Inspection Reports for Vista Springs Timber Ridge Village

The inspection was conducted in response to a complaint alleging insufficient staffing on the third shift at the facility.

The investigation confirmed that the facility had insufficient staff on duty during certain third shifts, with only two employees present when more were needed to meet resident care requirements, including residents requiring two-person assistance.

Complaint received on 07/03/2025 alleged that on 06/25/2025 only one employee worked the third shift. Investigation established the violation of insufficient staffing.

The inspection was conducted as a renewal licensing study for Vista Springs Imperial Park at Timber Ridge to assess compliance with licensing requirements.

The facility was found to be in non-compliance with medication management rules, specifically regarding prescribed medications and documentation in residents' service plans. Similar deficiencies were noted for multiple residents.

The inspection was conducted in response to an anonymous complaint alleging insufficient staffing at the facility.

The investigation found that the facility had insufficient staff at times to meet resident needs, particularly for residents requiring two-person assistance. However, the allegation that residents do not receive showers was not substantiated. Additional findings included incomplete details in some resident service plans regarding care needs.

The complaint alleged insufficient staffing and that residents do not receive showers. The insufficient staffing allegation was substantiated; the shower allegation was not substantiated.

The document serves as a notification of license renewal following an administrative review of licensing activity for the past year, confirming substantial compliance with applicable regulations.

The administrative review revealed substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in license renewal.

The inspection was conducted in response to a complaint received from Adult Protective Services alleging neglect and disrespectful treatment of Resident B at the facility.

The investigation found no evidence to support the allegation that Resident B was treated disrespectfully. However, a repeat violation was established regarding staff training, specifically that a new employee did not complete the required orientation competency quiz.

Complaint from Adult Protective Services alleging Resident B was neglected, including claims that staff did not respond to calls for assistance and that Resident B smelled of urine and feces. The allegation of disrespectful treatment was not substantiated.

The inspection was conducted in response to a complaint alleging that residents do not receive medications and that food is not properly stored at the facility.

The investigation found no evidence to support the allegation that residents did not receive medications. However, a violation was established regarding improper food storage, including undated opened food items and leftover cooked chicken without use-by dates.

Complaint alleged residents do not receive medications and food is not properly stored, including chemicals stored with food and raw hamburger left on the counter. The medication allegation was not substantiated; the food storage violation was substantiated.

The inspection was conducted as a renewal licensing study for Vista Springs Imperial Park at Timber Ridge to assess compliance with regulatory requirements and determine eligibility for license renewal.

The facility was found to be non-compliant with multiple rules including tuberculosis screening for residents and employees, failure to conduct hourly and bi-hourly resident checks as required, medication administration errors, failure to post menus, incomplete meal census records, inadequate ventilation in certain rooms, lack of dishwasher heat sanitation testing, and improper food storage practices.

The investigation was initiated due to a complaint alleging that Resident A eloped from the facility and subsequently passed away. The purpose was to investigate the circumstances of the elopement and assess compliance with resident safety and care requirements.

The investigation substantiated violations related to inadequate monitoring and protection of Resident A, who had Alzheimer’s dementia and a recent change in condition. Staff failed to conduct required routine checks, resulting in Resident A being outside unattended for several hours, leading to her death. Additional violations included deficiencies in Resident A's service plan and incomplete staff training and employee records, particularly for Employee #3.

Complaint investigation initiated after Resident A eloped from the facility on 12/23/2022 and later died. The complaint was substantiated based on findings that staff failed to monitor Resident A as required, and there were deficiencies in staff training and resident service planning.

The investigation was initiated due to a complaint alleging that Resident A was not administered medications as prescribed.

The investigation found that Resident A did not receive prescribed medications (Ibuprofen, Alprazolam, Gabapentin) for multiple days due to lack of valid prescriptions and delays in obtaining refills. The facility lacked an organized program of protection as they did not have an active physician for Resident A and delayed obtaining medication orders.

The complaint alleged that Resident A was not administered medications. The violation was established based on the investigation findings.

The facility requested to modify rooms 8, 16, 17, 20, 21, 22, 25, 27, and 28 to have double occupancy, increasing the licensed bed capacity.

On 11/13/20, the licensing staff reviewed photographs of the modified rooms and found no issues with the changes to double occupancy. The recommendation was to increase the licensed capacity to 40 beds.

The facility requested to modify room five to have double occupancy, increasing the licensed bed capacity from 30 to 31.

On 11/8/20, licensing staff reviewed photographs of room five and found no issues with modifying it to a double occupancy room. The recommendation was to increase the licensed capacity to 31.

The document is an Original Licensing Study Report for Vista Springs Imperial Park at Timber Ridge to determine compliance with licensing statutes and administrative rules for issuance of a temporary license.

The facility was found to be in substantial compliance with applicable licensing statutes and administrative rules. The physical facility and program were described in detail, and the facility was recommended for issuance of a temporary license with a maximum capacity of 30 beds.