Inspection Report
FEOS
Census: 22
Capacity: 30
Deficiencies: 37
Sep 11, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2021 to 2025 with deficiency history and enforcement actions.
Findings
Across multiple inspections from 2021 to 2025, the facility demonstrated repeated deficiencies including failure to investigate and report abuse, inaccurate medication administration and documentation, inadequate staffing and training, failure to maintain infection control protocols, and environmental maintenance issues. Some improvements were noted in follow-up inspections but multiple deficiencies remained uncorrected.
Complaint Details
Multiple complaint investigations documented failures including inadequate staffing, failure to investigate and report abuse, medication errors, and failure to maintain infection control protocols.
Severity Breakdown
Not Corrected: 38
Deficiencies (37)
| Description | Severity |
|---|---|
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to conduct investigations of injuries of unknown cause and report suspected abuse to local SPD office. | Not Corrected |
| C0303 - Systems: Treatment Orders: Failed to ensure medication and treatment orders were carried out as prescribed. | Not Corrected |
| C0310 - Systems: Medication Administration: Failed to maintain accurate MAR and follow PRN parameters for medications. | Not Corrected |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules. | Not Corrected |
| C0362 - Acuity Based Staffing Tool - Abst Time: Failed to update and implement acuity-based staffing tool accurately. | Not Corrected |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Failed to ensure direct care staff completed required training within 30 days of hire. | Not Corrected |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for the facility. | Not Corrected |
| Z0155 - Staff Training Requirements: Failed to ensure staff completed required dementia and infectious disease training. | Not Corrected |
| C0420 - Fire and Life Safety: Safety: Failed to provide fire and life safety training at required intervals. | Not Corrected |
| C0510 - General Building Exterior: Failed to maintain exterior pathways and prevent pests. | Not Corrected |
| C0513 - Doors, Walls, Elevators, Odors: Failed to keep interior materials and equipment clean and in good repair. | Not Corrected |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to provide emergency call systems and exit door alarms. | Not Corrected |
| H1517 - Individual Privacy: Own Unit: Concerns regarding privacy, dignity, and respect in resident settings. | — |
| H1518 - Individual Door Locks: Key Access: Concerns regarding lockable entrance doors with key access. | — |
| Z0164 - Activities: Failed to provide meaningful activities and individualized activity plans. | Not Corrected |
| Z0165 - Behavior: Failed to evaluate and include behavioral symptoms in service plans. | Not Corrected |
| C0010 - Licensing Complaint Investigation: Various failures documented during complaint investigations. | Not Corrected |
| C0000 - Comment: Various comments documented during inspections. | — |
| C0154 - Facility Administration: Policy & Procedure: Failed to implement policies to promote high quality services and safety. | Not Corrected |
| C0156 - Facility Administration: Quality Improvement: Failed to develop and conduct ongoing quality improvement programs. | Not Corrected |
| C0200 - Resident Rights and Protection - General: Failed to ensure privacy, respect, and dignity for residents. | Not Corrected |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements. | Not Corrected |
| C0270 - Change of Condition and Monitoring: Failed to evaluate and monitor changes of condition appropriately. | Not Corrected |
| C0280 - Resident Health Services: Failed to ensure RN completed assessments for significant changes of condition. | Not Corrected |
| C0295 - Infection Prevention & Control: Failed to maintain infection prevention protocols and designate trained specialist. | Not Corrected |
| C0330 - Systems: Psychotropic Medication: Failed to document non-pharmacological interventions prior to PRN psychotropic medication administration. | Not Corrected |
| C0350 - Administrator Qualification and Requirements: Failed to employ fully licensed administrator. | Not Corrected |
| C0361 - Acuity-Based Staffing Tool: Failed to review and update ABST quarterly and accurately reflect ADLs. | Not Corrected |
| C0365 - Staffing Rqmt and Training: Training Rqmts: Failed to maintain documentation of staff competency and training. | Not Corrected |
| C0000 - Comment: Kitchen inspections documented with findings and compliance status. | — |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure food prepared in accordance with sanitation rules. | Not Corrected |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication system and adequate oversight. | Not Corrected |
| C0304 - Systems: Medication and Treatment Review: Failed to review and implement pharmacist recommendations. | Not Corrected |
| C0360 - Staffing Requirements and Training: Staffing: Failed to provide sufficient caregiving staff to meet resident needs. | Not Corrected |
| C0422 - Fire and Life Safety: Training For Residents: Failed to provide required fire and life safety training to residents. | Not Corrected |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure relicensure survey plan of correction was implemented. | Not Corrected |
| Z0140 - Administration Responsibilities: Failed to provide effective administrative oversight of Memory Care Community. | Not Corrected |
Report Facts
Inspections on page: 10
Total Surveys: 10
Total Deficiencies: 77
Licensing Violations: 10
Notices: 15
Licensed Beds: 30
Resident Census: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Ehlers | Administrator | Named as facility administrator in facility information |
| Staff 1 | Memory Care Director/Administrator | Named in multiple findings related to abuse investigations, medication administration, and administrative oversight |
| Staff 2 | Health Wellness Director/LPN | Named in findings related to medication administration and infection control |
| Staff 3 | Community Nurse/Regional Director | Named in findings related to infection control and administrative oversight |
| Staff 4 | Business Office Manager | Named in findings related to staff training and documentation |
| Staff 5 | Campus Administrator | Named in medication administration findings |
| Staff 6 | Care Partner | Named in training deficiency findings |
| Staff 7 | Med Room Supervisor/RCC | Named in multiple findings related to training and administrative compliance |
| Staff 10 | Maintenance Director | Named in findings related to environmental maintenance and fire safety |
| Staff 11 | Housekeeper/Bus Driver | Named in staff training findings |
| Staff 12 | Medication Technician | Named in medication administration findings |
| Staff 13 | Medication Technician | Named in staff training findings |
| Staff 16 | Medication Aide | Named in training deficiency findings |
| Staff 18 | Medication Aide | Named in training deficiency findings |
| Staff 19 | Personal Care Associate | Named in staff training and competency findings |
| Staff 20 | Personal Care Associate | Named in staff training and competency findings |
| Staff 21 | Executive Director | Named in administrative oversight findings |
| Staff 22 | Personal Care Associate | Named in behavioral and care findings |
| Staff 24 | Resident Care Coordinator | Named in staff training findings |
| Staff 25 | Regional Director | Named in multiple findings related to administrative oversight and compliance |
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