Inspection Reports for El Rio Memory Care Community
2828 Healthcare Way, Modesto, CA 95356, United States, CA, 95356
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with routine and case management visits consistently showing compliance and a well-maintained environment. Several complaint investigations were substantiated, primarily involving issues with medication management, resident care including supervision and hygiene, and infection control, with some findings posing immediate risks to resident health and safety. The facility faced a significant enforcement action in September 2024, when civil penalties totaling $10,000 were assessed due to neglect resulting in serious injury from a pressure wound. More recent reports from June through September 2025 show improvement, with no deficiencies cited and compliance maintained, including proper posting of licensing documents and staff training updates. The latest inspection on September 11, 2025, had no deficiencies, indicating progress following earlier concerns.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
95% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
79% occupied
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Census: 57
Capacity: 72
Deficiencies: 0
Date: Sep 11, 2025
Visit Reason
The unannounced visit was conducted to ensure compliance with Health and Safety Code (HSC) 1569.38 regarding the posting of licensing reports and disclosure to new residents, specifically related to the facility's receipt and posting of an Accusation to suspend or revoke the license.
Findings
The facility was found to be in compliance with HSC 1569.38, as the Accusation was properly posted in a location easily viewable by residents and visitors, and written notices were distributed to current residents and mailed to responsible parties within the required timeframe.
Report Facts
Civil penalty amount per day: 100
Maximum total civil penalty: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Pettapiece | Administrator | Met with during inspection and responsible for posting Accusation and notices |
| Lisa Rios | Licensing Program Manager | Conducted the inspection visit |
| Ellen Lindstrom | Licensing Program Analyst | Conducted the inspection visit and observation |
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 1
Date: Aug 21, 2025
Visit Reason
This was an unannounced complaint investigation visit triggered by an allegation that the facility did not ensure that staff receive CPR/First Aid training.
Complaint Details
The complaint was substantiated. The allegation was that the facility did not ensure staff received CPR/First Aid training. The investigation confirmed this deficiency.
Findings
The investigation found that while all Med Techs and Licensing Vocational Nurses had valid CPR/First Aid training, only five of twenty-four Resident Assistants had valid CPR/First Aid training. The facility policy required only one staff member on premises to have First Aid training, which posed a potential risk to residents' health and safety.
Deficiencies (1)
Personnel Requirements: All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training including appropriate first aid training. The facility policy requiring only one staff on premises to be First Aid trained was not met.
Report Facts
Facility capacity: 72
Resident Assistants with valid CPR/First Aid training: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Pettapiece | Administrator | Met with during the investigation |
| Reshmika Sharma | Director of Resident Services | Interviewed during the investigation |
| Ellen Lindstrom | Licensing Program Analyst | Conducted the investigation |
| Lisa Rios | Licensing Program Manager | Oversaw the investigation |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 72
Deficiencies: 1
Date: Jul 24, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff restrained a resident in care.
Complaint Details
The complaint alleged that staff restrained a resident in care. After investigation, including interviews and observations, the allegation was determined to be unsubstantiated.
Findings
The investigation included inspections, interviews with residents and staff, and records review. The allegation that staff restrained a resident was found to be unsubstantiated due to lack of preponderance of evidence.
Deficiencies (1)
This 9099D was written in error.
Report Facts
Capacity: 72
Census: 61
Estimated Days of Completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ellen Lindstrom | Licensing Program Analyst | Conducted the complaint investigation and inspections |
| Lisa Rios | Licensing Program Manager | Oversaw the complaint investigation and delivered findings |
| Reshmika Sharma | Director of Resident Services | Met with investigators during the visit |
Inspection Report
Census: 61
Capacity: 72
Deficiencies: 0
Date: Jun 17, 2025
Visit Reason
The visit was an unannounced case management site visit to check in with facility administration about the Absence Without Leave (AWOL) of a resident in the Memory Care unit on 05/28/2025, which was self-reported by the facility.
Findings
No deficiencies were cited during this site visit. The facility conducted staff training on elopement prevention following the incident, and the resident involved was reclassified as an elopement risk with increased monitoring.
Report Facts
Staff trained on elopement prevention: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Pettapiece | Designated Facility Administrator | Met with Licensing Program Analyst during the visit and involved in the incident review |
| Reshmika Sharma | Director of Resident Services | Met with Licensing Program Analyst during the visit and provided care plans and incident details |
| Ellen Lindstrom | Licensing Program Analyst | Conducted the unannounced case management site visit |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Routine
Census: 61
Capacity: 72
Deficiencies: 0
Date: Jun 17, 2025
Visit Reason
The visit was an unannounced case management site visit to check in with facility management about a recent COVID-19 outbreak at the facility, which had been self-reported by the facility.
Findings
The facility implemented infection control practices including isolating COVID-positive residents, testing symptomatic residents, providing masks, and temporarily relocating residents in double-occupancy rooms. Management reported no further COVID cases since 06/06/2025. No deficiencies were cited during this visit.
Report Facts
COVID positive residents: 15
COVID positive staff: 9
COVID positive residents: 6
COVID positive staff: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reshmika Sharma | Director of Resident Services | Interviewed regarding infection control practices during COVID outbreak |
| Ellen Lindstrom | Licensing Program Analyst | Conducted the site visit and interview |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Census: 59
Capacity: 72
Deficiencies: 0
Date: Mar 7, 2025
Visit Reason
The visit was a Case Management inspection conducted to review hospice client care and documentation at the facility.
Findings
No deficiencies were cited during the visit. The facility maintains required admission documentation from third-party hospice services and provides coordinated care for hospice clients. The facility expressed intent to increase hospice client capacity and staffing.
