Inspection Report Summary
Most inspections found no deficiencies, with several complaint investigations determined to be unsubstantiated. However, some deficiencies were cited over time, primarily related to resident care issues such as failure to provide timely showers and incontinence care, lapses in supervision, and infection control concerns. The most recent report from June 16, 2025, found one deficiency involving inadequate supervision that allowed a resident to elope by climbing out a window, but the facility promptly addressed the issue with increased monitoring and window locks. Earlier complaints about lack of hot water and shower access in February 2025 were substantiated but corrected by the time of follow-up visits. Overall, the facility shows some improvement in addressing prior issues, though occasional isolated deficiencies related to resident care and supervision have occurred.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
90% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 61
Capacity: 68
Deficiencies: 1
Date: Jun 16, 2025
Visit Reason
An unannounced case management visit was conducted to discuss a recent incident report involving a resident who eloped from the facility by climbing out of a bedroom window.
Findings
The resident eloped by removing a window screen and climbing out, posing an immediate risk to health and safety. The facility responded by returning the resident, increasing room check frequency from every two hours to every hour, and installing new metal window locks on memory care windows. A citation under Title 22 was issued and a plan of correction was implemented and cleared during the visit.
Deficiencies (1)
Failure to provide care and supervision as necessary to meet the client's needs, evidenced by a resident eloping out of her bedroom window and subsequently calling her family.
Report Facts
Capacity: 68
Census: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel A Bruce | Licensing Program Analyst | Conducted the unannounced case management visit and signed the report |
| Sergiy Pidgirny | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Brenda Myers | Interim Administrator | Met with during the inspection visit |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 68
Deficiencies: 1
Date: May 8, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2025-02-11 regarding resident care issues including lack of showers, rough handling, untimely response to calls, improper billing, mail handling, supervision, and diet adherence.
Complaint Details
The complaint investigation was substantiated for the allegation that residents lacked hot water and shower access for over 7 days in February 2025. Other allegations including rough handling of residents, untimely response to calls, charging for services not rendered, opening residents' mail, lack of supervision leading to resident altercation, and failure to follow special diets were unsubstantiated or unfounded.
Findings
The investigation substantiated the allegation that residents did not have hot water and access to showers for over 7 days in February 2025, posing a potential health risk. Other allegations including rough handling, untimely assistance, improper billing, mail handling, lack of supervision, and diet noncompliance were found to be unsubstantiated or unfounded based on interviews and record reviews.
Deficiencies (1)
Personal Rights 87468.1(2): Facility did not provide safe, healthful and comfortable accommodations as shower equipment (hot water) was not available and functioning for several days, causing residents to go without showers.
Report Facts
Capacity: 68
Census: 66
Days without hot water: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel A Bruce | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brandon Weber | Administrator | Met with Licensing Program Analyst during the investigation |
| Douglas Rice | Administrator | Named as facility administrator in report header |
| Sergiy Pidgirny | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Annual Inspection
Census: 64
Capacity: 68
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
The visit was an unannounced required annual inspection conducted by Licensing Program Analysts to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with all licensing requirements with no deficiencies cited. Observations included proper lighting, furnishings, operational safety equipment, and appropriate food storage.
Report Facts
Residents receiving Hospice services: 4
Residents receiving Home Health Care services: 5
Facility temperature: 71
Hot water temperature: 118
Fire extinguisher service date: Feb 14, 2025
Last emergency drill date: Feb 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Rice | Administrator | Facility Administrator present during the inspection |
| Lisa Salazar | Licensing Program Analyst | One of the Licensing Program Analysts conducting the inspection |
| Melinda Hoffmann | Licensing Program Manager | Licensing Program Manager named on the report |
Inspection Report
Plan of Correction
Census: 64
Capacity: 68
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
Unannounced Plan of Correction visit conducted to follow up on the 02/29/25 complaint visit.
Findings
The facility developed a memo draft to inform residents about building issues affecting daily living, with plans to document meetings and distribute information to all residents. The Plan of Correction from 02/19/25 is cleared.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Rice | Administrator | Met with Licensing Program Analysts during the Plan of Correction visit. |
Inspection Report
Annual Inspection
Census: 64
Capacity: 68
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
The inspection was an unannounced Case Management visit conducted for the purpose of an annual continuation visit.
