Inspection Reports for Meadow Oaks of Roseville
930 Oak Ridge Dr, Roseville, CA 95661, United States, CA, 95661
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally consistent compliance over time. However, earlier reports from late 2024 through early 2025 revealed multiple deficiencies primarily related to medication management, staffing shortages—especially in dementia care—and failures in resident supervision and communication, some posing immediate health and safety risks. Serious events included civil penalties assessed in April 2025 for medication errors and supervision failures, and staff disciplinary actions following a substantiated incident of forced medication in June 2024. The most recent report from September 25, 2025, showed no deficiencies, reflecting improvement after prior issues. While isolated minor deficiencies appeared occasionally, the facility’s recent record suggests corrective actions have been effective.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
70% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Capacity: 108
Deficiencies: 0
Date: Sep 25, 2025
Visit Reason
The inspection was a case management visit conducted by Licensing Program Analyst Kevin Mknelly to review a recent death notification and discuss another resident issue unrelated to the incident.
Findings
No deficiencies were noted as a result of the inspection. The Licensing Program Analyst reviewed resident records and interviewed facility staff, including the administrator and resident care director.
Report Facts
Facility capacity: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and inspection |
| Nathan Condie | Administrator/Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Monitoring
Census: 76
Capacity: 108
Deficiencies: 0
Date: Aug 19, 2025
Visit Reason
The visit was a case management monitoring inspection conducted to deliver complaint findings related to an incident report received on 08/08/2025 regarding a resident fall with injuries.
Complaint Details
The visit was triggered by a complaint involving an incident report about a resident (R1) who had a fall with injuries. The complaint findings were delivered during this visit.
Findings
No deficiencies were noted during the inspection. The Licensing Program Analyst will continue to gather additional information.
Report Facts
Capacity: 108
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and delivered complaint findings |
| Nathan Condie | Administrator | Met with Licensing Program Analyst during the inspection |
Inspection Report
Follow-Up
Census: 76
Capacity: 108
Deficiencies: 0
Date: May 22, 2025
Visit Reason
The visit was a non-compliance conference held to review the status of the facility's compliance plan established on 02/06/2025, focusing on ongoing non-compliance issues and medication errors identified in March 2025.
Findings
The report details continued incidents of non-compliance related to previous findings, including medication errors and issues identified in monthly audits such as communication with physicians, medication records, and medication refills. The licensee agreed to submit amended quality assurance policies and procedures to address these ongoing issues.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Present at the non-compliance conference and involved in the review of the facility's compliance plan. |
| Maribeth Senty | Licensing Program Manager | Present at the non-compliance conference and involved in the review of the facility's compliance plan. |
| Nathan Condie | Administrator | Facility representative present at the non-compliance conference and involved in discussions regarding compliance. |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 108
Deficiencies: 1
Date: Apr 10, 2025
Visit Reason
The inspection was conducted as a case management visit following receipt of an incident report regarding a medication error involving resident R1 on 3/26/25.
Complaint Details
The visit was complaint-related due to an incident report of a medication error involving resident R1 on 3/26/25. The error was substantiated as resident R1 received a discontinued medication. Hospice was notified and no adverse effects were reported.
Findings
The investigation found that resident R1 received a discontinued medication, hydrocodone, which had been stopped due to adverse effects. The error was due to lapses in communication and documentation policies. No adverse effects were noted for the resident. Deficiencies were cited posing immediate and potential health and safety risks, and a civil penalty was assessed.
Deficiencies (1)
The licensee failed to assist residents with self-administered medications as needed, resulting in resident R1 receiving a discontinued medication.
Report Facts
Capacity: 108
Census: 67
Plan of Correction Due Date: Apr 11, 2025
Staff Training Completion Date: Apr 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and signed the report |
| Nathan Condie | Administrator | Facility administrator met during the inspection |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 2
Date: Mar 27, 2025
Visit Reason
The visit was conducted to review a recently reported incident involving a medication error reported on 3/20/25 related to an event on 3/14/25.
Complaint Details
The visit was complaint-related due to a medication error incident reported on 3/20/25 involving resident R1 on 3/14/25. The medication error was substantiated with a deficiency cited.