Report Facts
Hospice clients: 15
Hospice clients observed: 5
Facility capacity: 72
Current census: 59
Hospice client increase plan: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reshmika Sharma | Director of Resident Services | Met with Licensing Program Analyst during the visit and provided documentation and information about hospice care |
| Renee Campbell | Licensing Program Analyst | Conducted the Case Management visit and inspection |
| Lisa Rios | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 72
Deficiencies: 3
Date: Dec 19, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including resident falls resulting in injuries, neglect leading to hospitalization due to dehydration, failure to follow resident care plans, and other care concerns.
Complaint Details
The complaint investigation was substantiated for allegations that a resident sustained multiple falls resulting in injuries, the facility neglected the resident leading to severe dehydration and hospitalization, and staff did not follow the resident's care plan. The investigation included interviews with current and former staff, hospice agency staff, residents, and review of medical and facility records. Some allegations such as failure to provide proper food service and timely toileting were unsubstantiated, and the allegation that staff failed to notify hospice care in a timely manner was unfounded.
Findings
The investigation substantiated multiple allegations including that a resident sustained multiple falls with injuries due to inadequate supervision, the facility's neglect resulting in severe dehydration and hospitalization, and staff failure to follow the resident's care plan. The facility was found to be understaffed, impacting proper care and supervision. Some allegations related to food service and toileting needs were unsubstantiated, and one allegation regarding timely notification of hospice care was unfounded.
Deficiencies (3)
Failure to provide care and supervision as required, resulting in multiple falls with injury to a resident.
Failure to regularly observe residents for changes in physical, mental, emotional and social functioning, resulting in failure to recognize severe dehydration.
Inadequate direct care staff to support residents with dementia, including failure to complete required 30-minute checks due to understaffing.
Report Facts
Civil penalty amount: 1500
Number of unwitnessed falls for Resident 1: 9
Staff hired since complaint: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Pettapiece | Executive Director | Met with Licensing Program Analyst during investigation and named in findings. |
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Annual Inspection
Census: 53
Capacity: 72
Deficiencies: 0
Date: Dec 5, 2024
Visit Reason
The inspection was an unannounced required one year annual visit conducted by Licensing Program Analyst Maja Jensen to evaluate the facility's compliance with regulatory standards.
Findings
The facility was found to be sanitary, well-maintained, and compliant with all regulatory requirements. No deficiencies were observed during the inspection. Residents and staff expressed satisfaction with care, activities, and food service.
Report Facts
Hospice residents: 10
Hospice waiver capacity: 15
Perishable food supply: 2
Non-perishable food supply: 7
Staff files reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and provided technical assistance |
| Theresa Pettapiece | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Census: 53
Capacity: 72
Deficiencies: 0
Date: Dec 5, 2024
Visit Reason
The visit was an unannounced case management inspection conducted in relation to multiple death reports received for residents on hospice between 11/2/24 and 11/9/24.
Findings
No deficiencies were observed during the inspection. The reporting of deaths appeared to be compliant with timely submission of required documentation.
Report Facts
Resident deaths reported: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Pettapiece | Executive Director | Met with Licensing Program Analyst during inspection |
| Maja Jensen | Licensing Program Analyst | Conducted the case management inspection |
| Lisa Rios | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 0
Date: Nov 21, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 08/14/2024 regarding resident assessments prior to admission and staff meeting residents' dietary needs.
Complaint Details
The complaint investigation was unsubstantiated. Allegation 1 regarding failure to assess residents prior to admission was found unsubstantiated due to incomplete but present assessments. Allegation 2 regarding staff not meeting residents' dietary needs was also unsubstantiated with no evidence of inappropriate diets served.
Findings
The investigation found both allegations to be unsubstantiated. Staff indicated assessments prior to admission were often incomplete but not absent, and there was no evidence that residents' dietary needs were unmet. Technical assistance was provided and new policies are being implemented.
Report Facts
Facility capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and provided technical assistance |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Theresa Pettapiece | Executive Director | Met with Licensing Program Analyst during the investigation and discussed policy changes |
| Carlin Robertson | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 0
Date: Nov 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 08/16/2024 regarding resident care and environment at the facility.
Complaint Details
The complaint included allegations that staff did not ensure residents ate breakfast timely, residents were being neglected, and staff did not provide a comfortable environment. All allegations were found unsubstantiated based on evidence gathered during the investigation.
Findings
The investigation found all allegations unsubstantiated after interviews with staff, residents, and family members, and multiple facility inspections. No deficiencies were cited, and technical assistance was provided on managed incontinence.
Report Facts
Capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Theresa Pettapiece | Executive Director | Facility administrator met during the investigation |
| Lisa Rios | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 1
Date: Oct 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to multiple allegations received on 07/22/2024 regarding resident care and facility conditions at El Rio Memory Care Community.
Complaint Details
The complaint investigation was triggered by multiple allegations including staff not allowing a resident to remain in the dining hall, lack of private visits, residents not kept in clean dry clothing, unsanitary conditions, and failure to follow infection control guidelines. One allegation regarding soiled clothing due to delayed incontinence care was substantiated. Other allegations were unsubstantiated or unfounded.
Findings
The investigation found one allegation substantiated related to failure to provide timely incontinence care resulting in a resident being in soiled clothing in a common area. Other allegations including residents not being allowed to remain in the dining hall, lack of private visits, unsanitary conditions, and infection control violations were found to be unsubstantiated or unfounded.
Deficiencies (1)
Managed Incontinence - The licensee failed to ensure that incontinent residents are kept clean and dry as evidenced by a resident being in soiled clothing in a common area.