Findings
The Licensing Program Analysts conducted a health and safety check, reviewed resident and staff files, finding that 3 of 6 resident files had required documentation while 3 of 3 resident files were missing updated TB testing. Three of five staff files had required documentation. Technical assistance was provided.
Report Facts
Resident files reviewed: 6
Resident files with required documentation: 3
Resident files missing updated TB testing: 3
Staff files reviewed: 5
Staff files with required documentation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Rice | Executive Director | Met with Licensing Program Analysts during inspection |
| Mary Garza | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Capacity: 68
Deficiencies: 1
Date: Feb 19, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to a complaint received on 2025-02-11 regarding the facility being without hot water in the residential section.
Complaint Details
Complaint was substantiated based on interviews, observations, and records review. The allegation that the facility was without hot water in the residential section was confirmed.
Findings
The investigation substantiated that the facility did not have hot water available to residents for over 7 days, posing a potential risk to their health, safety, and personal rights. A deficiency was cited under CCR 87303(a) for failure to maintain the facility in a clean, safe, sanitary, and good repair condition.
Deficiencies (1)
Hot water system was not functioning and residents were without access to hot running water in their units, posing a potential risk to health, safety, and personal rights.
Report Facts
Capacity: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel A Bruce | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Douglas Rice | Administrator | Facility administrator present during exit interview |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 60
Capacity: 68
Deficiencies: 0
Date: Sep 25, 2024
Visit Reason
The visit was an unannounced case management visit based on a self-reported incident involving a resident.
Findings
No deficiencies were cited during the visit. Licensing Program Analysts reviewed requested documents related to the incident and toured the facility, noting recently completed new flooring.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Rice | Administrator | Met with during the visit and stated the purpose of the visit. |
| Lisa Salazar | Licensing Program Analyst | Conducted the case management visit and signed the report. |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| M. Medina | Licensing Program Analyst | Conducted the case management visit. |
Inspection Report
Annual Inspection
Census: 65
Capacity: 68
Deficiencies: 0
Date: May 29, 2024
Visit Reason
The inspection was an unannounced annual continuation visit conducted to review resident and staff records for compliance.
Findings
The Licensing Program Analyst reviewed a sample of resident and staff records and found them complete with required documentation and updated training records. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Salazar | Licensing Program Analyst | Conducted the inspection and reviewed records. |
| Douglas Rice | Administrator | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Census: 65
Capacity: 68
Deficiencies: 0
Date: May 29, 2024
Visit Reason
The visit was an unannounced case management inspection conducted due to an incident involving a physical altercation between two residents in the memory care unit.
Findings
The incident involved Resident R1 and Resident R2, with R1 receiving PRN medication for agitation and R2 receiving first aid. Both families were notified, and no deficiencies were cited during the visit.
Report Facts
Incident date: May 21, 2024
Observation period: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Salazar | Licensing Program Analyst | Conducted the case management visit |
| Douglas Rice | Administrator | Facility administrator met during inspection |
Inspection Report
Annual Inspection
Census: 67
Capacity: 68
Deficiencies: 0
Date: May 2, 2024
Visit Reason
The visit was an unannounced required annual inspection conducted by Licensing Program Analyst L. Salazar to evaluate the facility's compliance with regulatory standards.
Findings
The facility was found to be in compliance with no deficiencies cited. Observations included proper lighting, furnishings, safety measures, food storage, and required postings. Fire extinguishers and first aid kits were properly maintained.
Report Facts
Residents receiving Hospice services: 10
Residents receiving Home Health Care services: 4
Residents in Assisted Living: 39
Residents in Memory Care: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Rice | Administrator | Met with Licensing Program Analyst during the inspection and named as Administrator on record |
| Lisa Salazar | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 68
Deficiencies: 0
Date: Jan 3, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations regarding resident care including pressure injuries, rough handling, lack of medical attention, inadequate food service, and call button access.
Complaint Details
Complaint allegations included multiple pressure injuries due to staff neglect, rough handling, failure to seek medical attention, denial of hospice care, inadequate food service, leaving resident in soiled diapers, and failure to respond to or provide access to call button. The complaint was determined to be unfounded.
Findings
The investigation found the allegations to be unfounded after reviewing resident records, interviewing staff and family, and observing the facility. The facility was found to be in compliance with the hospice care plan and no deficiencies were cited.
Report Facts
Capacity: 68
Census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Salazar | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Douglas Rice | Administrator | Facility administrator who met with the investigator |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 68
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
Unannounced visit/investigation of a complaint alleging that staff do not provide the resident with water.
