Inspection Reports for AvantGarde Senior Living | Tarzana

An unannounced complaint investigation visit was conducted regarding an allegation that staff sexually assaulted a resident in care.

The investigation included interviews with staff and residents, review of records, and a police report. No sufficient evidence was found to substantiate the allegation, and the complaint was deemed unsubstantiated. No immediate health or safety hazards were observed during the visit.

The complaint alleged that Staff #1 sexually assaulted Resident #1 about two months prior. Investigations included multiple visits, interviews with residents and staff, and review of police and facility records. Staff #1 denied the allegations and stated awareness of facility policies prohibiting sexual contact. The police investigation ended due to consensual encounters unrelated to the facility. The allegation was unsubstantiated due to insufficient evidence.

Unannounced complaint investigation visit conducted to investigate allegations that facility staff were not following physician's orders related to Resident #1's post-surgery discharge instructions.

The investigation found that Resident #1 was capable of following discharge orders independently and did not report needing assistance. Staff were aware of the orders, and the allegation that staff failed to follow physician's orders was deemed unsubstantiated.

The complaint alleged that facility staff did not follow discharge orders from Resident #1's surgery on 03/06/2025. The allegation was unsubstantiated based on interviews, observations, and record review.

An unannounced annual inspection was conducted to evaluate compliance with Title 22 regulations and assess the facility's conditions and operations.

The facility was found to be in compliance with Title 22 regulations with no immediate health and safety risks observed. All resident files were complete, safety equipment was operational, and medication storage and records were accurate.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations that a resident sustained injury from a fall due to lack of supervision and that the resident did not receive timely medical attention.

The investigation found that staff provided sufficient supervision to the resident and timely medical attention was offered but refused by the resident. Both allegations were deemed unsubstantiated based on interviews, record reviews, and observations.

The complaint involved two allegations: 1) Resident sustained injury from a fall due to lack of supervision, and 2) Resident did not receive timely medical attention. Both allegations were investigated and found to be unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate an allegation that staff did not ensure reporting requirements were followed regarding a cut on the arm of a resident.

The investigation found that the injury was reported to the resident's hospice agency and the responsible party, and facility staff followed reporting requirements. The allegation was deemed unsubstantiated. No immediate health and safety hazards were observed.

The complaint alleged that staff did not report a cut on the arm of Resident #1 to family in April 2023. The investigation revealed the injury was reported to the hospice agency and the responsible party, leading to the allegation being unsubstantiated.

The visit was an unannounced complaint investigation conducted to investigate the allegation that staff did not safeguard a resident's personal belongings.

The investigation found that the facility properly safeguarded the resident's belongings and sent them to the resident's Skilled Nursing Facility and new residence. Therefore, the allegation was unsubstantiated. No immediate health and safety risks were observed during the visit.

The complaint alleged that staff did not safeguard resident's personal belongings, including a dresser, monitor, blanket, shirts, compression socks, sodas, waters, and a wheelchair. After interviews and record reviews, the allegation was found to be unsubstantiated.

The inspection was conducted as an unannounced complaint investigation visit to address allegations of unlawful eviction of a resident from the facility.

The investigation found that the facility did not evict the resident; the resident was noncompliant with medical advice and was recommended for placement at an alternate facility. The allegation of unlawful eviction was deemed unsubstantiated. No immediate health and safety risks were observed.

The complaint alleged unlawful eviction of Resident #1 (R1) from the facility. After interviews and record reviews, it was determined that R1 was not evicted but was placed in an alternate facility based on medical recommendations and social worker advice. The allegation was unsubstantiated.

The visit was an unannounced complaint investigation conducted to investigate allegations that the facility was overcharging a resident in care.

The investigation found that the resident was not being overcharged. Interviews and record reviews confirmed that the resident did not pay rent on time but was not charged any late fees or extra charges, and was not charged for belongings left in a previous room. The allegation was deemed unsubstantiated.

The complaint alleged that the facility was overcharging a resident by charging $75 per day for leaving belongings in a previous room. The allegation was investigated and found to be unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not report resident relocations to the required agencies.

The investigation found that the facility properly notified the appropriate individuals and agencies regarding resident relocations. The allegation was deemed unsubstantiated based on interviews and record reviews.

