Inspection Report
Complaint Investigation
Census: 36
Capacity: 54
Deficiencies: 40
Jul 17, 2024
Visit Reason
State-compiled facility profile showing 6 inspections from 2022-2024 with deficiency history and enforcement notices
Findings
Across multiple inspections from 2022 to 2024, the facility exhibited numerous deficiencies including failures in resident record keeping, abuse investigation and reporting, implementation of service plans, medication administration, staffing adequacy, resident rights and privacy, and environmental safety. Some deficiencies were corrected over time while others remained uncorrected as of the latest inspections.
Complaint Details
Multiple complaint investigations documented including failures to investigate and report abuse, medication errors, staffing inadequacies, and resident rights violations.
Deficiencies (40)
| Description |
|---|
| C0155 - Facility Administration: Records: Failed to ensure the preparation, completeness, accuracy, and preservation of resident records |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to promptly investigate all reports of abuse and suspected abuse and take measures to protect residents and prevent reoccurrence |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report any suspected abuse to the local APS office |
| C0235 - Reporting & Investigating Abuse-Other Action |
| C0260 - Service Plan: General: Failed to ensure the implementation of services for sampled residents |
| C0303 - Systems: Treatment Orders: Failed to carry out medication orders as prescribed |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update an acuity-based staffing tool |
| C0270 - Change of Condition and Monitoring: Failed to ensure a resident monitoring and reporting system was implemented |
| C0200 - Resident Rights and Protection - General: Failed to ensure residents were treated with dignity and respect and received services protecting privacy and dignity |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to immediately investigate injuries of unknown cause and report to local SPD office |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' needs and provided clear descriptions |
| C0270 - Change of Condition and Monitoring: Failed to monitor and document actions or interventions for short-term changes of condition |
| C0280 - Resident Health Services: Failed to ensure timely RN assessment for significant change of condition |
| C0300 - Systems: Medications and Treatments: Failed to ensure a safe medication and treatment administration system |
| C0303 - Systems: Treatment Orders: Failed to ensure medication orders were carried out as prescribed |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician if resident refused medication orders |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN medications had resident-specific parameters and non-pharmacological interventions |
| C0361 - Acuity-Based Staffing Tool: Failed to update acuity-based staffing tool to reflect evaluated care needs and generate adequate staffing plan |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure written record of resident fire safety training within 24 hours of admission and annually |
| C0510 - General Building Exterior: Failed to maintain exterior pathways in good repair and grounds orderly |
| C0511 - General Building Interior: Failed to ensure handrails installed along resident-use corridors |
| C0513 - Doors, Walls, Elevators, Odors: Failed to keep environment clean and in good repair |
| C0530 - Housekeeping and Laundry: Failed to ensure soiled linens and clothing were kept in closed containers and one way flow followed |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to ensure exit doors had operable alarming devices |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| Z0155 - Staff Training Requirements: Failed to ensure direct care staff completed 16 hours of in-service training annually |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules |
| Z0163 - Nutrition and Hydration: Failed to ensure individualized nutrition and hydration plans were developed and included in service plans |
| Z0164 - Activities: Failed to ensure activity evaluations and individualized activity plans reflective of resident preferences and needs |
| Z0165 - Behavior: Failed to ensure behavioral symptoms impacting resident or others were evaluated and included in service plans |
| C0000 - Comment: Kitchen inspections documented substantial compliance |
| C0010 - Licensing Complaint Investigation: Findings of complaint investigation conducted 02/14/2023 |
| C0200 - Resident Rights and Protection - General: Failed to implement resident's right to informed choice and notification of service plan changes |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report suspected abuse to local APS office |
| C0260 - Service Plan: General: Failed to provide service plan with written description of services and dated/initialed changes |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient staff to meet scheduled and unscheduled resident needs |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement acuity based staffing tool including all ADLs |
| C0365 - Staffing Rqmt and Training: Training Rqmts: Failed to have training program to determine competency of direct care staff |
Report Facts
Inspections on page: 6
Total deficiencies: 37
Total surveys: 6
Licensing violations: 10
Abuse violations: 0
Notices: 1
Licensed beds: 54
Residents observed in dining room: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| JEFFREY WELLINGTON | Administrator | Named in multiple findings and acknowledgments across inspections |
| Staff 6 | Administrator | Named in medication error and abuse investigation findings |
| Staff 1 | Administrator | Named in multiple inspection findings and acknowledgments |
| Staff 3 | Health Services Director | Named in multiple inspection findings and acknowledgments |
| Staff 4 | Administrator | Named in resident monitoring deficiency |
| Staff 10 | Caregiver | Named in exit door alarm deficiency and behavioral observations |
| Staff 12 | Caregiver | Named in behavioral observations and housekeeping deficiency |
| Staff 18 | Medication Technician | Named in psychotropic medication deficiency |
| Staff 2 | Business Office Manager | Named in staff training deficiency |
| Staff 14 | Caregiver | Named in staff training deficiency |
| Staff 19 | Medication Technician | Named in staff training deficiency |
| Staff 8 | Registered Nurse | Named in medication administration deficiency |
| Staff 2 | Medication Technician | Named in acuity-based staffing deficiency |
| Staff 3 | MT/CG | Named in service plan and acuity-based staffing deficiencies |
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