Inspection Report
Capacity: 30
Deficiencies: 45
May 14, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2021 to 2025 with deficiency history and enforcement notices
Findings
Across multiple inspections, the facility demonstrated numerous deficiencies including failures in administrative oversight, resident evaluations, service plans, change of condition monitoring, medication administration, staffing, fire and life safety training, physical accessibility, and privacy protections. Several deficiencies were repeated or unresolved at follow-up visits.
Complaint Details
The complaint investigation conducted on 09/10/2024 found no deficiencies related to the complaint.
Deficiencies (45)
| Description | Severity |
|---|---|
| C0010 - Licensing Complaint Investigation: No deficiencies identified in relation to the complaint investigation conducted on 09/10/24. | — |
| C0150 - Facility Administration: Operation: Failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. | Not stated |
| C0160 - Reasonable Precautions: Failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents related to the MCC entry door. | Not stated |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to promptly investigate incidents to rule out abuse and report incidents to local SPD office for 2 sampled residents with altercations or unwitnessed falls. | Not stated |
| C0252 - Resident Move-in and Eval: Res Evaluation: Failed to ensure resident move-in evaluations addressed all required elements for 1 sampled resident. | Not stated |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' current care needs and preferences, provided clear direction, and were implemented for 2 sampled residents. | Not stated |
| C0270 - Change of Condition and Monitoring: Failed to ensure actions or interventions for short-term changes of condition were determined, documented, communicated, and monitored for 2 sampled residents. | Not stated |
| C0280 - Resident Health Services: Failed to ensure an RN completed a timely assessment documenting findings, resident status, and interventions for 1 sampled resident with significant change of condition. | Not stated |
| C0310 - Systems: Medication Administration: Failed to ensure resident-specific parameters and instructions for PRN medications were included on the MAR for 1 sampled resident. | Not stated |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN psychotropic medications were administered only after documented nonpharmacological interventions were tried for 2 sampled residents. | Not stated |
| C0361 - Acuity Based Staffing Tool: Development: Failed to accurately capture care time and care elements provided to residents in the acuity-based staffing tool for 2 sampled residents. | Not stated |
| C0363 - Acuity Based Staffing Tool: Frequency of Updates/Staffing Plan: Failed to develop and maintain an updated posted staffing plan and consistently staff to meet or exceed the staffing plan 24/7. | Not stated |
| C0422 - Fire and Life Safety: Training for Residents: Failed to instruct residents within 24 hours of admission and annually in fire and life safety procedures and keep written records. | Not stated |
| C0513 - Doors, Walls, Elevators, Odors: Failed to ensure the interior was maintained in clean and good repair including dust, stains, gouged furniture, non-functioning light fixtures, and missing baseboards. | Not stated |
| H1510 - Individual Rights Settings: Privacy, Dignity: Failed to ensure privacy and dignity related to no locking mechanism on shared bathroom doors for residents sharing rooms. | Not stated |
| H1515 - Physical Setting: Individual Accessible: Failed to ensure the outdoor courtyard was physically accessible to all residents due to thresholds. | Not stated |
| H1518 - Individual Door Locks: Key Access: Failed to ensure residents were provided a key to their room unless requested and able to use independently. | Not stated |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities as evidenced by multiple cited deficiencies. | Not stated |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired staff completed all preservice orientation training and demonstrated satisfactory performance within 30 days of hire. | Not stated |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules, referencing multiple cited deficiencies. | Not stated |
| Z0163 - Nutrition and Hydration: Failed to ensure individualized nutrition and hydration plans were developed and documented for 2 sampled residents. | Not stated |
| Z0164 - Activities: Failed to ensure residents were evaluated for activities and individualized activity plans were developed for 2 sampled residents. | Not stated |
| C0000 - Comment (2023): Facility was in substantial compliance with food sanitation and resident services meals rules. | — |