Complaint Details
Complaint was unsubstantiated and dismissed as unfounded, meaning the allegation was false or without reasonable basis.
Findings
The complaint was found to be unfounded after review of Hospice Care notes and interviews with the Administrator and a resident's relative. No deficiencies were cited during the visit.
Report Facts
Complaint Control Number: 24
Complaint Control Number Suffix: 20230626122017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Salazar | Licensing Program Analyst | Conducted the complaint investigation and site inspection. |
| Doug Rice | Administrator | Interviewed during the investigation. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 68
Deficiencies: 0
Date: Jun 14, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was being left in soiled linens/diapers.
Complaint Details
The complaint alleged that a resident was left in soiled linens/diapers. The resident was receiving hospice care and had refused care and medication. Multiple care conferences documented that the allegations were not true. The complaint was found to be unfounded.
Findings
The investigation found the complaint to be unfounded after reviewing records, interviews, and hospice care notes. No deficiencies were cited, and the allegation was determined to be false or without reasonable basis.
Report Facts
Capacity: 68
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Salazar | Licensing Program Analyst | Conducted the complaint investigation |
| Doug Rice | Administrator | Facility administrator met during investigation |
| Melinda Hoffmann | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 68
Deficiencies: 1
Date: Jun 8, 2023
Visit Reason
An unannounced complaint investigation was conducted following allegations that facility staff were not present at the facility and did not respond to a resident's pull chord for assistance.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The allegations involved staff absence and failure to respond to resident pull chords. A civil penalty was issued and additional deficiencies were referred to Case Management.
Findings
The investigation substantiated the allegations that one staff member was not present at the facility for approximately 30 minutes and that staff did not answer pull chords for residents in care. A civil penalty was issued for absence of supervision.
Deficiencies (1)
Absence of supervision as required by statute or regulation; facility staff not present and did not provide care to resident for at least 30 minutes.
Report Facts
Civil penalty amount: 500
Civil penalty daily continuation amount: 100
Capacity: 68
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Rice | Administrator | Met with Licensing Program Analysts during investigation and named in findings |
| Shawna Doucette | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Darius Williams | Licensing Program Analyst | Assisted in complaint investigation |
| Sergiy Pidgirny | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 68
Deficiencies: 1
Date: Jun 8, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not answering call bells timely.
Complaint Details
The complaint was substantiated. The allegation was that staff were not answering call bells timely. Evidence included a timed response of 4 minutes and 32 seconds, a Kern Fire Department record of no staff present for 30 minutes, and witness interviews confirming delayed responses.
Findings
The investigation found that staff response times to call bells were delayed, with documented instances of staff taking over 4 minutes to respond and one incident where staff were absent for approximately 30 minutes, posing a potential health and safety risk. The allegation was substantiated based on interviews, record reviews, and evidence.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to provide necessary services, as staff failed to respond timely to call bells, including a 30-minute absence.
Report Facts
Response time: 272
Capacity: 68
Census: 65
Plan of Correction due date: Jun 16, 2023
Staff absence duration: 30
Call log request period: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Rice | Administrator | Met with Licensing Program Analysts during the complaint investigation and discussed the purpose of the visit and plan of correction. |
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation, interviewed witnesses and the Administrator, reviewed records, and signed the report. |
| Shawna Doucette | Licensing Program Analyst | Assisted in conducting the complaint investigation and requested signal system call logs. |
| Serigy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 68
Deficiencies: 2
Date: Jun 8, 2023
Visit Reason
The visit was an unannounced complaint investigation to deliver findings for two complaints (AS-20230321111428 and 24-AS-20230330093440).
Complaint Details
The investigation was triggered by complaints AS-20230321111428 and 24-AS-20230330093440. The facility was unable to provide an incident report for resident R1 related to complaint 24-AS-20230330093440, and the complaint was substantiated by the findings.
Findings
Deficiencies were found related to the administrator's failure to provide requested records for the signal system from 3/15/23 to 3/31/23 and the facility's failure to produce an incident report for a resident (R1) regarding an incident in one of the complaints. Additionally, the facility did not report emergency services responding for R1 as required.
Deficiencies (2)
Administrator did not provide requested records for the signal system from 3/15/23 to 3/31/23, posing a potential health, safety, and/or personal rights risk to residents.
Facility did not report emergency services responding for resident R1, posing a potential health, safety, and/or personal rights risk.