Findings
A medication technician mistakenly administered a blood pressure medication twice in one day to resident R1, resulting in increased monitoring and emergency responder involvement but no hospitalization. Four falls by resident R2 were also discussed, with no deficiencies cited for that issue. Deficiencies were cited related to medication administration and assistance with self-administered medications.
Deficiencies (2)
Medication technician mistakenly administered a once per day blood pressure medication twice in one day to resident R1.
The licensee failed to assist residents with self-administered medications as needed, based on records and statements, posing a potential risk to resident R1.
Report Facts
Capacity: 108
Falls: 4
Plan of Correction Due Date: Mar 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the inspection and signed the report |
| Nathan Condie | Administrator/Director | Facility Administrator/Director met during inspection and discussed findings |
| Maribeth Senty | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 108
Deficiencies: 1
Date: Mar 11, 2025
Visit Reason
The visit was a case management and complaint investigation related to an incident report received on March 6, 2025, concerning a resident (R1) who left the memory care enclosed patio by climbing over a fence using patio furniture.
Complaint Details
The visit was complaint-related, triggered by an incident report regarding R1 leaving the enclosed patio unsupervised, resulting in injury. The complaint findings were delivered during the visit.
Findings
The investigation found that the door alarm batteries were low and caregivers did not hear the alarm when R1 exited. R1 scaled the fence, fell, and received medical assistance for an abrasion. Internal communication failures and inadequate staffing to meet R1's care needs were also identified, posing an immediate health and safety risk.
Deficiencies (1)
Care of Persons with Dementia (c) - Licensees who accept and retain residents with dementia shall ensure an adequate number of direct care staff to support each resident’s safety needs as identified in their appraisal and behaviors. This requirement was not met, posing an immediate risk to R1.
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Mar 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and complaint investigation |
| Maribeth Senty | Licensing Program Manager | Supervisor overseeing the inspection |
| Nathan Condie | Acting Administrator | Met with Licensing Program Analyst during the visit and involved in interviews |
| Jessica Sanders | Administrator/Director | Named as facility administrator |
Inspection Report
Census: 70
Capacity: 108
Deficiencies: 1
Date: Feb 13, 2025
Visit Reason
The visit was a case management visit conducted to review an amended report from 01/14/2025 regarding an incorrectly cited deficiency related to Advanced Directives and Requests Regarding Resuscitative Measures.
Findings
The previously cited deficiency was removed from the 01/14/2025 report and re-issued correctly. The plan of correction for the deficiency has been completed, and no new deficiencies were noted during this inspection. A medication error from 01/31/2025 was reviewed, with supervisory action initiated and no harm to the resident.
Deficiencies (1)
Advanced Directives and Requests Regarding Resuscitative Measures: Facility staff failed to immediately telephone emergency response (9-1-1) for a resident with an unwitnessed fall, posing an immediate risk to the resident.
Report Facts
Deficiency Plan of Correction Due Date: Feb 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and inspection |
| Jessica Sanders | Administrator | Met with Licensing Program Analyst during the visit |
| Maribeth Senty | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Census: 70
Capacity: 108
Deficiencies: 0
Date: Feb 6, 2025
Visit Reason
The visit was an unannounced office inspection conducted due to significant deficiencies noted at the facility from May 2024 to present, leading to a Non-compliance Conference.
Findings
Significant deficiencies were identified related to administrator qualifications, incidental medical and dental care services violations, personal rights violations, communication systems and audits, staffing and staff training, and observation of resident change in condition procedures.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Sanders | Administrator | Named in the Non-compliance Conference and related discussions. |
| Nathan Condie | Regional Director of Operations | Met during the inspection and named in the Non-compliance Conference. |
| Kevin Mknelly | Licensing Program Analyst | Present for the Non-compliance Conference. |
| Alycia Rayner | Regional Manager | Present for the Non-compliance Conference. |
| Maribeth Senty | Licensing Program Manager | Present for the Non-compliance Conference and named as Licensing Program Manager. |
Inspection Report
Census: 72
Capacity: 108
Deficiencies: 0
Date: Jan 29, 2025
Visit Reason
The inspection visit was conducted as a case management meeting to assist in resolving outstanding plans of correction related to previous citations.