The complaint alleged that the facility failed to report the relocation of resident R1 to R1’s case manager and failed to report resident R2’s hospitalization and placement in a skilled nursing facility to R2’s family member. The investigation revealed that notifications were properly made, and the legal authority of the family member was expired.

The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff would not accept a resident back into the facility.

The investigation found that the facility refused to readmit the resident due to an unstageable pressure injury, which was supported by medical advice and compliance with Title 22 regulations. The allegation was deemed unsubstantiated, and no immediate health and safety risks were observed.

The complaint alleged that staff would not accept Resident #1 back into the facility. The investigation revealed the resident was hospitalized due to a fall and had an unstageable pressure injury. The facility refused readmission until the injury could be treated at a skilled nursing facility. The resident was readmitted on 04/09/2024. The allegation was unsubstantiated.

The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2024-02-23 regarding staff assistance with medical care, notice of rate increase, unspecified fees, assistance with showering and grooming, and the comfort of the resident's environment.

All allegations were investigated through interviews, record reviews, and observations. The investigation found that the facility assisted the resident with obtaining medical care, provided proper notice of rent increase, did not charge unspecified fees, offered assistance with showering and grooming which the resident refused, and allowed the resident to control lighting in their room. Therefore, all allegations were deemed unsubstantiated with no immediate health or safety concerns observed.

The complaint investigation was unsubstantiated. Allegations included failure to assist resident with medical care, failure to provide notice of rate increase, charging unspecified fees, failure to assist with showering and grooming, and not providing a comfortable environment. Interviews and record reviews showed the resident refused some services, was properly notified of rent increases, and had control over their environment.

The inspection was an unannounced continuation of the 2024 annual inspection to review compliance with Title 22 regulations.

During the inspection conducted on 02/29/2024 and 03/01/2024, the facility was found to be in compliance with Title 22 regulations.

An unannounced annual inspection was conducted by Licensing Program Analyst Nicholas Reed to evaluate compliance with Title 22 regulations and assess the facility's conditions and operations.

The facility was found to be in compliance with Title 22 regulations with no immediate health and safety risks observed. The inspection included a review of the facility's environment, medication management, emergency preparedness, and resident living areas.

An unannounced complaint investigation visit was conducted to investigate the allegation that staff did not seek timely medical attention for a resident.

The investigation found that the resident did not report signs of distress to staff and vital signs were normal, indicating no medical attention was necessary. The allegation was deemed unsubstantiated.

The complaint alleged that staff did not call 9-1-1 when Resident #1 experienced a serious health condition. After investigation, including interviews and record review, the allegation was unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate allegations that staff did not ensure residents had access to a working telephone in the memory care unit.

The investigation found that the facility phone was operational, the memory care unit phone was recently misplaced but promptly replaced, and no immediate health and safety hazards were observed. Therefore, the allegation was deemed unsubstantiated.

The complaint alleged that staff did not ensure residents had access to a working telephone, specifically that the memory care unit phone was not working and calls were disconnected. The allegation was found unsubstantiated after investigation.

An unannounced complaint investigation was conducted regarding allegations that staff stole residents' personal belongings, specifically cash and perfume from Resident #1.

The investigation included interviews with staff and residents, record reviews, and a facility tour. No evidence was found to substantiate the theft allegations, and the facility followed policies to safeguard residents' property and offered reimbursement for missing items. The allegation was deemed unsubstantiated.

The complaint alleged staff stole cash and perfume from Resident #1. Interviews with staff and residents, including 14 residents and 6 staff, revealed no evidence supporting theft. Residents #2 and #3 believed items were taken but did not report or document missing items. The facility provided lockboxes and reimbursement offers. The allegation was unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate multiple allegations including unexplained injuries to residents, rough handling by staff, improper medication assistance, residents sustaining rashes due to incontinence care, and staff yelling at residents.

After interviews with staff and residents, record reviews, medication checks, and observations, all allegations were found to be unsubstantiated. No unexplained injuries, rough handling, improper medication assistance, unmet incontinence needs, or staff yelling were observed or reported during the investigation.

