Inspection Reports for
Van Mall Retirement

Complaint #228331 concerned a fire alarm activation on 06/13/2026. The fire department responded but could not determine the cause. No fire or sprinkler activation occurred. A resident fell and was hospitalized for evaluation.

A fire alarm activated on 06/13/2026, but no fire or sprinkler activation was found. Staff responded appropriately, and a resident was transported to the hospital for evaluation after a fall. The fire department was unable to diagnose the cause of the alarm. The facility's approval status is Approved.

The complaint investigation was completed on April 16, 2026, and found the medication service deficiencies substantiated, resulting in a civil fine. The deficiency was recurring with prior citations on August 1, 2025, June 3, 2025, and April 10, 2025.

The licensee failed to develop and implement systems that support safe medication services, resulting in one resident receiving the wrong type of insulin at the wrong time, requiring frequent overnight monitoring and placing both residents at risk. This deficiency is recurring and has led to an $800 civil fine.

The complaint investigation involved multiple allegations: neglect where a resident fell and was on the floor for a day without intervention; failure to provide negotiated safety checks and meal escorts; insufficient staffing; failure to reconcile medication orders leading to wrong doses; and failure to identify proper insulin medications resulting in wrong insulin administration. Citations were issued for neglect and medication errors.

The investigation found multiple failed provider practices including failure to provide agreed upon services such as escorting a resident to meals, failure to implement prescribed medication changes, and medication administration errors involving insulin. Citations were written for these deficiencies.

The follow-up inspection found no deficiencies and confirmed that all previously cited deficiencies were corrected. The facility meets the Assisted Living Facility licensing requirements.

The facility was found to have multiple fire safety violations including failure to provide annual fire door inspections, missing fire sprinkler inspection reports, lack of carbon monoxide detection, and unsecured compressed gas cylinders. The overall approval status was Disapproved.

The report details multiple uncorrected deficiencies related to medication services, staff training, negotiated service agreements, and resident records. Civil fines totaling $1,500 were imposed due to failure to correct these issues since the prior citation on April 10, 2025.

The complaint investigation included multiple allegations: quality of care issues such as bathing, CPAP, cleaning, and laundry not being done; dietary services with missing meals; falsification of medication records; insufficient staffing; admission and discharge concerns; poor catheter care; quality of life issues including hallucinations; physical environment cleanliness; and fraud false billing. Some allegations were corroborated and addressed by the new executive director, while others were not substantiated. Citations were written for failed provider practices.

Multiple allegations were substantiated including insufficient staffing, missed showers and meals, and failure to fully provide agreed services. These issues were identified and addressed by the new executive director through additional staffing, retraining, and replacement of staff. Some allegations such as falsification of records, poor catheter care, and fraud false billing were not substantiated. Citations were written for failed provider practices.