Findings
No deficiencies were noted during this inspection. The Licensing Program Analyst and Regional Clinical Specialist discussed outstanding plans of correction and reestablished timelines for their submission.
Report Facts
Capacity: 108
Census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management inspection and discussed outstanding plans of correction |
| Jessica Sanders | Administrator | Named as facility administrator |
Inspection Report
Annual Inspection
Census: 70
Capacity: 108
Deficiencies: 1
Date: Jan 22, 2025
Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate the health and safety compliance of the facility using the CARE inspection tool.
Findings
The facility was toured with no immediate health, safety, or personal rights violations observed. However, 3 of 6 resident service plans lacked signatures for review, and 1 of 5 staff files lacked required dementia care training documentation, resulting in a cited deficiency.
Deficiencies (1)
3 of 6 resident service plans did not have signatures for review by resident and/or representative.
Report Facts
Resident files reviewed: 6
Staff files reviewed: 5
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the inspection and cited deficiency |
| Jessica Sanders | Administrator | Facility administrator who assisted with the inspection |
| Maribeth Senty | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 108
Deficiencies: 1
Date: Jan 22, 2025
Visit Reason
The inspection was conducted as a case management visit following a death notification of resident R1, to investigate the circumstances surrounding the resident's passing and review related records and care.
Complaint Details
The visit was complaint-related following a death notification for resident R1. The complaint investigation found that the resident's changes in condition and missed medications were not reported to the physician, and assistance was not provided. The resident's death was unexpected and not under hospice care.
Findings
The department found that the resident exhibited changes in condition and had missed several prescribed medications for three days prior to hospitalization. These changes and missed medications were not reported to the resident's physician, and assistance for medical care was not provided, posing an immediate health and safety risk.
Deficiencies (1)
Failure to ensure residents are regularly observed for changes in physical, mental, emotional and social functioning, and failure to document and report such changes to the resident's physician, posing an immediate risk to the resident.
Report Facts
Capacity: 108
Census: 70
Deficiencies cited: 1
Plan of Correction Due Date: Jan 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and inspection |
| Maribeth Senty | Licensing Program Manager | Named in relation to the inspection and deficiency report |
| Jessica Sanders | Administrator | Facility administrator met during the inspection |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 108
Deficiencies: 4
Date: Jan 14, 2025
Visit Reason
The visit was conducted as a case management investigation to deliver incident investigation findings related to a resident's fall, elopement, and unexpected death.
Complaint Details
The investigation was triggered by a complaint regarding a resident's elopement and subsequent unexpected death. The complaint was substantiated with findings of insufficient care, failure to report incidents, and unsafe conditions.
Findings
The investigation found that staff failed to provide sufficient care and supervision to resident R1, did not seek timely medical treatment after an unwitnessed fall, and were unclear about facility policies regarding emergency response. Additionally, multiple elopements were not reported to the licensing agency, and unsafe walkway conditions were observed. Immediate civil penalties were assessed for serious bodily injury and deficiencies related to supervision, administration, and reporting.
Deficiencies (4)
Lack of supervision at the time of R1's fall on 5/2/24, posing an immediate risk to the resident.
Administrator failed to ensure provision of services with appropriate regard for residents' physical and mental well-being, including ambulation supervision and awareness of emergency procedures, posing an immediate risk.
Failure to report incidents of elopements by R1 to the licensing agency, posing a potential risk to the resident.
Unsafe walkway surface presenting an uneven surface for unsteady, unsupervised resident to fall, posing a potential risk.
Report Facts
Immediate civil penalty amount: 500
Facility capacity: 108
Resident census: 70
Plan of Correction due date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Sanders | Executive Director | Met with Licensing Program Analyst and was interviewed regarding facility policies and incident awareness |
| Kevin Mknelly | Licensing Program Analyst | Conducted investigation and authored the report |
| Maribeth Senty | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Census: 73
Capacity: 108
Deficiencies: 0
Date: Dec 30, 2024
Visit Reason
The visit was a case management inspection conducted following a death notification received by the department regarding an unexpected resident death.
Findings
The inspection found no deficiencies. The resident's death appeared natural with multiple co-morbidities, and the coroner's report was pending.