The complaint investigation was unsubstantiated. Allegations included unexplained injuries, rough handling, improper medication assistance, rashes from incontinence care neglect, and staff yelling. All were found unsubstantiated based on interviews, observations, and record reviews.

Unannounced complaint investigation visit conducted due to an allegation that licensee neglect resulted in a resident sustaining unexplained injuries.

The investigation included record reviews, staff and resident interviews, and facility tours. The allegation was found to be unsubstantiated as staff followed the resident's care plan, injuries were reported timely, and no staff witnessed or knew the cause of the injuries. No immediate health or safety hazards were observed during the visit.

The complaint alleged licensee neglect causing unexplained bruising and swelling to Resident #1. The investigation found no evidence to confirm the allegation; it was deemed unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-06-22 regarding personnel qualifications and alleged unprofessional conduct by the administrator.

The investigation included interviews with residents, staff, and the administrator, as well as a review of records. The findings revealed that the administrator conducts themselves professionally and is knowledgeable and respectful. There was insufficient information to support the allegation, and the complaint was unsubstantiated.

The complaint alleged that the administrator conducted themselves in an unprofessional manner. The allegation was found to be unsubstantiated based on interviews and record reviews.

Unannounced complaint investigation visit conducted due to multiple allegations including resident injury, rough handling by staff, unexplained injuries, inappropriate medication, and force feeding.

After interviews, observations, and record reviews, there was insufficient evidence to substantiate any of the allegations. No immediate health or safety risks were observed, and staff were found to be following proper procedures.

The complaint investigation was triggered by allegations that a resident sustained a fracture due to staff neglect, staff handled a resident roughly causing bruises, residents sustained unexplained injuries due to neglect, staff were inappropriately medicating residents, and staff forcefed a resident. All allegations were found to be unsubstantiated based on interviews, observations, and record reviews.

The inspection was conducted as an unannounced complaint investigation visit to investigate allegations that a resident developed a pressure injury due to staff neglect, that staff were not repositioning the resident, and that staff failed to monitor the resident's water and food intake resulting in hospitalization.

The investigation found insufficient evidence to substantiate the allegations. The resident was repositioned every two hours and had only a stage II pressure injury being treated by hospice and facility staff. The resident was hospitalized for weakness and loss of appetite, but there was no evidence that staff failed to monitor water and food intake causing the hospitalization. Therefore, all allegations were deemed unsubstantiated.

The complaint investigation was unannounced and conducted due to allegations of neglect causing a pressure injury, failure to reposition the resident, and failure to monitor water and food intake resulting in hospitalization. The allegations were found unsubstantiated based on staff interviews, record reviews, and resident interview.

An unannounced complaint investigation was conducted to investigate an allegation that staff did not issue a refund to the responsible party for the unused portion of an advance payment after a resident passed away.

The investigation found that the Power of Attorney had already received the requested refund check of $580.65 four days prior to the visit, and the allegation was deemed unsubstantiated based on interviews and record review.

The complaint alleged that staff did not issue a refund to the responsible party. The allegation was investigated and found to be unsubstantiated.

The inspection was an unannounced complaint investigation triggered by allegations that staff refused to admit a resident back to the facility and that staff were withholding a resident's personal belongings.

The investigation found insufficient evidence to substantiate the allegations. The resident had self-admitted to a Skilled Nursing Facility without notifying the facility and had departed with personal belongings. Staff and witnesses denied withholding belongings. The allegations were deemed unsubstantiated.

The complaint involved two allegations: 1) staff refused to admit resident back to the facility, and 2) staff withheld resident's personal belongings. Both allegations were investigated and found unsubstantiated based on interviews, record reviews, and witness statements.

The visit was a Case Management inspection conducted in conjunction with a complaint regarding an incident involving kitchen plumbing that was not reported to the Community Care Licensing Department as required.

The inspection found that the administrator failed to notify the licensing agency about the kitchen plumbing incident that occurred on 05/26/2023, which posed a potential health and safety risk to residents. A written Incident Report was provided during the visit.

Complaint number 31-AS-20230622091845 triggered the visit. The deficiency was substantiated based on the administrator's admission of failure to notify the department about the incident.

The visit was a Case Management inspection conducted in conjunction with a complaint regarding the facility's failure to submit an incident report in a timely manner related to an event on 11/04/22 involving resident R1.

