Deficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Inspection Report
Follow-Up
Census: 75
Capacity: 80
Deficiencies: 21
Mar 19, 2025
Visit Reason
Follow-up survey to determine correction of orders from the survey completed on December 20, 2024.
Findings
The follow-up survey verified that the facility is in substantial compliance with previous correction orders.
Severity Breakdown
Level 1: 1
Level 2: 18
Level 3: 1
Deficiencies (21)
| Description | Severity |
|---|---|
| Failed to establish and maintain an infection control program consistent with accepted standards, including hand hygiene and glove use. | Level 2 |
| Failed to post the 911 emergency number in common areas and near telephones. | Level 2 |
| Employee records lacked required documentation including orientation, competency evaluations, and RN signatures. | Level 2 |
| Failed to post emergency preparedness plan and emergency exit diagrams prominently on each floor. | Level 2 |
| Failed to provide required training and conduct evacuation drills for fire safety and evacuation plans. | Level 2 |
| Assisted living contract included waiver of liability for resident personal property. | Level 1 |
| Failed to provide required written notice for emergency relocation and notify Ombudsman for Long-Term Care. | Level 2 |
| Training and competency evaluations for unlicensed personnel lacked required content. | Level 2 |
| Failed to ensure RN supervision of unlicensed personnel within 30 days of performing delegated tasks. | Level 2 |
| Staff providing services failed to complete orientation including review of policies and person-centered care principles. | Level 2 |
| Failed to ensure required annual training topics were completed for staff. | Level 2 |
| Failed to complete resident reassessments timely within 14 days of initiation and every 90 days thereafter. | Level 2 |
| Service plans lacked resident or facility signature documenting agreement on services to be provided. | Level 2 |
| RN failed to conduct individualized medication assessments with required content for residents. | Level 2 |
| Failed to document medication setup with required details including date, medication, dose, times, route, and preparer. | Level 2 |
| Failed to develop written procedures for unlicensed personnel providing medications during unplanned time away. | Level 2 |
| Failed to develop and maintain individualized treatment and therapy management plan with all required content. | Level 2 |
| Failed to document administration of treatments including reasons for not administering and follow-up. | Level 2 |
| Failed to provide required dementia care policies and procedures to residents and/or representatives at move-in. | Level 2 |
| Failed to provide care and services according to accepted health care standards for residents with assistive devices, including unsafe bedrails. | Level 3 |
| Resident was treated without dignity and respect, including sleeping on a soiled mattress pad without linens. | Level 2 |
Report Facts
Residents present at survey: 75
Licensed bed capacity: 80
Fines assessed: 3500
Days late for reassessment: 29
Days between assessments: 96
Days between assessments: 146
Days between assessments: 275
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessie Chenze | Supervisor, State Evaluation Team | Signed follow-up survey letter and correspondence |
| John Boettcher | Public Health Sanitarian 3 | Conducted food and beverage establishment inspection |
| Tony Zamora | Kitchen Manager | Food and beverage establishment inspection |
Loading inspection reports...
