The most recent inspection on October 15, 2024, found deficiencies related to inconsistent water temperatures, incomplete behavioral documentation, missing psychotropic medication review updates, and unsigned physician orders. Earlier inspections showed issues with fire safety equipment maintenance and prohibited electrical devices, as well as administrative and nursing documentation deficiencies at the time of initial licensure. Inspectors cited recurring themes involving documentation accuracy, medication and physician order management, and safety equipment compliance. There were no fines, immediate jeopardy findings, or enforcement actions listed in the available reports, and no substantiated complaints were noted. The pattern of findings suggests ongoing challenges with regulatory compliance, with similar types of deficiencies appearing across inspections.
Deficiencies (last 2 years)
Deficiencies (over 2 years)6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The visit was a health care licensure and follow-up survey conducted to assess compliance with regulatory requirements and verify correction of previous deficiencies.
Findings
The facility had multiple deficiencies including inconsistent water temperatures, missing behavioral updates on psychotropic medication reviews, incomplete behavior documentation for a resident, and lack of current signed physician orders for several residents.
Deficiencies (4)
Description
The facility's water temperatures were not consistently maintained between 105 and 120 degrees F, with observed temperatures ranging from 72 to 100 degrees F.
The facility did not include behavioral updates on residents' six-month psychotropic medication reviews.
The facility did not evaluate Resident #6's behaviors of refusing cares and hypersexual behavior, and had not updated or completed the evaluations.
The facility did not maintain current signed physician orders for six of ten sampled residents.
Report Facts
Number of residents without current signed physician orders: 6Number of medications Resident #10 was taking: 23
Employees Mentioned
Name
Title
Context
Kerri Wells
Administrator
Named as facility administrator aware of missing behavioral updates.
Megan Rideout
Survey Team Leader
Led the health care licensure and follow-up survey.
Inspection Report Life SafetyDeficiencies: 4Nov 17, 2023
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey for the facility Spring Gardens Meridian.
Findings
The facility did not maintain compliance with the 2018 edition of NFPA 101 Life Safety Code and related sprinkler inspection standards, including issues with a door held open by a non-interconnected magnetic device, a sprinkler pendant loaded with grease/dust, and uncalibrated sprinkler gauges. Additionally, prohibited use of Relocatable Power Taps powering appliances in resident and staff areas was observed.
Deficiencies (4)
Description
Door from kitchen to dining room held open by a magnetic hold open device not interconnected to the fire alarm system.
Sprinkler pendant in walk-in cooler loaded with grease/dust.
Sprinkler inspection/testing records showed gauges were not calibrated or replaced as part of the 5-year sprinkler inspection.
Relocatable Power Tap used to power microwave and small refrigerator in resident room #209 and a full-sized refrigerator in staff break room, which is prohibited.
Report Facts
Facility License Number: RC-1272
Employees Mentioned
Name
Title
Context
Kerri Wells
Administrator
Named as facility administrator
Linda Chaney
Survey Team Leader
Conducted fire life safety and sanitation licensure survey
Inspection Report Original LicensingDeficiencies: 4Feb 24, 2023
Visit Reason
The inspection was conducted as a health care initial licensure survey combined with a complaint investigation.
Findings
The inspection identified four deficiencies including an employee lacking a current criminal background check for over two months, incomplete admission agreements for five residents at the time of ownership change, failure of the Registered Nurse to perform quarterly assessments for four residents, and lack of a record for non-narcotic drug disposals.
Complaint Details
The visit included a complaint investigation component, but substantiation status is not stated.
Deficiencies (4)
Description
One employee did not have a current Department Criminal History and Background Check for over two months after ownership change.
Five residents' admission agreements were not completed at the time of the facility's ownership change.
Registered Nurse did not perform quarterly assessments for four of ten sampled residents.
Facility did not keep a record of non-narcotic drug disposals.
Report Facts
Employees reviewed: 10Residents sampled: 10Residents with incomplete admission agreements: 5Residents with missed quarterly assessments: 4
Employees Mentioned
Name
Title
Context
Kerri Wells
Administrator
Confirmed incomplete admission agreements and background check issues
Veronica LeMaster
Survey Team Leader
Led the inspection team
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