Report Facts
Facility capacity: 72
Plan of Correction due date: Oct 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Theresa Pettapiece | Executive Director | Interviewed during investigation and provided statements regarding allegations |
| Carlin Robertson | Administrator | Named as facility administrator |
| Lisa Rios | Licensing Program Manager | Oversaw licensing program and named in report |
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 3
Date: Sep 19, 2024
Visit Reason
The visit was an unannounced follow-up on a complaint investigation received on November 22, 2022, regarding allegations of neglect and failure to reposition a resident resulting in a pressure wound.
Complaint Details
The complaint investigation was substantiated for failure to reposition a resident and failure to seek timely medical care, resulting in serious bodily injury. Immediate civil penalties of $1,000 were previously issued, and an additional civil penalty of $9,000 was assessed for serious bodily injury.
Findings
The complaint investigation substantiated that the facility failed to reposition a resident, resulting in a pressure wound, and failed to seek timely medical care, leading to serious bodily injury including hospitalization for a stage 4 pressure injury and sepsis. Civil penalties totaling $10,000 were assessed, with $1,000 previously issued and an additional $9,000 assessed on this visit.
Deficiencies (3)
Facility did not reposition a resident resulting in a pressure wound.
Facility failed to seek timely medical care for a pressure wound.
Facility staff neglected a resident resulting in injury.
Report Facts
Civil penalty amount: 10000
Immediate civil penalties previously assessed: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Pettapiece | Executive Director | Met with Licensing Program Analyst during inspection and acknowledged receipt of appeal rights |
| Maja Jensen | Licensing Program Analyst | Conducted the unannounced complaint follow-up visit and signed the report |
| Lisa Rios | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 72
Deficiencies: 2
Date: Sep 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on June 25, 2024, alleging staff were not properly trained and not meeting residents' hygiene needs.
Complaint Details
The complaint investigation was substantiated for allegations that staff were not properly trained and were not meeting residents' hygiene needs.
Findings
The investigation substantiated that staff lacked specialized training for caring for residents with pressure injuries and use of a hoyer lift. Additionally, staff failed to meet residents' hygiene needs, as evidenced by observations of residents with soiled clothing, lack of shoes, and delayed assistance.
Deficiencies (2)
Staff providing care for residents with wounds and requiring hoyer lift use received no specialized training, posing immediate risk to residents' health and safety.
Multiple residents were observed in need of assistance with grooming, posing potential risk to safety and personal rights.
Report Facts
Capacity: 72
Census: 61
Plan of Correction Due Date: Sep 20, 2024
Plan of Correction Due Date: Oct 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Theresa Pettapiece | Executive Director | Met with Licensing Program Analyst during investigation |
| Carlin Robertson | Administrator | Facility administrator named in report header |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager overseeing investigation |
Inspection Report
Routine
Census: 56
Capacity: 72
Deficiencies: 0
Date: May 20, 2024
Visit Reason
The visit was an unannounced quarterly health and safety check conducted by Licensing Program Analyst Maja Jensen to assess the facility's compliance with health and safety standards.
Findings
The facility was observed to be sanitary, odor-free, and in substantial compliance with no deficiencies cited. The delayed egress doors and outdoor secured area met safety requirements, and staff followed safe food service principles. The facility is converting to an electronic medication administration record system.
Report Facts
Food supply duration: 2
Food supply duration: 7
Delayed egress door delay: 15
Fire clearance delayed egress limit: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Carlin Robertson | Executive Director | Met with Licensing Program Analyst during inspection |
| Kent E Mulkey | Administrator/Director | Facility Administrator named in report header |
Inspection Report
Routine
Census: 54
Capacity: 72
Deficiencies: 0
Date: Mar 20, 2024
Visit Reason
The visit was an unannounced quarterly health and safety check conducted by Licensing Program Analyst Maja Jensen to assess compliance and facility conditions.
Findings
The facility was found to be in compliance with no deficiencies issued. Technical assistance was provided regarding the administrator change, food supply recommendations, and medication documentation consolidation.
Report Facts
Staff files reviewed: 3
Resident files reviewed: 3
Food supply duration: 2
Hours per week: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carlin Robertson | Executive Director | Named as new Executive Director and interviewed during the visit |
| Maja Jensen | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 72
Deficiencies: 0
Date: Mar 4, 2024
Visit Reason
The visit was an unannounced case management inspection conducted regarding an incident reported to the department on 2024-02-23 involving a resident's fall.
Complaint Details
The visit was triggered by a complaint incident reported on 2024-02-23 concerning a resident's fall. The complaint was investigated and no deficiencies were found.
Findings
The Licensing Program Analyst reviewed the incident report of a witnessed fall of Resident 1, who was hospitalized and returned to the facility. The facility is conducting half-hour checks on the resident and has a fall plan in place. No deficiencies were observed or cited during the visit.
Report Facts
Census: 55
Total Capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carlin Robertson | Administrator | Met with Licensing Program Analyst during the visit and explained the reason for the visit |
| Jason Lund | Licensing Program Analyst | Conducted the unannounced case management visit |
| Lisa Rios | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 72
Deficiencies: 1
Date: Jan 8, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff mishandled a resident's medications while in care.
Complaint Details
The complaint was substantiated based on evidence that a resident did not receive a prescribed medication for 10 days, meeting the preponderance of evidence standard.
Findings
The investigation substantiated the allegation that a resident missed ten doses of a prescribed ACE inhibitor medication from 9/16/22 through 9/25/22 without explanation, posing an immediate risk to the resident's health and safety.
