Inspection Reports for
The Commons at Dallas Ranch

The complaint investigation was substantiated. Allegations included untimely medication administration, missed blood pressure checks, and failure to follow up with the primary care physician on discontinued medications and refills. Evidence included staff interviews, document reviews, and observations.

All three allegations were substantiated based on interviews, document reviews, and observations. Staff failed to timely administer medications, missed blood pressure checks due to lack of training, and did not timely follow up with the primary care physician regarding discontinued medications and refills.

The complaint investigation was substantiated for the allegation that staff did not respond timely to residents' call buttons. The allegations that staff were not properly trained to care and supervise residents and that staff did not assist with residents' basic ADLs were unsubstantiated.

The investigation substantiated that staff failed to respond to residents' call buttons in a timely manner, posing a potential health and safety risk. Two other allegations regarding staff training and assistance with residents' basic ADLs were found to be unsubstantiated.

The complaint was substantiated based on interviews and record reviews. Six residents' insurance invoices were confirmed by the Executive Director to have not been processed timely due to management changes.

The allegation was substantiated. The investigation found that six residents' insurance invoices were not processed timely due to a change in management, posing a potential health and safety risk to clients in care. The deficiency was cited under Title 22 California Code of Regulations.

The complaint was substantiated based on interviews with staff and observations that staff publicly discussed resident’s medical information at the front desk on 08/06/25, violating residents’ personal rights.

The allegation was substantiated after interviews and observations confirmed that staff publicly discussed resident’s medical information at the front desk, violating residents’ personal rights and posing a potential health and safety risk.

The complaint investigation was substantiated. Staff administered unauthorized medication to a resident on 04/16/25 at 12PM and disclosed personal information about the resident on the same date. The investigation included interviews with staff and review of resident and medication records.

Both allegations were substantiated after interviews and record reviews. Staff administered unauthorized medication to a resident due to a delayed prescription refill and publicly disclosed a resident's personal medication information in a common area.

The complaint investigation was substantiated for allegations that staff did not ensure adequate supervision resulting in residents eloping and that medications were not securely stored. Other allegations including failure to follow reporting requirements, lack of staff training in emergency evacuation, failure to conduct quarterly fire drills, and failure to ensure resident privacy were unsubstantiated.

The investigation substantiated two allegations: staff failed to provide adequate supervision leading to residents eloping due to a faulty delayed egress system, and staff failed to securely store medications as the medication room was found unlocked without staff present. Other allegations regarding reporting, emergency evacuation training, fire drills, and resident privacy were unsubstantiated.

The complaint investigation was substantiated for the allegation that staff left a resident on the floor for an extended period of time. The resident had an unwitnessed fall on 11/29/24 and was found confused and lethargic with blood on his elbow. The resident was hospitalized for altered mental status due to dementia precipitated by dehydration and rhabdomyolysis. The allegations that staff did not ensure hydration and did not communicate with the resident's responsible party were unsubstantiated.

The allegation that staff left a resident on the floor for an extended period was substantiated based on interviews, document reviews, and observations. The allegations that staff did not ensure resident hydration and did not communicate with the resident's responsible party were found to be unsubstantiated.

Complaint investigation was substantiated based on evidence including interviews, incident reports, and medication records showing incorrect medication dosage and improper record maintenance.

Both allegations were substantiated after interviews, record reviews, and observations. Medication was administered at incorrect dosages and medication records were not properly updated, posing potential health and safety risks to residents.

The complaint investigation was substantiated. Allegations included failure to keep the facility free from bedbugs and pests. Evidence showed bed bug infestations in resident apartments and memory care areas, and mice presence in kitchen and resident bedroom areas. Corrective actions were documented and deficiencies cleared during the visit.

The investigation substantiated the allegations of bed bug infestation and pest presence in the facility, posing potential health and safety risks to residents. The facility took corrective actions including scheduling extermination treatments and addressing mice infestation.

The visit was complaint-related due to an incident where Resident (R1) eloped from the memory care unit on 06/14/2024. The complaint was substantiated by findings of staff not responding timely to the elopement.

The licensee did not comply with regulations as staff did not respond timely to prevent the resident's elopement, posing a potential health and safety risk. A deficiency was cited but cleared during the visit after submission of corrective actions including in-service training and elopement drills.