The licensee failed to comply with reporting requirements by not notifying the Community Care Licensing Department about the incident involving resident R1, which poses a potential health and safety risk to persons in care.

Complaint #31-AS-20230615153708 triggered the visit. The complaint involved failure to timely report an incident that occurred on 11/04/22 with resident R1. The deficiency was substantiated as the licensee did not notify CCLD as required.

An unannounced complaint investigation was conducted to investigate the allegation that staff were not following the admission agreement, specifically regarding reimbursement of a resident's community fee.

The investigation found that the facility reimbursed Resident #1's Power of Attorney $2100 on 05/10/2023, representing 60% of the pro-rated refund for the community fee as per the admission agreement. The allegation was deemed unsubstantiated.

The complaint alleged that staff were not following the admission agreement related to reimbursement of a community fee. The allegation was investigated and found to be unsubstantiated.

An unannounced complaint investigation visit was conducted due to an allegation of financial abuse involving the prior facility administrator.

The investigation substantiated that the prior facility administrator was terminated for financial abuse/embezzlement. A deficiency was cited for failure to ensure residents' personal rights were observed and respected, posing an immediate safety and personal rights risk.

The complaint was substantiated. The allegation involved financial abuse by the prior administrator, who was terminated due to embezzlement. Documentation and police reports were reviewed, confirming the allegation.

The inspection was conducted as a complaint investigation following an allegation that facility staff were not providing adequate supervision.

The investigation found insufficient evidence to corroborate the allegation of inadequate supervision by staff. The complaint was deemed unsubstantiated as no recent incidents or witnesses were identified, and residents and staff interviews did not confirm the allegation.

The complaint alleged that facility staff were not providing adequate supervision, specifically regarding an incident where Resident 1 was reported to have hit Resident 2 several times in June 2021. The investigation found no visible bruising, no recent incidents, and no staff awareness of physical aggression, only verbal aggression. Resident 2 denied the allegation of inadequate supervision and declined to move rooms despite offers. The complaint was unsubstantiated.

Licensing Program Analysts conducted an Annual Required visit and inspection of the facility to evaluate compliance with licensing regulations.

The facility was found to be in compliance with no deficiencies observed. The physical plant, resident rooms, common areas, medication storage, and records were all reviewed and found satisfactory.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff do not treat residents with respect and do not follow through with residents' medical appointments.

The investigation found insufficient evidence to corroborate the allegations. Interviews with residents and staff, as well as record reviews, indicated that residents were not treated differently or disrespectfully, and that staff did assist with medical appointments, although one resident refused to attend some appointments independently.

The complaint included allegations that staff do not treat residents with respect and do not follow through with residents' medical appointments. Both allegations were deemed unsubstantiated after investigation, including interviews with residents, staff, social worker, and nurse practitioner, and review of records.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not answer authorized representatives' questions regarding a resident, did not provide updated medication lists, and did not ensure new doctor orders for medications were received.

The investigation found insufficient evidence to corroborate the allegations. Interviews with staff and review of records indicated that staff responded appropriately to family inquiries, provided updated medication lists, and received new medication orders as required. Therefore, all allegations were deemed unsubstantiated.

The complaint involved three allegations: staff not answering authorized representatives' questions, not providing updated medication lists, and not ensuring receipt of new doctor medication orders. All allegations were investigated and found unsubstantiated.

The visit was an unannounced complaint investigation conducted to investigate allegations that staff was threatening to drug a resident and that the facility did not safeguard a resident's personal belongings.

The investigation found insufficient evidence to corroborate the allegations. Interviews with staff, residents, and the administrator denied the claims, and records confirmed the resident had been refusing medication. The allegations were deemed unsubstantiated.

The complaint investigation was triggered by allegations that staff threatened to drug Resident 1 and that the facility failed to safeguard the resident's personal belongings. Both allegations were found unsubstantiated after interviews, record reviews, and verification with the resident's physician and law enforcement.

The visit was conducted as an unannounced investigation of a complaint received on 01/26/2021 alleging that the licensee was in financial distress and that several employees were not being paid during December 2020 through January 2021.