Deficiencies (1)
Incidental Medical and Dental Care: The licensee failed to assist residents with self-administered medications as needed, resulting in a resident missing prescribed medication for 10 days.
Report Facts
Deficiency Type: 1
Days medication missed: 10
Capacity: 72
Census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and reviewed Medication Administration Record. |
| Caress Brown | Resident Care Director | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 1
Date: Jan 8, 2024
Visit Reason
An unannounced complaint investigation was conducted based on an allegation that staff did not meet the needs of the resident in care.
Complaint Details
The complaint was substantiated based on evidence including missed medication doses documented in the Medication Administration Record and missed blood pressure readings with no corrective action taken by staff.
Findings
The investigation found substantiated evidence of missed medication doses and missed blood pressure readings with no action taken by staff to address resident non-compliance, posing a potential risk to residents' health and safety.
Deficiencies (1)
Basic services requirement was not met as evidenced by missed medication doses and lack of action on resident's treatment non-compliance.
Report Facts
Capacity: 72
Missed medication doses: 4
Missed medication doses: 2
Missed medication doses: 5
Blood pressure readings: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Caress Brown | Resident Care Director | Met with Licensing Program Analyst during the investigation |
| Kent E Mulkey | Administrator | Facility administrator named in the report |
| Lisa Rios | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 72
Deficiencies: 3
Date: Jan 4, 2024
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations regarding inaccurate record keeping, failure to address a resident's change in medical condition, and improper incident reporting involving a resident.
Complaint Details
The complaint investigation was substantiated for allegations of inaccurate record keeping, failure to address a resident's change in medical condition, and failure to properly report an incident. One allegation regarding failure to follow a licensed physician's orders was unsubstantiated.
Findings
The investigation substantiated three allegations: inaccurate medication administration records and incomplete Needs and Service Plan; failure to address discrepancies between physician's report and Needs and Service Plan; and failure to properly report a resident incident. One allegation regarding failure to follow a licensed physician's orders was unsubstantiated due to insufficient evidence.
Deficiencies (3)
Resident Records - failure to maintain a separate, complete, and current record for each resident.
Reappraisals - failure to update pre-admission appraisal to note significant changes and notify physician and responsible person.
Reporting Requirements - failure to submit a written report to the licensing agency within seven days of any incident threatening resident welfare, safety, or health.
Report Facts
Capacity: 72
Census: 57
Plan of Correction Due Date: Jan 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lisa Rios | Licensing Program Manager | Named in relation to the licensing program management and plan of correction oversight |
| Steve Sarine | Regional Director of Operations | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 72
Deficiencies: 1
Date: Dec 26, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations received on 2023-10-11 regarding resident care issues including grooming, room maintenance, soiled bedding, supervision, and timely bathing.
Complaint Details
The complaint investigation was unannounced and addressed multiple allegations. The majority of allegations were unsubstantiated except for the allegation regarding timely bathing of a resident, which was substantiated based on record review.
Findings
Most allegations including grooming, room maintenance, soiled bedding, and supervision were found to be unsubstantiated based on staff interviews, observations, and inspections. However, the allegation that staff did not timely bathe a resident was substantiated based on review of shower logs showing at least 11 weeks without twice weekly showers for a resident.
Deficiencies (1)
Basic services including personal assistance and care such as dressing, eating, and bathing were not met as evidenced by inconsistent showering records.
Report Facts
Weeks without twice weekly showers: 11
Capacity: 72
Census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kent E Mulkey | Administrator / Executive Director | Met with Licensing Program Analyst during investigation |
| Maja Jensen | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Lisa Rios | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 72
Deficiencies: 0
Date: Dec 26, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that a resident was being charged for unagreed services.
Complaint Details
The complaint alleged that a resident was being charged for unagreed services. After investigation, the allegation was determined to be unfounded, meaning it was false or without reasonable basis.
Findings
The investigation included review of resident files, admission agreements, and interviews with staff. The allegation was found to be unfounded as services charged aligned with the admission agreement and regulations.
Report Facts
Capacity: 72
Census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kent E Mulkey | Administrator | Met with Licensing Program Analyst during investigation |
| Maja Jensen | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Rios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 72
Deficiencies: 1
Date: Dec 21, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-08-25 regarding failure to seek medical attention for a resident, failure to report scabies, failure to notify responsible parties, failure to assist with medication administration, and failure to follow the infection control plan.
Complaint Details
The complaint investigation was triggered by allegations that the facility did not seek medical attention for a resident, failed to report a resident's scabies to Licensing, failed to notify responsible parties, failed to assist with medication administration, and failed to follow its infection control plan. The investigation included interviews with staff, residents, and a hospice nurse, as well as record reviews. The allegations about medical attention, reporting, and notification were unsubstantiated. The failure to assist with medication administration was substantiated. The failure to follow the infection control plan was previously substantiated with citations issued.
Findings
The investigation found the allegations that the facility did not seek medical attention, failed to report scabies, and failed to notify responsible parties were unsubstantiated. However, the allegation that the facility failed to assist with medication administration was substantiated due to failure to administer a second dose of prescribed antiparasitic medication to a resident, posing an immediate health and safety risk. The allegation regarding failure to follow the infection control plan had been previously substantiated with citations issued, and no new citations were issued.
Deficiencies (1)
The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by failure to give a second dose of antiparasitic medication as ordered by a physician.
