during the inspection, but some violations remain requiring further repair and documentation submission.

Complaint investigations were conducted related to a resident fall with injury and staff to resident mistreatment. Both investigations identified failed provider practices and citations were written.

The follow-up inspection found no deficiencies and confirmed that previously cited deficiencies related to service agreement planning and family assistance with medications and treatments were corrected.

The complaint investigation involved allegations that a named resident had a black eye and injured hand with no fall report, the facility lacked a nurse to meet the resident's needs, and a resident was running out of medication. The investigation confirmed failure to report the injury but found no failed practice regarding nursing coverage or medication administration. The facility was within their plan of correction period and no new Statement of Deficiencies was issued under 388-78A-2371.

The investigation found that the facility failed to investigate and report an unwitnessed accident/substantial injury involving a resident's black eye and hand injury to the Complaint Resolution Unit, placing the resident at risk for further injury. The facility was within their plan of correction period and no new deficiencies were cited for other allegations. The facility acknowledged the failure to report the injury and committed to corrective actions.

The complaint investigation was triggered by allegations including a resident fall on facility stairs causing injury, unclean cafeteria items, insufficient water temperature for sterilization, and a theft incident. The investigation found a failed provider practice related to stairway safety but no failed practices related to cleanliness, water temperature, or theft response.

The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies related to nonskid surfaces on stairways were corrected.

The visit was complaint-related and resulted in substantiated deficiencies leading to civil fines.

The investigation found that the licensee failed to ensure staff were nurse delegated to provide nursing services for six residents, resulting in an eye injury for one resident and risk to others. Additionally, the licensee failed to implement a safe medication system for one resident, causing missed medication and elevated blood pressure.

The complaint investigation was substantiated with findings of medication errors, record falsification, and failure to delegate nursing tasks for eye drop administration. Staff did not neglect the resident but made medication errors. The facility was cited for failed provider practices.

The investigation found that the named resident had not been receiving medication as ordered, with medication given once daily instead of twice daily since admission six months prior. The facility made a medication error and falsified the resident's records. Staff were not delegated to administer eye drops to six residents, which was a failed facility practice. Other allegations regarding insulin administration, staff qualifications, and resident assessments were not substantiated.

Multiple fire safety violations were observed including combustible materials stored improperly, missing light switch cover, use of unfused multiplug adapters, inadequate cleaning of exhaust system, disabled door self-closer, lack of documentation for smoke detector sensitivity testing, insufficient emergency lighting test duration, missing monthly elevator emergency recall testing documentation, and unsecured oxygen cylinders. Some violations were corrected during inspection.

The complaint involved an allegation that a named resident was verbally abused by a staff member and the administrator did not report the incident to the Department. The allegation was substantiated with findings of failed facility practice regarding reporting requirements.

The investigation found that the facility failed to immediately report allegations of verbal abuse to the Department's Complaint Resolution Unit hotline, resulting in a delayed investigation and potential risk to residents. The administrator did not report the incident, considering it verbal with no findings, despite staff disciplinary actions and training.

Complaint number 39283 triggered the full inspection. The facility was found non-compliant with multiple deficiencies related to resident care and medication management.

The inspection found multiple deficiencies including failure to complete annual resident assessments, inadequate investigation and documentation of incidents, failure to develop a safe medication system, failure to monitor medication refusals and notify physicians, and failure to maintain appropriate water temperatures. Several residents' records showed missed medication documentation and monitoring.