The investigation found that employees were paid during the period of December 2020 through January 2021 based on interviews with staff and review of payroll documents. The allegation was deemed unsubstantiated.

The complaint alleged that several employees were not paid during December 2020 through January 2021. The allegation was investigated and found to be unsubstantiated based on interviews and payroll documentation.

The inspection was conducted as a complaint investigation following an allegation that staff did not safeguard a resident's confidential information.

The investigation found insufficient evidence to prove that staff failed to safeguard the resident's confidential information. The resident confirmed willingly giving access to their personal information to the administrator's friend.

The complaint alleged that staff did not safeguard Resident 1's confidential information. The allegation was deemed unsubstantiated after investigation.

An unannounced Plan of Correction (POC) visit was conducted to follow up on pending Plan of Corrections issued during the annual visit on 01/25/2022 and additional citations from a complaint investigation on 07/27/2022.

The facility was re-cited for failure to submit complete Plans of Correction for multiple deficiencies including personal rights violations, infection control, reporting requirements, dementia care assessments, hospice care plans, and postural supports. Civil penalties were issued and continue to accrue until corrections are made.

An unannounced complaint investigation visit was conducted in response to an allegation that staff were not wearing masks in the facility.

The investigation substantiated the allegation that staff were not wearing masks appropriately, posing a potential health, safety, and personal rights risk to residents. Multiple staff were observed wearing masks improperly or not at all during the visit.

The complaint was substantiated. Staff were observed wearing masks inappropriately or not wearing masks at all during the unannounced visit. The administrator was contacted but was not present during the visit.

The visit was an unannounced Case Management-Deficiencies inspection conducted due to deficiencies observed during the investigation of complaint control #31-AS-20220721125636.

The facility failed to report a resident who tested positive for COVID-19 within 24 hours as required, posing an immediate health and safety risk. This was a repeat violation resulting in a civil penalty.

The visit was triggered by complaint control #31-AS-20220721125636. The deficiency was substantiated as the facility did not comply with reporting requirements for a COVID-19 positive resident.

The visit was conducted as a Case Management follow-up on an incident report alleging a possible personal rights violation involving a resident.

Based on interviews and record review, there was insufficient information to confirm a personal rights violation, and therefore no citations were issued.

The complaint involved an alleged personal rights violation of Resident 1 (R1). The allegation was not substantiated due to lack of sufficient information.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-02-09 regarding inappropriate staff comments towards residents, inadequate food service, and staff denying residents food.

The investigation found no sufficient evidence to substantiate any of the allegations. Interviews with residents and staff, as well as physical inspections, indicated that the allegations were unsubstantiated at this time.

The complaint investigation addressed three allegations: staff making inappropriate comments towards residents, inadequate food service, and staff denying residents food. All allegations were found to be unsubstantiated based on interviews and inspections.

The visit was an unannounced complaint investigation conducted to investigate an allegation that staff did not provide medical attention for a resident in care.

The investigation found that the resident had called 911 on their own and was transported to the hospital, with no evidence supporting the allegation that staff failed to provide medical attention. The allegation was deemed unsubstantiated.

The complaint alleged that staff did not provide medical attention for a resident who complained of shortness of breath. The allegation was investigated and found to be unsubstantiated based on interviews, record review, and statements from the resident's responsible person.

The visit was conducted to investigate a complaint received on 2020-09-14 regarding multiple allegations including staff failing to protect residents from harm, improper destruction of non-active medications, residents receiving hospice care without cause, and administrator availability.

The investigation found insufficient evidence to substantiate any of the allegations. Interviews, record reviews, and facility inspections did not corroborate claims of staff failing to protect residents, improper medication destruction, inappropriate hospice care, or administrator unavailability. All allegations were deemed unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included staff failing to protect residents from harm by another resident, failure to destroy non-active medications, residents receiving hospice care without cause, and administrator not being available. None of these allegations were supported by evidence.

The visit was conducted as a case management visit in conjunction with a complaint investigation regarding an incident involving staff and a resident.

It was found that staff member S1 engaged in a sexual relationship with resident R1, posing an immediate health and safety risk. S1 was removed from the facility and the Los Angeles Police Department was notified but did not take a report as the relationship was deemed consensual. A deficiency was cited for conduct inimical to the health, morals, welfare, or safety of residents.