Report Facts
Capacity: 72
Census: 57
Deficiencies cited: 1
Plan of Correction Due Date: Dec 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kent E Mulkey | Administrator | Interviewed during complaint investigation and named in findings |
| Caress Brown | Director of Resident Services | Met with Licensing Program Analyst during investigation and exit interview |
| Vincent Moleski | Licensing Program Analyst | Conducted the complaint investigation |
| Stephen Richardson | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Annual Inspection
Census: 58
Capacity: 72
Deficiencies: 4
Date: Dec 4, 2023
Visit Reason
The inspection was an unannounced required 1 year annual inspection conducted to evaluate compliance with licensing regulations.
Findings
The facility was generally found to be sanitary, odor free, and in good repair with compliant water and thermostat temperatures. However, deficiencies were noted including insufficient non-perishable food supply, presence of alcohol and disinfectants accessible to residents with dementia, expired or missing first aid certifications in staff files, and missing physician reports in some resident files.
Deficiencies (4)
Insufficient 7 day supply of non-perishable food on site.
Alcohol and disinfectants accessible in resident rooms, posing risk to persons with dementia.
Two staff files lacked current first aid certification.
Two of four resident files lacked a physician's report completed within the last year.
Report Facts
Census: 58
Total Capacity: 72
Staff files reviewed: 10
Resident files reviewed: 4
Non-perishable food supply: 7
Perishable food supply: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kent E Mulkey | Administrator | Met with Licensing Program Analyst during inspection. |
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Lisa Rios | Licensing Program Manager | Supervisor of the Licensing Program Analyst. |
Inspection Report
Routine
Census: 58
Capacity: 72
Deficiencies: 1
Date: Dec 4, 2023
Visit Reason
The visit was an unannounced quarterly health and safety check conducted by Licensing Program Analyst Maja Jensen to assess compliance with regulatory requirements and review recent incidents and documentation.
Findings
The inspection found that incident reports were being sent timely, but 2 of 4 resident files reviewed contained physician reports over 12 months old, which is a deficiency. Needs and service plans were current. Pest control services were verified as contracted and up to date.
Deficiencies (1)
Care of Persons with Dementia: Each resident with dementia shall have an annual medical assessment as specified in Section 87458. Two of four resident files did not contain a current LIC 602, posing a potential risk to residents.
Report Facts
Resident files reviewed: 4
Resident files with outdated physician reports: 2
Needs and service plans reviewed: 4
Capacity: 72
Census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maja Jensen | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Kent E Mulkey | Administrator | Facility administrator met during inspection |
| Lisa Rios | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 72
Deficiencies: 5
Date: Oct 27, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations including a scabies outbreak, failure to meet residents' hygiene needs, failure to follow infectious outbreak protocols, and failure to report the rash to families and licensing.
Complaint Details
The complaint investigation was substantiated. Allegations included a scabies outbreak, failure to meet hygiene needs, failure to follow infectious outbreak protocols, failure to report the rash to families and licensing. One allegation of staff falsifying resident records was unsubstantiated.
Findings
The investigation substantiated multiple allegations including a scabies outbreak with 29 additional residents treated without proper notification, failure to follow infection control protocols, inadequate resident hygiene due to staffing shortages, and failure to notify families and licensing about the outbreak. One allegation regarding falsification of resident records was unsubstantiated.
Deficiencies (5)
Failure to report an outbreak of scabies within 24 hours and failure to notify licensing of additional cases and treatments after 08/02/23.
Failure to maintain infection control practices including lack of resident isolation, inadequate environmental cleaning, and failure to identify contacts.
Failure to ensure incontinent residents are kept clean and dry, with reports of residents found in soaked briefs and delayed care due to staffing shortages.
Failure to notify responsible parties about residents' scabies diagnosis and treatment as required by the plan of operation.
Failure to report changes in residents' conditions and scabies treatment to licensing within required timeframes.
Report Facts
Residents treated for scabies: 29
Facility capacity: 72
Census: 56
Responsible parties interviewed: 6
Staff interviewed: 6
Deficiency plan of correction due date: Oct 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Stephen Richardson | Licensing Program Manager | Oversaw the complaint investigation. |
| Kent Mulkey | Executive Director | Facility representative interviewed during the investigation. |
| Karan Bassi | Director of Resident Services | Provided information about scabies outbreak and infection control practices. |
| Carlin Robertson | Campus Business Office Manager | Provided information during investigation about scabies cases. |
| Jay Duarte | Physical Plant Director | Interviewed regarding environmental cleaning and housekeeping. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 72
Deficiencies: 0
Date: Oct 18, 2023
Visit Reason
An unannounced visit was conducted as part of a complaint investigation to interview staff and observe residents regarding a reported issue.
Complaint Details
The visit was triggered by a complaint investigation related to scabies treatment and reporting. The investigation found that the facility did not report the scabies outbreak as required.
Findings
The Licensing Program Analyst observed a resident exhibiting symptoms consistent with scabies and learned that 31 additional residents were suspected of and treated for scabies. The facility failed to report this outbreak to Community Care Licensing and the Department of Public Health.
Report Facts
Residents treated for scabies: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kent E Mulkey | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephen Richardson | Licensing Program Manager | Named in exit interview |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 72
Deficiencies: 1
Date: Oct 12, 2023
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident reported to the department on 2023-10-10.
Complaint Details
The visit was triggered by an incident reported on 2023-10-10. The complaint was investigated through document review and interviews. The deficiency was substantiated as the staff member was observed roughly handling a resident.
Findings
The inspection found a deficiency related to the personal rights of residents, specifically an incident where a staff member was observed roughly handling a resident in the shower, posing a potential health, safety, and personal rights risk.
Deficiencies (1)
Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was met as evidenced by statements and witnesses who observed staff member roughly handling a resident in the shower, which poses a potential health, safety and personal rights risk to residents in care.