Report Facts
Plan of Correction Due Date: Jun 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Rice | Administrator | Met with Licensing Program Analysts during the investigation and was involved in the findings related to record keeping and incident reporting. |
| Emily Conrad | Resident Care Coordinator | Unable to provide a copy of the incident report for resident R1. |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 68
Deficiencies: 2
Date: May 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2022-12-09 regarding staff not cleaning residents' rooms timely, not meeting feeding needs, insufficient staffing, medication mismanagement, and failure to safeguard resident's personal property.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not clean residents' rooms timely and did not meet feeding needs of Resident R1. Other allegations of insufficient staffing, medication mismanagement, and failure to safeguard personal property were found to be unfounded.
Findings
The investigation substantiated allegations that staff did not clean Resident R1's room timely and failed to meet feeding needs as documented. Other allegations regarding insufficient staffing, medication mismanagement, and safeguarding personal property were found to be unfounded. Deficiencies related to infection control and functional assessment were cited with plans of correction required.
Deficiencies (2)
Failure to ensure infection control practices with timely cleaning and disinfection of Resident R1's room surfaces, including visibly soiled bathroom and floor.
Failure to assess and document Resident R1's need for assistance with feeding following a change of condition.
Report Facts
Facility capacity: 68
Census: 67
Number of caregivers per shift: 4
Plan of Correction due date: Jun 12, 2023
Proof of checklist submission due date: Jun 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Salazar | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Melinda Hoffmann | Licensing Program Manager | Oversaw the licensing program and named in the report |
| Doug Rice | Administrator | Facility administrator involved in interviews and plan of correction development |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 68
Deficiencies: 0
Date: Apr 14, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff were not meeting residents' hygiene, dietary needs, cleaning of rooms and linens, and repositioning of residents.
Complaint Details
The complaint was found to be unfounded, meaning the allegations were false or without reasonable basis, and the complaint was dismissed.
Findings
The investigation found the complaint to be unfounded after observations, interviews, and records review showed the resident's room and bedding were clean, the resident was able to reposition their bed independently, and dietary needs were being met according to hospice records and facility menus. No deficiencies were cited.
Report Facts
Capacity: 68
Census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Salazar | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Doug Rice | Administrator | Met with Licensing Program Analyst during the investigation |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Capacity: 68
Deficiencies: 0
Date: Apr 14, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 01/09/2023 regarding medication administration timeliness and staff intimidation of a resident.
Complaint Details
The complaint was found to be unfounded, meaning the allegations were false or without reasonable basis, and the complaint was dismissed.
Findings
The investigation found the complaint to be unfounded after interviews, records review, and observation, with no deficiencies cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Salazar | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Doug Rice | Administrator | Met with Licensing Program Analyst during the investigation. |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 66
Capacity: 68
Deficiencies: 0
Date: Apr 14, 2023
Visit Reason
The visit was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations at the facility.
Findings
The facility was found to be in compliance with no deficiencies cited. Observations included proper lighting, furnishings, safety measures, operational fire extinguishers, locked medications, and adequate food supplies.
Report Facts
Residents receiving Hospice services: 9
Residents receiving Home Health Care services: 4
Fire Extinguishers: 35
Hot water temperature: 119
Facility temperature: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Rice | Administrator | Administrator on record and participated in the inspection visit and exit interview |
| Lisa Salazar | Licensing Program Analyst | Conducted the inspection visit |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Routine
Census: 64
Capacity: 68
Deficiencies: 0
Date: Mar 10, 2022
Visit Reason
An unannounced Infection Control Inspection was conducted as a required 1-year visit to assess compliance with infection control standards.
Findings
The facility was found clean with no fire clearance issues, adequate supplies of medications, food, cleaning, and PPE were observed, and staff and residents were compliant with mask-wearing and social distancing. No deficiencies were issued.
Report Facts
Capacity: 68
Census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Rice | Administrator | Met with Licensing Program Analyst during inspection |
| Alexandria Walton | Licensing Program Analyst | Conducted the Infection Control Inspection |
| Melinda Hoffmann | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 68
Deficiencies: 0
Date: Feb 18, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that staff do not prevent a resident from wandering while in care.
Complaint Details
The complaint alleging staff do not prevent a resident from wandering while in care was investigated and found to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.
Findings
The complaint was found to be unfounded after investigation, with no deficiencies issued. Interviews and record reviews showed the resident was not found wandering outside the facility and had never left unsupervised.