Complaint visit 31-AS-20211101161122 triggered the investigation. The complaint was substantiated based on interviews and observations.

An unannounced complaint investigation visit was conducted in response to an allegation of sexual abuse of a resident while in care.

The investigation found that the alleged sexual abuse was unsubstantiated as the relationship between the resident and staff was consensual according to interviews and police information.

The complaint alleged that resident #1 was sexually abused by staff #1. Interviews and review of physician reports were conducted. The Los Angeles Police Department noted the relationship was consensual and no incident report was filed. The allegation was deemed unsubstantiated.

The visit was an unannounced complaint investigation triggered by an allegation that the facility had insects, specifically fleas, observed in a resident's room, bed, and carpeting.

The investigation found that two residents were observed with fleas and flea eggs and were treated accordingly. The facility took preventive measures including quarantining the residents, disinfecting the room, and laundering bedding. No other residents were affected, and the allegation was determined to be unsubstantiated.

The complaint alleged the presence of insects (fleas) in the facility. The investigation included resident and staff interviews, physical inspection, and record review. The allegation was found to be unsubstantiated as the facility acted appropriately to treat the affected residents and prevent spread.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations that the facility was not keeping residents' rooms free from pests and that staff were isolating residents.

The investigation included resident and staff interviews, physical inspection, and record review. The allegations of pest infestation and staff isolating residents were found to be unsubstantiated due to lack of sufficient evidence.

The complaint investigation was triggered by allegations of pest infestation (cockroaches and lice) and staff isolating residents. Both allegations were found unsubstantiated after investigation.

The inspection visit was conducted to investigate a complaint alleging unqualified staff assessing resident's care, signing off on resident's documents, and that resident's care is not being assessed for a higher level of care.

The investigation included a physical plant inspection, record review, and interviews with residents and staff. It was found that the allegations of unqualified staff assessing care or signing documents, and failure to assess residents for higher levels of care, could not be substantiated based on the evidence gathered.

The complaint alleged that unqualified staff were assessing resident care, signing prescription forms, and placing residents on hospice care improperly. It also alleged that residents were not being assessed for higher levels of care and that staff were signing forms to receive kickbacks. The investigation found no evidence to substantiate these allegations, and the complaint was deemed unsubstantiated.

The visit was an unannounced complaint investigation conducted to investigate allegations including staff pushing a resident and staff stealing a resident's personal property.

The investigation found that the allegations were unsubstantiated. Staff #1 was not on duty at the times of the alleged incidents, and no evidence supported the claims of pushing or theft.

The complaint investigation was unsubstantiated based on interviews, record reviews, and lack of evidence supporting the allegations of staff pushing a resident and stealing personal property.

The inspection was conducted as an unannounced complaint investigation visit following allegations received on 2022-02-09 regarding hospice resident ratios, qualifications of the facility director, and overmedication of residents.

The investigation included a physical plant inspection, record review, and interviews with residents and staff. All allegations were found to be unsubstantiated based on evidence and interviews; the facility was not out of hospice resident ratio, the director was qualified, and there was no evidence of overmedication.

The complaint investigation addressed three allegations: 1) Facility is out of ratio with hospice residents; 2) Unqualified Director operating facility; 3) Residents are being overmedicated. All allegations were deemed unsubstantiated after review and interviews.

An unannounced complaint investigation visit was conducted to investigate an allegation that the facility did not issue a refund to a resident's Power of Attorney (POA).

The investigation found that the resident had lived in the facility for more than four months, and according to the admission agreement, the licensee may but is not required to refund the pre-admission fee. Based on the information obtained, the allegation was deemed unsubstantiated.

The complaint alleged that the facility did not refund resident #1's pre-admission fee after the resident moved out. The allegation was investigated and found to be unsubstantiated.

An unannounced required annual inspection was conducted with a specific emphasis on infection control practices and procedures.

The facility was inspected for compliance with health and safety regulations including infection control, physical plant conditions, resident care documentation, and staff training. Several deficiencies were identified related to fire clearance for bedridden residents, incomplete hospice care plans, lack of physician orders for bed rails, missing annual medical assessments for residents with dementia, incomplete staff training and documentation, and failure to properly notify the department of COVID-19 cases.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-11-03 regarding residents being left in soiled diapers for extended periods, untimely medication administration, and understaffing at the facility.