Report Facts
Capacity: 72
Census: 56
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kent E Mulkey | Administrator | Facility administrator present during the inspection |
| Kesha Lewis | Licensing Program Analyst | Conducted the inspection and investigation |
| Caress Brown | Resident Services Director | Present during the inspection |
| Liza King | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 72
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff were not ensuring the facility was free of bed bugs.
Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.
Findings
The investigation found the allegations to be unsubstantiated with no deficiencies observed or cited at the time of the visit.
Report Facts
Capacity: 72
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kesha Lewis | Licensing Program Analyst | Conducted the complaint investigation |
| Kent E Mulkey | Administrator | Facility administrator met with the investigator |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 72
Deficiencies: 2
Date: Oct 3, 2023
Visit Reason
An unannounced Case Management visit was conducted to discuss resident on resident altercations involving resident R1, specifically related to incidents dated 07/26/23 and 08/21/23.
Complaint Details
The visit was complaint-related, focusing on resident on resident altercations involving resident R1. The complaint was substantiated by findings of deficiencies in care planning and staffing.
Findings
The inspection found that the facility failed to update the needs and services plan for resident R1 after two resident on resident altercations, despite R1's history of physical aggression. Additionally, staffing levels were insufficient to prevent escalation of violent incidents. Two Type A deficiencies were cited related to dementia care and staffing adequacy.
Deficiencies (2)
Dementia care resident has not had a new LIC 602 since 3/3/2021 and the licensee failed to update the needs and services plan of R1 after R1 was involved in 2 separate resident on resident altercations.
Sufficient staffing would have provided the opportunity for staff to redirect R1 before either of the 2 situations escalated to violence. Per R1's appraisal, R1 has a history of physical aggression or violence.
Report Facts
Residents observed in dining room: 18
Resident rooms inspected: 5
Safety checks frequency: 4
Safety checks frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Stephen Richardson | Licensing Program Manager | Supervisor overseeing the inspection |
| Karan Bassi | Director of Residential Services | Met with Licensing Program Analyst during the visit |
| Carlin Robertson | Business Office Manager | Accompanied Licensing Program Analyst during facility tour |
| Kent E Mulkey | Administrator | Facility Administrator requested to be spoken with by Licensing Program Analyst |
Inspection Report
Monitoring
Census: 62
Capacity: 72
Deficiencies: 0
Date: Aug 22, 2023
Visit Reason
The visit was a Non-Compliance Conference conducted to discuss existing deficiencies, problem areas in the operation of the facility, and ways to bring the facility into compliance to avoid legal action.
Findings
The report identified concerns related to reporting requirements, assessment and reassessment, restricted health conditions, resident on resident altercations, and outbreak infestations. The licensee agreed to corrective actions including ensuring an administrator presence 40 hours a week and conducting regular staff training.
Report Facts
Facility capacity: 72
Census: 62
Administrator presence: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kent E Mulkey | Executive Director | Facility Administrator named in the report |
| Steve Sarine | Regional Director of Operations | Met with during the visit |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager involved in the report |
| Kimberly Viarella | Licensing Program Analyst | Named as Licensing Program Analyst involved in the report |
Inspection Report
Census: 62
Capacity: 72
Deficiencies: 0
Date: Aug 8, 2023
Visit Reason
The visit was an unannounced collaborative case management visit focused on addressing a recent scabies outbreak at the facility, providing technical support and education.
Findings
The team met with facility leadership and public health representatives to review current infection control practices and provided additional suggestions to improve procedures to eradicate scabies. No citations were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Viarella | Licensing Program Analyst | Conducted the visit and provided technical support regarding the scabies outbreak. |
| Kent Mulkey | Executive Director | Met with the inspection team to discuss infection control practices. |
| Karan Bassi | Director of Nursing Staff | Shared current practices and procedures addressing the scabies outbreak. |
| Carlin Robertson | Campus Business Office Manager | Met with the inspection team during the visit. |
| Zaurina Jones | Public Health Nurse | Participated in the collaborative visit and provided infection control suggestions. |
| Gorlia Xiong | Medical Investigator | Participated in the collaborative visit and provided infection control suggestions. |
Inspection Report
Plan of Correction
Census: 59
Capacity: 72
Deficiencies: 0
Date: Mar 21, 2023
Visit Reason
The visit was an unannounced Proof of Correction (POC) visit to amend the 9099D page of the complaint.
Findings
Licensing Program Analyst Jason Lund met with Administrator Mary Keaton, explained the reason for the visit, and conducted the Proof of Correction visit. An exit interview was conducted and the report was left at the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the Proof of Correction visit and met with the Administrator. |
| Mary Keaton | Administrator | Facility Administrator met with the Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 72
Deficiencies: 2
Date: Mar 14, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 11/22/2022 regarding neglect and failure to provide timely medical care to a resident resulting in injury.
Complaint Details
The complaint was substantiated based on evidence that the facility neglected a resident by failing to provide timely medical care for a pressure wound, which led to serious injury and death. Another allegation regarding failure to reposition the resident was unsubstantiated.
Findings
The investigation substantiated that the facility failed to provide timely medical care to a resident with a pressure wound, which progressed to a stage 4 wound and sepsis, leading to the resident's death. Another allegation of neglect related to repositioning was found to be unsubstantiated due to insufficient evidence.
Deficiencies (2)
The licensee failed to arrange or assist in arranging timely medical care for the resident's pressure wound, posing an immediate health, safety, and personal rights risk.
Staff failed to notice changes in the resident's condition and failed to seek medical attention, resulting in a stage 4 wound and sepsis.