The complaint investigation was substantiated for allegations that staff overmedicated a resident and did not follow doctor's orders. Other allegations including failure to safeguard resident's property, failure to notify POA of changes or incidents, failure to respond to POA, and failure to ensure hygiene care were unsubstantiated.

The investigation substantiated allegations that staff overmedicated a resident and did not follow doctor's orders, citing medication errors and failure to verify physician's orders. Other allegations related to safeguarding resident property, notifying POA of changes or incidents, responding to POA, and ensuring hygiene care were found unsubstantiated.

The complaint investigation was substantiated for allegations related to failure to assist residents with hygiene needs, failure to ensure residents had clean clothing, and residents being left in soiled clothing for extended periods. The allegations related to medication administration, response to authorized representatives, facility cleanliness, and safe environment were unsubstantiated.

The investigation substantiated allegations that staff failed to assist residents with hygiene needs, ensure residents had clean clothing, and left residents in soiled clothing for extended periods due to insufficient staffing. Other allegations related to medication administration, response to authorized representatives, facility cleanliness, and safety were unsubstantiated.

The complaint investigation was triggered by allegations including staff not cleaning residents' rooms, residents left in soiled diapers for extended periods, residents not receiving showers, and feces found on a resident's carpet. The allegation of uncleaned rooms was substantiated, while the others were unsubstantiated.

The investigation substantiated that staff failed to clean resident R3's room, posing a potential health and safety risk. Other allegations regarding residents left in soiled diapers, lack of showers, and feces on carpet were unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for the allegation that staff do not answer residents' call pendents in a timely manner. Other allegations including insufficient staff, untimely medication dispensing, unmet incontinence needs, lack of dignity in treatment, and untimely meal provision were unsubstantiated.

The investigation substantiated that staff failed to respond to residents R1 and R2's pendant calls in a timely manner, with 21 calls responded to after more than 30 minutes. Other allegations including insufficient staffing, medication administration, incontinence care, dignity, and meal delivery were unsubstantiated based on interviews and record reviews.

The complaint investigation was substantiated. The medication error involved a double dose administered for 14 days due to system update failure. Staff did not seek timely medical attention for the resident after the error was discovered. The Executive Director confirmed the findings and staff notified the hospice nurse and resident's family accordingly.

Both allegations were substantiated. Staff administered a double dose of a discontinued medication to a resident for 14 days due to failure to update the medication system. Additionally, staff failed to seek timely medical attention for the resident after the medication error was discovered.

Investigation found that staff assisted resident R1 with Morphine from 5/17/22 to 5/21/22 despite hospice care plan stating 'Do not use until directed by hospice'.

A deficiency was cited for failure to comply with hospice care plan requirements, specifically for assisting a resident with Morphine administration without hospice direction, posing a potential health and safety risk.

A deficiency was cited for failure to comply with hospice care regulations, specifically assisting a resident with medication against hospice instructions, posing a potential health and safety concern.

The complaint investigation was substantiated for allegations of failure to provide basic services, insufficient staffing, lack of assistance with incontinence care, and medication administration errors. The allegation of staff verbally abusing residents was unsubstantiated due to lack of evidence.

The investigation substantiated allegations of failure to provide basic services, insufficient staffing, lack of assistance with incontinence care, and improper medication administration, all posing potential health and safety risks to residents. The allegation of staff verbally abusing residents was unsubstantiated.

The complaint investigation was substantiated with findings that a resident sustained a lumbar spinal compression fracture due to improper use of a Hoyer lift by untrained staff, staff delayed seeking medical attention for the resident by two days, and staff failed to assist residents with ADLs in a timely manner due to insufficient staffing. One allegation that the incident was not reported to licensing was unfounded.

The investigation substantiated three allegations: a resident sustained a fractured back due to improper use of a Hoyer lift by untrained staff; staff did not seek timely medical attention for the injured resident; and staff did not assist residents with ADLs in a timely manner due to insufficient staffing. One allegation regarding failure to report the incident to licensing was found unfounded.

A deficiency was observed where a staff member (S1) was fingerprint cleared but not associated with the facility, which poses an immediate health and safety risk. The deficiency was cited under California Code of Regulations, Title 22, Section 87355(e)(2).