The investigation included interviews with residents and staff and a physical plant tour. All allegations were found to be unsubstantiated based on interviews and schedule reviews, with residents satisfied with care and medication administration occurring on schedule.

The complaint investigation addressed three allegations: 1) residents left in soiled diapers for extended periods, 2) untimely medication administration, and 3) facility understaffing. All allegations were deemed unsubstantiated after interviews and review of staff schedules.

An unannounced case management visit was conducted following a serious incident report regarding a staff member acting inappropriately in a resident's room.

No immediate health and safety issues were noted during the physical plant tour. The staff member involved was immediately escorted out, and the administrator notified law enforcement, Adult Protective Services, Long Term Care Ombudsman, and the resident's family. Interviews and file reviews were conducted, with a follow-up visit planned for further information.

The visit was triggered by a serious incident report involving a staff member seen acting inappropriately in a resident's room. The staff member was removed, and authorities and relevant parties were notified. Interviews and file reviews were conducted, and a follow-up visit is planned.

An unannounced complaint investigation was conducted in response to allegations that smoke alarms were not working and that staff working with hospice residents were not qualified.

The investigation found that the smoke alarms were functioning properly and did not activate due to the small amount of smoke from a lamp incident. The allegation regarding unqualified hospice staff was unsubstantiated as hospice and facility staff were appropriately providing care and assistance.

The complaint was unsubstantiated. The smoke alarm allegation was investigated through interviews and testing, confirming proper function. The hospice staff qualification allegation was investigated through interviews with staff and administrators, confirming appropriate qualifications and staffing.

An unannounced complaint investigation visit was conducted to investigate allegations that the facility did not issue a refund to a Resident's Representative and did not provide timely written notice of policies regarding contract termination upon death.

The investigation found no immediate health and safety issues. The allegation that the facility did not issue a refund was unsubstantiated as records showed the resident's rent for October 2021 had not been paid. The allegation that the facility did not provide timely written notice regarding contract termination policies was also unsubstantiated, with no fees charged after the resident's death and the family managing personal belongings.

The complaint was unsubstantiated. Allegations included failure to issue a refund for prepaid rent after resident's death and failure to provide written notice of contract termination policies. Interviews and record reviews showed no refund was owed and no additional fees were charged after death.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-01-20 regarding medication administration, resident's ability to purchase a new bed, and resident's access to outdoors.

The investigation found all allegations unsubstantiated based on interviews, record reviews, and observations. Staff were not found to be improperly administering medications, restricting bed purchases, or denying outdoor access to the resident.

The complaint involved three allegations: 1) staff not administering medications according to physician instructions, 2) staff not allowing a resident to purchase a new bed, and 3) staff not allowing a resident to go outdoors. All allegations were investigated and deemed unsubstantiated.

Unannounced complaint investigation visit to investigate allegations that staff do not ensure residents are properly fed and that residents' personal belongings are mishandled while in care.

Both allegations were found to be unsubstantiated after interviews with residents and observations. Residents reported receiving enough food and no lost personal items in laundry were reported.

The complaint involved allegations that staff did not ensure residents were properly fed, with claims of poor food quality, small portions, and inconsistent meal times, and that residents' personal belongings were mishandled, specifically lost in laundry. Both allegations were unsubstantiated based on resident interviews and observations.

The inspection was an unannounced visit to investigate a complaint alleging that staff failed to check on residents in a timely manner when they pushed their pendant in their room.

The investigation included interviews with random residents and found the allegation to be unsubstantiated based on the information obtained during the visit.

The complaint alleged that staff failed to check on residents in a timely manner when they pushed their pendant in their room. The allegation was investigated through interviews and previous visits, and was determined to be unsubstantiated.

An unannounced complaint investigation was conducted in response to allegations received on 08/16/2021 regarding communication issues with staff, unanswered facility phone calls due to insufficient staffing, and inadequate resident services.

The investigation found all allegations to be unsubstantiated based on interviews with residents and staff, observations of communication, phone responsiveness, and resident services including meal service and bathing.

