Inspection Reports for
Ivy Park at San Marino

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

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

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

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

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

The facility was found to be in compliance with all applicable regulations, including infection control, operational requirements, physical plant safety, staffing, personnel records, resident records, food service, and disaster preparedness. No deficiencies were cited during this inspection.

The complaint alleged that a resident's family member was not allowed to speak to the resident due to staff following a directive from the resident's authorized representative. Interviews and record reviews showed no evidence of staff preventing communication. The allegation was unsubstantiated.

The investigation found insufficient evidence to substantiate the allegation. Interviews with residents, staff, and family members, as well as record reviews, indicated no health and safety concerns and that residents have access to phone communication. The allegation was determined to be unsubstantiated.

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

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

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

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

The complaint alleged a questionable death of a 97-year-old Memory Care resident on 2024-08-17 and failure to provide resident records to the responsible party. After investigation including staff interviews, record reviews, and obtaining the death certificate, the allegations were found unsubstantiated due to insufficient evidence and lack of facility negligence.

The investigation found insufficient evidence to substantiate the allegations. The resident's death was determined to be due to COVID-19 with no facility negligence, and the issue regarding records was unsubstantiated as the requesting family member was not the authorized representative.

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

The facility was found to be in compliance with no items of correction needed. The physical plant, safety systems, food service, and staff and resident files were all inspected and found satisfactory. Fire clearance was granted for 74 residents with specific allowances for non-ambulatory and bedridden residents.