Inspection Reports for
Ivy Park at San Marino

The complaint alleged that Resident #1 sustained multiple severe pressure injuries due to staff neglect, including unstageable wounds and deep tissue injuries. The investigation included interviews with staff, residents, and review of home health and facility documents. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The investigation found insufficient evidence to substantiate the allegation of staff neglect causing multiple severe pressure injuries to the resident. Interviews and document reviews indicated that wound care was provided and redness was reported promptly, with no indication of neglect.

The complaint included three allegations: 1) staff did not address a resident's change in condition related to diabetes management and death, 2) call button in resident's room was not working leading to delayed staff response, and 3) residents were not provided clean clothing. After investigation including interviews with seven staff and seven residents, record reviews, and signal system testing, all allegations were found unsubstantiated due to lack of supporting evidence.

The investigation found insufficient evidence to substantiate the allegations. Staff and resident interviews, record reviews, and signal system tests showed no health and safety concerns. The allegations were deemed unsubstantiated.

The facility was found to be in compliance with all licensing requirements. Infection control, operational requirements, physical plant safety, staffing, personnel records, resident records, food service, disaster preparedness, and special health needs were all reviewed and found satisfactory. No deficiencies were cited.

The complaint alleged that a resident's family member was not allowed to speak to the resident due to staff following a directive from the resident's authorized representative. Interviews and record reviews showed no written document or restraining order prohibiting family contact. The allegation was unsubstantiated due to insufficient evidence.

The investigation found no health or safety concerns and determined there was insufficient evidence to substantiate the allegation that staff prevented the resident from communicating with family. Interviews with residents, staff, and family members indicated that residents have access to phone calls and staff did not prevent communication.

The complaint alleged a questionable death of a 97-year-old Memory Care resident who died after being transferred to the hospital, and that the licensee did not provide resident records to the responsible party despite requests. The investigation included interviews with staff and review of records. The allegations were found unsubstantiated due to lack of evidence.

The investigation found insufficient evidence to substantiate the allegations. The resident's death was due to COVID-19 as confirmed by the death certificate, and there was no evidence that the facility failed to provide records to the authorized representative.

The facility was found to be in compliance with no items of correction needed. The physical plant and safety systems were inspected and found operational, including fire clearance for 74 residents. Some bathique rooms were inoperable but planned for future conversion. The facility maintains proper food storage, hygiene supplies, and emergency preparedness.