The complaint investigation was unsubstantiated. Allegations included residents not able to communicate with staff, facility phone not answered due to lack of staff, and residents not being provided adequate service. Interviews and observations did not support these claims.

An unannounced complaint investigation visit was conducted due to an allegation that the facility failed to report active COVID-19 cases.

The investigation found that the facility did conduct COVID-19 testing and reported the positive cases to the Department of Public Health in a timely manner. The allegation was deemed unsubstantiated based on interviews and documentation.

The complaint alleged that the facility failed to report COVID-19 cases. The allegation was investigated and found to be unsubstantiated as the facility reported the cases promptly.

Unannounced visit to investigate complaints alleging that staff did not give a resident a sufficient amount of water and that staff handled a resident in a rough manner.

The investigation found that staff routinely checked on residents' needs and that the resident had water and juice at their bedside. Interviews with staff and residents revealed no evidence of rough handling or mistreatment. Both allegations were deemed unsubstantiated based on gathered information.

The complaint investigation was unsubstantiated. Allegations included insufficient water given to a resident and rough handling by staff. Interviews and record reviews did not support these allegations.

Unannounced visit/investigation of a complaint received on 2020-05-19 regarding allegations that the facility denied resident access to oxygen, forced residents into receiving hospice services, and gave false information to a resident's family member.

The investigation found that the allegations were unsubstantiated. Resident #1 had an order for oxygen administration under specific conditions but was not denied oxygen. Hospice services were not forced by facility staff but suggested by hospice agency staff, with all hospice agreements properly signed. The facility promptly reported COVID-19 cases and coordinated with public health authorities. Attempts to identify who gave false information were unsuccessful.

Complaint investigation was unsubstantiated based on interviews, record reviews, and findings. Allegations included denial of oxygen, forced hospice services, and false information to family members.

Unannounced visit/investigation of a complaint received on 01/27/2021 regarding staff failing to check on residents in a timely manner.

The investigation found that residents feel they are checked on in a timely manner, and the allegation that staff failed to respond promptly to a resident's call button was deemed unsubstantiated.

The complaint alleged that resident #1 sustained a fall on 01/26/2021 and staff took over thirty minutes to respond to the call button. After interviews and file review, the allegation was unsubstantiated.

Unannounced visit/investigation of a complaint received on 01/20/2021 regarding allegations that the facility has insufficient staff to meet resident's needs and that staff yell at resident's family while at the facility.

The investigation found that the facility has sufficient staff to meet resident's needs and that staff do not yell at resident's family while in the facility. Both allegations were deemed unsubstantiated based on interviews and observations.

Complaint investigation was unsubstantiated based on interviews with residents and the Long Term Care Ombudsman, and a physical plant walkthrough.

An unannounced complaint investigation visit was conducted to investigate multiple allegations including physical assault, neglect of injury care, over medication, denial of access to medication records, and failure to safeguard resident's personal belongings.

All allegations investigated were found to be unsubstantiated based on interviews with the resident, administrator, staff, and review of relevant documentation and records.

The complaint investigation was unsubstantiated. Allegations included physical assault resulting in injury, staff neglect of injury care, over medication, denial of access to medication records, and failure to safeguard personal belongings. Interviews and record reviews did not support these claims.

The visit was a case management incident investigation conducted due to a serious incident report involving an allegation that a resident was hit by staff.

Interviews and a medical evaluation found no signs of abuse or staff misconduct. The resident was determined to be confused and disoriented, and no further action was necessary.

The complaint involved resident #1 alleging being hit by staff. The allegation was investigated and found unsubstantiated based on interviews and medical evaluation.

The visit was conducted as a case management incident investigation following an allegation by resident #1 that they were being hit by staff while lying in bed.

The investigation included interviews with the administrator, staff, residents, and a body check of the resident, which found no physical evidence of abuse. The administrator implemented a two-person assist for the resident and reported the incident to Adult Protective Services, the Long Term Care Ombudsman, and the police. Further investigation was deemed necessary.

Resident #1 alleged being hit by staff. The allegation was investigated with interviews and a body check showing no bruising or marks. The administrator took precautionary measures and reported to appropriate authorities. More investigation is needed.