Report Facts
Capacity: 68
Census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Rice | Administrator | Met with Licensing Program Analyst during investigation |
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Hoffmann | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 68
Deficiencies: 1
Date: Feb 18, 2022
Visit Reason
An unannounced Case Management inspection was conducted to investigate complaint number 24-AS-20211012140617 regarding an incident involving a resident exhibiting aggressive behavior.
Complaint Details
Investigation of complaint number 24-AS-20211012140617 found the facility did not file an incident report after police responded to a call for aggressive behavior by resident R1.
Findings
The facility failed to submit an incident report after a resident (R1) exhibited aggressive behavior requiring police intervention and hospital transport, which poses a potential health and safety risk to persons in care.
Deficiencies (1)
Failure to submit an incident report for R1 when R1 became aggressive towards staff and other residents resulting in R1 being transported to the hospital.
Report Facts
Capacity: 68
Census: 66
Plan of Correction Due Date: Mar 18, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Rice | Administrator | Met with Licensing Program Analyst during inspection and agreed to staff training for deficiency correction |
| Alexandria Walton | Licensing Program Analyst | Conducted the inspection and authored the report |
| Melinda Hoffmann | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 68
Deficiencies: 1
Date: Mar 19, 2021
Visit Reason
The visit was conducted as a Case Management-Deficiencies inspection via telephone due to COVID-19 precautions, following a complaint investigation regarding staff not wearing face coverings while providing care.
Complaint Details
The visit was complaint-related, substantiated by video evidence showing staff not wearing face coverings as required, violating personal rights and health safety regulations.
Findings
The investigation found that on 10/21/2020, the Administrator failed to protect clients' personal rights by allowing staff to not wear face coverings while providing care, violating official government orders. A deficiency was cited based on video evidence.
Deficiencies (1)
Failure to ensure residents were accorded safe, healthful, and comfortable accommodations when staff S1 removed face mask while providing care to resident R1 on 10/21/2020.
Report Facts
Capacity: 68
Census: 39
Plan of Correction Due Date: Mar 22, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Rice | Administrator | Named in relation to the deficiency and Plan of Correction |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 68
Deficiencies: 1
Date: Mar 19, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 11/20/2020 alleging that staff failed to treat a resident with dignity and respect.
Complaint Details
The complaint was substantiated based on staff interviews, personnel records review, and video observation. The allegation was that staff failed to treat a resident with dignity and respect by recording the resident without consent and laughing instead of redirecting the resident appropriately.
Findings
The investigation found that on 10/21/2020, staff recorded a resident's behavior without consent and failed to appropriately redirect the resident, which substantiated the allegation of failure to treat the resident with dignity and respect.
Deficiencies (1)
Failure to ensure residents were accorded dignity in their relationships with staff, evidenced by staff recording a resident without consent and not appropriately redirecting the resident.
Report Facts
Capacity: 68
Census: 39
Deficiency Type Count: 1
Plan of Correction Due Date: Mar 17, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Rice | Administrator | Named in relation to the investigation findings and exit interview |
| Alexandria Walton | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Hoffmann | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 68
Deficiencies: 1
Date: Jan 7, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple complaints received on 03/24/2020 regarding resident care issues including incontinence needs, showering needs, rough handling, injuries, supervision, food quantity, and pest presence.
Complaint Details
The complaint investigation was substantiated for failure to meet residents' incontinence and showering needs. Other complaints regarding rough handling, injuries, supervision, food quantity, and facility ants were unsubstantiated or unfounded.
Findings
The investigation substantiated that staff failed to meet residents' incontinence and showering needs, posing an immediate health and safety risk. Other allegations such as rough handling, injuries, supervision, food quantity, and presence of ants were found unsubstantiated or unfounded. A deficiency was cited related to residents not being changed or showered as scheduled.
Deficiencies (1)
Residents were left unchanged for extended periods and did not receive showers as scheduled, violating personal rights to safe, healthful, and comfortable accommodations.
Report Facts
Capacity: 68
Census: 45
Deficiency count: 1
Plan of Correction due date: Jan 11, 2021
Training submission due date: Feb 8, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Rice | Administrator | Named in findings and exit interviews |
| Alexandria Walton | Licensing Program Analyst | Conducted investigation and delivered findings |
| Melinda Hoffmann | Licensing Program Manager | Oversaw complaint investigation |
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