Report Facts
Estimated Days of Completion: 90
Capacity: 72
Census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lund | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Mary Keaton | Administrator | Facility administrator met during investigation and mentioned in findings |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Carlin Robertson | Administrator | Facility administrator met during exit interview and mentioned in findings |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 72
Deficiencies: 0
Date: Feb 14, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to an allegation that staff were not following COVID-19 guidelines.
Complaint Details
The complaint alleged that staff were not following COVID-19 guidelines. The investigation found no evidence to substantiate this allegation, and the complaint was determined to be unsubstantiated.
Findings
Based on interviews with residents, staff, and the administrator, as well as facility observations, it was determined that the facility was following COVID-19 precautions appropriately. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 72
Census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Keaton | Administrator | Met with Licensing Program Analyst during the investigation and named in the report |
| Michael Bilger | Licensing Program Analyst | Conducted the complaint investigation |
| Liza King | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Census: 60
Capacity: 72
Deficiencies: 1
Date: Feb 14, 2023
Visit Reason
The visit was an unannounced case management visit relating to previous COVID-19 positive cases at the facility.
Findings
It was determined that 15 residents and 2 staff members had positive COVID-19 test results between 1/31/22 and 2/13/22 which were reported to the local health department but not to the licensing department as required. There were no current active COVID-19 cases at the time of the visit, and the facility had been cleared by the local health department since 2/13/23. A citation was issued for failure to report.
Deficiencies (1)
Failure to report occurrences such as epidemic outbreaks within 24 hours to the licensing agency and local health officer as required.
Report Facts
COVID-19 positive cases: 15
COVID-19 positive cases: 2
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Keaton | Administrator | Met with Licensing Program Analyst during the visit and involved in interview regarding COVID-19 cases and reporting |
| Michael Bilger | Licensing Program Analyst | Conducted the case management visit and interview |
| Liza King | Licensing Program Manager | Supervisor and Licensing Program Manager named in the report |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 1
Date: Nov 3, 2022
Visit Reason
The inspection visit was conducted to investigate a complaint received on 2022-08-22 regarding the facility's failure to report incidents and supervision concerns.
Complaint Details
The complaint investigation was substantiated for failure to report incidents, specifically multiple unwitnessed falls not reported to the department. The allegation of lack of supervision to protect a resident from sexual assault was unsubstantiated.
Findings
The complaint that the facility did not report incidents was substantiated based on multiple unwitnessed falls documented without corresponding incident reports sent to the department. The allegation that the facility failed to provide supervision to protect a resident from sexual assault was unsubstantiated.
Deficiencies (1)
Failure to submit written incident reports to the licensing agency within seven days of occurrence, including incidents threatening resident welfare such as falls.
Report Facts
Capacity: 72
Census: 72
Deficiency count: 1
Plan of Correction due date: Nov 4, 2022
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Keaton | Administrator | Met with during investigation and named in findings |
| Kesha Lewis | Licensing Program Analyst | Conducted the complaint investigation |
| Albert Johnson | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Liza King | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 70
Capacity: 72
Deficiencies: 0
Date: Nov 1, 2022
Visit Reason
The inspection was an unannounced required 1 year annual inspection conducted to evaluate the health and safety of residents and compliance with regulations.
Findings
The facility was found to be clean, odor-free, and in good repair with no active COVID cases. All safety equipment and supplies were compliant, and no deficiencies were cited during the inspection.
Report Facts
Water temperature: 107
Capacity: 72
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Keaton | Administrator | Met with Licensing Program Analyst during inspection and participated in facility tour |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 72
Deficiencies: 0
Date: Oct 11, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/07/2022 regarding staff training, resident care, and supervision issues at the facility.
Complaint Details
The complaint investigation addressed three allegations: improper staff training, residents left in soiled diapers, and lack of supervision leading to resident altercation. All allegations were found unsubstantiated due to insufficient evidence to prove violations.
Findings
The investigation found all allegations to be unsubstantiated. Staff were properly trained to care for dementia residents, residents were not left in soiled diapers for extended periods despite some refusal of care, and an alleged altercation between residents was determined to be minor with conflicting witness accounts.
Report Facts
Capacity: 72
Census: 69
Training hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Robin Mendez | Facility Lead Nurse | Met with Licensing Program Analyst during inspection and involved in findings |
| Mary Keaton | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 72
Deficiencies: 0
Date: Sep 26, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 08/15/2022 regarding bed bugs in the facility, unqualified staff giving insulin to residents, and unqualified staff performing wound care.
Complaint Details
The complaint investigation was unsubstantiated for all allegations: bed bugs, unqualified staff giving insulin, and unqualified staff doing wound care. Evidence did not support that violations occurred.
Findings
The investigation found no current evidence of bed bugs in resident rooms, no unqualified staff giving insulin, and no unqualified staff performing wound care. All allegations were determined to be unsubstantiated based on interviews and records reviewed.
Report Facts
Capacity: 72
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Keaton | Administrator | Met with Licensing Program Analyst during investigation and provided information regarding bed bug treatments and facility procedures |
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
Inspection Report
Annual Inspection
Census: 66
Capacity: 72
Deficiencies: 0
Date: Nov 4, 2021
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with regulations.
Findings
The facility was found to be in good condition with no deficiencies observed or cited. All safety equipment and protocols were verified as operational and compliant.
Report Facts
Residents on hospice care: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carlin Robertson | Business Office Manager | Met with Licensing Program Analyst during inspection and exit interview |
| Sarah Hurt | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 72
Deficiencies: 1
Date: Oct 4, 2021
Visit Reason
The inspection visit was an unannounced case management visit related to two incidents reported to licensing: a resident fall on 09/16/2021 and an AWOL incident reported on 09/21/2021.
