Deficiencies per Year
20
15
10
5
0
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 10
Jul 2, 2025
Visit Reason
The inspection was conducted as a health care complaint investigation to address concerns related to resident care, activity engagement, medication administration, and facility staffing.
Findings
Multiple deficiencies were identified including lack of resident engagement in scheduled activities, failure to provide diets as ordered, inadequate resident health assessments after incidents, poor infection control practices, inconsistent offering of snacks and fluids, use of disposable items due to lack of clean supplies, insufficient personnel to meet resident needs, delays in providing resident records, and failure of the former administrator to implement corrective actions after resident incidents.
Complaint Details
The visit was complaint-related, investigating multiple allegations including inadequate resident care, failure to follow medication orders, insufficient staffing, and failure to address resident safety incidents. Substantiation status is not explicitly stated.
Deficiencies (10)
| Description |
|---|
| Residents in the memory care unit were not engaged in scheduled activities; many were left sitting without encouragement to participate. |
| Resident #4 did not receive thickened liquids as ordered, risking aspiration. |
| Facility nurse did not assess residents after changes in mental or health status, including after falls and injuries. |
| Staff failed to follow standard precautions, including glove use and hand hygiene during medication passes. |
| Menus were not posted or current in memory care and assisted living units. |
| Residents were not consistently offered snacks and fluids between meals, with some residents observed drinking salsa due to lack of fluids. |
| Facility used disposable cups due to lack of clean cups in memory care dining room. |
| Insufficient personnel to provide care as required; residents not assisted with toileting, showers, or changing clothes as needed. |
| Facility did not provide immediate access to resident records and copies within two business days as required. |
| Former administrator failed to implement corrective actions after resident altercations causing injury. |
Report Facts
Residents observed not participating in activity: 11
Residents offered participation: 7
Dates of resident falls and incidents: Resident #4 fell on 1/7/25 and 1/26/25; Resident #6 fell on 4/9/25; vomiting and diarrhea on 5/27/25; Resident #7 vomiting on 4/30/25; Resident #1 injured on 5/9/25.
Date of previous citation: Frequency of meals deficiency previously cited on 4/19/24.
Resident admission date: Resident #3 admitted on 9/10/24.
Dates of incidents involving unsampled resident: Incidents on 5/4/25 and 5/9/25 involving resident altercations.
Inspection Report
Complaint Investigation
Deficiencies: 19
Apr 19, 2024
Visit Reason
The inspection was conducted as a health care licensure and follow-up combined with a complaint investigation at Table Rock Senior Living at Barber Station.
Findings
Multiple deficiencies were identified including incomplete criminal background checks for employees, inadequate investigations of incidents involving residents, failure to notify Adult Protective Services of abuse allegations, lack of corrective actions for resident falls, incomplete nursing assessments, medication management issues, incomplete resident care records, insufficient behavior documentation, and inconsistent offering of snacks and fluids to memory care residents.
Complaint Details
The visit was complaint-related, involving allegations of inadequate investigations of incidents, failure to notify Adult Protective Services of abuse, neglect, and exploitation, and other care deficiencies. The administrator admitted to not following facility policies and failing to notify Adult Protective Services of multiple incidents.