Report Facts
Facility Capacity: 108
Resident Census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Sanders | Executive Director | Met with Licensing Program Analyst during case management visit |
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit |
Inspection Report
Census: 73
Capacity: 108
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
The visit was a case management incident inspection conducted following a death notification received for a resident (R1) who passed away while hospitalized. The inspection involved review of records and interviews related to the incident.
Findings
No deficiencies were noted during the inspection. The Licensing Program Analyst reviewed resident records, conducted interviews with staff, and requested additional documentation related to the resident's care.
Report Facts
Capacity: 108
Census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Sanders | Executive Director | Met with Licensing Program Analyst during the case management visit |
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and inspection |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 108
Deficiencies: 2
Date: Nov 6, 2024
Visit Reason
The inspection was a case management visit triggered by incident reports involving medication documentation irregularities and a resident missing from memory care.
Complaint Details
The visit was complaint-related due to incident reports received on 11/5/24 involving medication errors for resident R1 and a missing resident R2 from memory care. The complaint was substantiated with findings of staff noncompliance and inadequate staffing.
Findings
The investigation found staff failed to follow medication policies resulting in a resident not receiving prescribed medication, and inadequate staffing to monitor a resident with exit-seeking behavior, posing immediate health and safety risks.
Deficiencies (2)
Insufficient number of direct care staff to support each resident’s safety needs as identified in his/her current appraisal, posing an immediate risk to resident R2.
Care staff were not compliant with assisting resident R1 correctly with medications, posing an immediate risk to R1.
Report Facts
Capacity: 108
Census: 74
Civil Penalties: 3
Plan of Correction Due Date: Nov 7, 2024
Plan of Correction Due Date: Nov 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Sanders | Administrator/Director | Met with Licensing Program Analyst during inspection and involved in interviews regarding resident R2 incident |
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and inspection |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 1
Date: Sep 17, 2024
Visit Reason
The inspection was conducted as a case management visit following receipt of an incident report regarding resident R1 leaving the facility unassisted on 2024-09-07.
Complaint Details
The visit was complaint-related due to an incident report of R1 leaving the facility unassisted. The incident was substantiated as an immediate health and safety risk due to inadequate staffing and monitoring.
Findings
The investigation found that R1, a memory care resident with mild cognitive impairment, exited the facility unassisted due to insufficient monitoring after front desk alarms were only monitored until 5 PM and staffing was limited. This posed an immediate health and safety risk to the resident.
Deficiencies (1)
Licensees who accept and retain residents with dementia shall ensure an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and current health care needs. This requirement was not met, posing an immediate risk to R1's health and safety.
Report Facts
Facility Capacity: 108
Deficiency Count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and inspection |
| Charles Howard | Generations Program Director | Met with Licensing Program Analyst during inspection and provided information about the incident |
| Yvonne Williams | Regional Clinical Specialist | Met with Licensing Program Analyst during inspection |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager and Supervisor |
Inspection Report
Capacity: 108
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
The visit was an unannounced case management visit to confirm orders for immediate exclusion of an individual from all facilities.
Findings
The facility was informed of an immediate exclusion effective 09/13/2024, prohibiting the excluded individual (S1) from working, living in, or having contact with clients in any residential facility licensed by the California Department of Social Services.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Yang | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Jessica Sanders | Administrator | Facility administrator named in the report. |
| Charles Howard | Met with Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 108
Deficiencies: 0
Date: Aug 30, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2024-06-12 regarding concerns about the cleanliness and sanitation of a resident's bathroom.
Complaint Details
The complaint alleged that staff did not ensure that a resident's bathroom was clean and sanitary. The investigation included interviews and records review. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found the allegation to be unsubstantiated as there was insufficient evidence to prove the alleged violation occurred. The resident interviewed expressed satisfaction with the cleaning assistance provided.
Report Facts
Complaint Control Number: 59
Capacity: 108
Census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Sanders | Administrator | Met with during the investigation and mentioned in findings |
| Kevin Mknelly | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Monitoring
Census: 78
Capacity: 108
Deficiencies: 0
Date: Aug 30, 2024
Visit Reason
The visit was a case management follow-up conducted to review incident reports related to resident falls and an altercation between residents.