Complaint Details
The visit was complaint-related, investigating two incidents: a fall and an AWOL. The report details the circumstances of both incidents and cites deficiencies related to supervision and safety.
Findings
The inspection found that the egress door alarm was not heard due to multiple alarms sounding simultaneously, and no staff was present at the entrance when a resident left the facility unnoticed. Additionally, a resident fall incident was reported where the resident was found in urine and blood, and the nurse was unaware of the duration due to missed rounds during a busy time. Deficiencies were cited related to insufficient staff supervision and delayed egress device requirements.
Deficiencies (1)
Care of persons with dementia 87705K(8) Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility. This requirement has not been met as evidenced by facility awareness of residents' behaviors but no staff was at entrance, posing an immediate health and safety risk.
Report Facts
Capacity: 72
Census: 67
Plan of Correction Due Date: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stephenie Doub | Licensing Program Manager | Supervisor overseeing the inspection |
| Carlin Robertson | Business Office Manager | Facility staff member interviewed regarding incidents |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 72
Deficiencies: 0
Date: Sep 3, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 07/28/2021 regarding denial of visitors, privacy, and phone access for a resident.
Complaint Details
The complaint involved allegations that staff denied a resident from having visitors, denied privacy, and denied phone access. The investigation determined these allegations were false and without reasonable basis, resulting in the complaint being dismissed as unfounded.
Findings
The investigation found all allegations to be unfounded. The facility did not deny visitors except those restricted by a temporary restraining order, did not deny resident privacy, and did not violate the resident's rights to use the telephone.
Report Facts
Facility capacity: 72
Resident census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Hurt | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Mary Keaton | Administrator | Facility administrator interviewed during the investigation |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 72
Deficiencies: 0
Date: Jun 28, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 10/21/2020 concerning pressure injury care, multiple falls, a fracture, failure to report incidents, and questionable death at El Rio Memory Care Community.
Complaint Details
The complaint involved multiple allegations including improper care of pressure injuries, multiple falls, a fracture, failure to report incidents to authorized representatives, and questionable death. The investigation concluded the allegations were unsubstantiated due to lack of evidence.
Findings
The investigation found that the facility implemented appropriate fall prevention measures and provided pressure injury care with no concerns. The resident had a pre-existing vertebral fracture prior to admission. There was no preponderance of evidence to substantiate the allegations, including questionable death, which was related to declining health and hospice care. No deficiencies were cited.
Report Facts
Falls documented: 6
Facility capacity: 72
Census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Mary Keaton | Administrator | Facility administrator met during the investigation and received the report |
Inspection Report
Follow-Up
Census: 49
Capacity: 72
Deficiencies: 1
Date: Apr 16, 2021
Visit Reason
The case management visit was conducted via telephone on 04/16/2021 to follow up on a medication deficiency identified during a prior complaint investigation related to medication administration records for Tea Tree oil.
Complaint Details
The visit was a follow-up to a medication deficiency discovered during a complaint investigation (27-AS-20200930112221).
Findings
The licensee failed to maintain accurate and complete Medication Administration Record (MAR) sheets for Tea Tree oil for resident 1, with multiple blank and incomplete entries noted from March through June 2020, posing a potential health and safety risk.
Deficiencies (1)
Failure to maintain Medication Administration Record (MAR) sheets for Tea Tree oil for resident 1, with incomplete and blank entries noted.
Report Facts
Facility capacity: 72
Census: 49
Plan of Correction due date: Apr 19, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Keaton | Administrator | Facility administrator involved in the case management visit and exit interview |
| Avelina Martinez | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Czarrina A Camilon-Lee | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 72
Deficiencies: 2
Date: Apr 16, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 09/30/2020 regarding resident care issues including incorrect placement of medical devices and unmet basic needs.
Complaint Details
The complaint investigation was substantiated for allegations that resident's medical device was placed incorrectly and basic needs were not met. Other allegations regarding resident hygiene, grooming, shoe wearing, and file maintenance were unsubstantiated.
Findings
The investigation substantiated that resident 1's hearing aids were sometimes inserted in the wrong ears and that prescribed Tea Tree oil medication was not administered, resulting in unmet basic care needs. Other complaints about resident hygiene and file maintenance were found to be unsubstantiated.
Deficiencies (2)
The licensee did not ensure resident 1's basic service/medication needs were met; Tea Tree oil was not administered as prescribed.
The licensee did not ensure resident 1's hearing aids were inserted in the correct ears.
Report Facts
Capacity: 72
Census: 49
Deficiencies cited: 2
Plan of Correction Due Date: Apr 19, 2021
Plan of Correction Due Date: Apr 22, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Mary Keaton | Administrator | Facility administrator involved in investigation and exit interviews |
| Czarrina A Camilon-Lee | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 72
Deficiencies: 0
Date: Feb 8, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff did not safeguard a resident's personal items.
Complaint Details
The complaint alleged that staff did not safeguard a resident's personal items. The investigation included interviews with the responsible party and staff, and review of documentation. It was found that the iPad and glasses were not lost but placed in a secure drawer by staff. The allegation was determined to be unfounded.
Findings
Based on interviews and documentation reviewed, the allegation was found to be unfounded, meaning the complaint was false or without reasonable basis, and the complaint was dismissed.
Report Facts
Facility capacity: 72
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Keaton | Executive Director | Interviewed during complaint investigation and exit interview |
| Anthony Tuck | Licensing Program Analyst | Conducted complaint investigation |
| Stephen Richardson | Licensing Program Manager | Named in report as Licensing Program Manager |
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