| C0240 - Resident Services Meals, Food Sanitation Rule (2022): Failed to ensure food was prepared in accordance with Food Sanitation Rules with multiple sanitation issues noted. | — |
| C0455 - Inspections and Investigation: Insp Interval (2022): Failed to ensure relicensure survey plan of correction was implemented and satisfied the Department. | — |
| C0000 - Comment (2021): COVID-19 Preparedness Questionnaire documented. | — |
| C0160 - Reasonable Precautions (2021): Failed to exercise reasonable precautions against conditions threatening health, safety or welfare of residents related to COVID-19 infection control. | — |
| C0231 - Reporting & Investigating Abuse-Other Action (2021): Failed to thoroughly investigate and report an unwitnessed incident resulting in hip fracture for 1 sampled resident. | — |
| C0240 - Resident Services Meals, Food Sanitation Rule (2021): Failed to ensure kitchen was clean and in good repair with multiple sanitation issues noted. | — |
| C0242 - Resident Services: Activities (2021): Failed to provide activity program based on individual and group interests with lack of scheduled and unscheduled activities. | — |
| C0243 - Resident Services: ADLs (2021): Failed to provide assistance with activities of daily living for 3 sampled residents and unsampled residents requiring oversight and assistance. | — |
| C0252 - Resident Move-In and Eval: Res Evaluation (2021): Failed to ensure move-in evaluations were completed prior to move-in and contained all elements for multiple residents. | — |
| C0260 - Service Plan: General (2021): Failed to ensure service plans were reflective, person centered, updated, and provided clear direction for 3 sampled residents. | — |
| C0270 - Change of Condition and Monitoring (2021): Failed to evaluate, refer, and monitor significant and short term changes of condition for multiple residents. | — |
| C0280 - Resident Health Services (2021): Failed to ensure RN assessment was completed for significant change of condition for multiple residents. | — |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc (2021): Failed to coordinate care with outside providers for 2 sampled residents. | — |
| C0360 - Staffing Requirements and Training: Staffing (2021): Failed to have sufficient number of caregivers to meet 24-hour scheduled and unscheduled needs of residents. | — |
| C0420 - Fire and Life Safety: Safety (2021): Failed to conduct fire drills every other month and provide fire and life safety training on alternate months with required documentation. | — |
| C0540 - Heating and Ventilation (2021): Failed to ensure wall heater covers did not exceed 120 degrees Fahrenheit; electric fireplace removed. | — |
| Z0142 - Administration Compliance (2021): Failed to follow licensing rules for Residential Care and Assisted Living Facilities as evidenced by multiple cited deficiencies. | — |
| Z0145 - Administrator Training (2021): Facility administrator failed to acquire required continuing education credits related to dementia care. | — |
| Z0155 - Staff Training Requirements (2021): Failed to ensure newly hired employees completed all required pre-service training prior to working independently. | — |
| Z0162 - Compliance With Rules Health Care (2021): Failed to provide health care services in accordance with licensing rules referencing multiple deficiencies. | — |
| Z0163 - Nutrition and Hydration (2021): Failed to ensure individualized nutritional and hydration plans were developed and included in service plans for 3 sampled residents. | — |
| Z0164 - Activities (2021): Failed to develop individualized activity plans based on evaluations for 3 sampled residents and failed to provide meaningful activities. | — |
Report Facts
Inspections on page: 6
Total deficiencies: 45
Licensing violations: 10
Notices: 1
Licensed beds: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Seth Hobson | Administrator | Named as facility administrator in facility information |
| Staff 1 | Memory Care Administrator | Named in multiple findings related to administrative oversight and deficiency acknowledgements |
| Staff 2 | Assisted Living Administrator | Named in multiple findings related to administrative oversight and deficiency acknowledgements |
| Staff 3 | Wellness Director/RN | Named in findings related to nursing assessments and investigations |
| Staff 4 | RN | Named in findings related to nursing assessments and deficiency acknowledgements |
| Staff 5 | Maintenance Director | Named in findings related to facility maintenance and fire safety training |
| Staff 8 | Regional RN | Named in multiple findings and deficiency acknowledgements |
| Staff 11 | MT | Named in findings related to privacy and key access |
| Staff 12 | MT | Named in findings related to staff training deficiencies |
| Staff 15 | Care Partner | Named in findings related to staff training deficiencies |
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