Deficiencies (19)
| Description |
|---|
| One of ten employees did not have a Department Criminal History and Background Check completed. |
| One of five employees did not have a state police background check completed prior to working alone with residents. |
| Administrator did not ensure all policies and procedures for investigations of incidents were completed, including missing interviews and failure to notify Adult Protective Services. |
| Administrator failed to report all allegations of abuse, neglect, and exploitation to Adult Protective Services. |
| Facility administrator did not consistently implement corrective actions to prevent resident falls from recurring. |
| Administrator did not have a process to monitor patterns of incidents and accidents to develop interventions. |
| Registered Nurse did not complete all residents' initial and quarterly nursing assessments. |
| Medication refrigerator temperatures were not monitored and documented daily, with multiple instances of temperatures below 38 degrees F. |
| Residents taking psychotropic medications did not have required six-month medication reviews completed. |
| Residents admitted without required demographics, nursing, and maladaptive behavior assessments prior to admission. |
| Residents' Negotiated Service Agreements (NSAs) did not clearly reflect needs, describe services, or were not updated to reflect current needs. |
| NSAs for 8 of 10 sampled residents did not include all required components such as medication management, supervision, and night needs. |
| NSAs were not signed and dated by some residents or their legal guardians. |
| Resident care records lacked documentation by caregivers of unusual events, medical issues, and calls to nurse and administrator. |
| Assessments of residents' medical issues were not consistently documented. |
| Facility did not evaluate or document maladaptive behaviors of certain residents in a timely manner. |
| Facility did not develop sufficient behavior plans with specific interventions for residents with maladaptive behaviors. |
| Facility did not document times, dates, interventions, or effectiveness related to residents' maladaptive behaviors. |
| Residents in memory care unit were not consistently offered snacks and fluids during the day, with some requests repeatedly denied. |
Report Facts
Employee background check missing: 1
Employee state police background check missing: 1
Resident falls: 10
Resident falls: 9
Medication refrigerator temperature below 38°F: 23
Medication refrigerator temperature not documented: 42
Residents without six-month psychotropic medication review: 4
Residents admitted without required assessments: 4
Residents with incomplete NSAs: 8
Residents with unsigned NSAs: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Velasquez | Administrator | Named in multiple findings related to failure to complete background checks, investigations, notifications, and corrective actions. |
| Melvin Lu | Survey Team Leader | Led the health care licensure and follow-up plus complaint investigation survey. |
Inspection Report
Original Licensing
Deficiencies: 11
Jan 6, 2023
Visit Reason
The inspection was conducted as an initial licensure survey combined with a complaint investigation at Table Rock Senior Living at Barber Station.
Findings
The facility was found deficient in multiple areas including incomplete criminal background checks for employees, failure to ensure residents received ordered medications and treatments, inadequate documentation of medication refrigerator temperatures, unclear and inconsistently followed Negotiated Service Agreements, insufficient resident care record documentation, lack of orientation and specialized training for staff, expired food protection certification, insufficient staffing levels, and lack of infection control training.
Complaint Details
The visit included a complaint investigation component as indicated by the survey type 'health care initial licensure + complaint investigation'.
Deficiencies (11)
| Description |
|---|
| One of eight employees did not have a Department Criminal History and Background Check. |
| Three of eight employees who required a state police background check did not have one completed. |
| Facility nurse did not ensure all residents received their medications, specialized diets, and treatments as ordered, including failure to provide low-sodium meals and scheduled medications. |
| Medication refrigerator temperatures were not monitored and documented daily, with multiple days missing documentation and temperatures below required levels. |
| Residents' Negotiated Service Agreements did not clearly reflect needs nor describe services, and care needs were inconsistently met. |
| Resident care records lacked documentation of unusual events, medical issues, and wound assessments. |
| Eight of eight staff members lacked documentation of completing 16 hours of orientation. |
| Facility did not have a Certified Food Protection Manager; certification had expired. |
| Facility did not schedule sufficient personnel to meet residents' needs, resulting in units being left unsupervised and delays in call light responses. |
| Eight of eight employees did not receive infection control training. |
| Eight of eight staff lacked specialized training for caring for residents with mental illness and developmental disability. |
Report Facts
Employees without Department Criminal History and Background Check: 1
Employees without state police background check: 3
Staff lacking orientation documentation: 8
Staff lacking infection control training: 8
Staff lacking specialized training for mental illness and developmental disability care: 8
Staff without current CPR/First aid certifications on overnight shift: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| John Jackson | Administrator | Named as the facility administrator who provided statements regarding background checks, orientation, staffing, and training deficiencies. |
| Melvin Lu | Survey Team Leader | Named as the survey team leader conducting the inspection. |
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