Findings
The Licensing Program Analyst observed that the residents involved had their care needs met, no further falls occurred, and no health, safety, or supervision issues were noted. No deficiencies were found during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Sanders | Director | Met with Licensing Program Analyst during case management visit and discussed resident incidents and supervision. |
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and reviewed incident reports. |
| Maribeth Senty | Licensing Program Manager | Named in report header and signature section. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 108
Deficiencies: 2
Date: Jun 12, 2024
Visit Reason
The visit was a case management incident investigation conducted due to a report received on 6/6/24 regarding an incident on 6/4/24 where a medication technician forced a resident (R1) to take medications against their will.
Complaint Details
The complaint involved a report submitted by the Director on 6/6/24 about an incident on 6/4/24 where medication tech S1 forced resident R1 to take medications by restraining and covering the resident's mouth. The incident was reported to the Memory Care Director and the facility Director. Employment and disciplinary actions were taken against involved staff. The complaint was substantiated with deficiencies cited.
Findings
The investigation found that medication tech S1, assisted by caregivers S2 and S3, forcibly administered medications to resident R1 by restraining and covering the resident's mouth. S1's employment was terminated and S2 and S3 were suspended pending further action. Staff training on mandated reporting, resident rights, and restraint policy was reviewed and additional training planned. Two Type A deficiencies were cited related to forcing medication and failure to report suspected physical abuse within 24 hours, both posing immediate risk to residents.
Deficiencies (2)
Assistance with self-administration does not include forcing a resident to take medication without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication.
Failure to report suspected physical abuse that does not result in serious bodily injury within 24 hours as required by Welfare and Institutions Code Section 15630(b)(1).
Report Facts
Deficiencies cited: 2
Plan of Correction Due Date: Jun 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Sanders | Director | Facility Director who submitted the SOC 341 report and was interviewed during the visit. |
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and inspection. |
| Maribeth Senty | Licensing Program Manager | Supervisor overseeing the licensing evaluation. |
Inspection Report
Capacity: 108
Deficiencies: 0
Date: May 16, 2024
Visit Reason
The visit was a case management follow-up conducted by Licensing Program Analyst Kevin Mknelly to follow up on an incident involving resident R1 that occurred on 2024-05-02.
Findings
No deficiencies were noted as a result of the inspection. The analyst conducted six interviews with caregivers and med techs and requested additional records related to resident R1's hospice care and prior hospitalization.
Report Facts
Number of interviews conducted: 6
Document submission deadline: May 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and follow-up on incident involving resident R1 |
| Jessica Sanders | Administrator | Met with Licensing Program Analyst during the visit |
Inspection Report
Census: 80
Capacity: 108
Deficiencies: 1
Date: May 3, 2024
Visit Reason
The inspection was a case management visit conducted following an incident report received on 04/24/2024 regarding a resident (R1) who exited the memory care unit and left the property unassisted on 04/20/2024.
Findings
The investigation found that the facility's delayed egress alarms were functioning properly, but exit doors sometimes did not close completely. There were insufficient direct care staff on duty to support residents with dementia, posing an immediate risk to R1's health and safety.
Deficiencies (1)
Care of Persons with Dementia: Licensees failed to ensure an adequate number of direct care staff to support each resident's physical, social, emotional, safety and current appraisal health care needs, posing an immediate risk to R1's health and safety.
Report Facts
Census: 80
Total Capacity: 108
Direct Care Staff on Duty: 2
Residents in Memory Care Unit: 12
Plan of Correction Due Date: May 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Sanders | Executive Director | Met with Licensing Program Analyst during case management visit and provided information about the incident |
| Kevin Mknelly | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the inspection |
Inspection Report
Annual Inspection
Census: 82
Capacity: 108
Deficiencies: 0
Date: Feb 21, 2024
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to evaluate the health and safety conditions of the facility and ensure compliance with licensing requirements.
Findings
The inspection found the facility to be in compliance with no deficiencies cited. The environment was clean and safe, medications were properly stored and administered, and all required safety equipment was operable.
Report Facts
Resident files reviewed: 4
Staff records reviewed: 4
Fire extinguisher last serviced: Oct 11, 2023
Fire drill last conducted: Jan 18, 2024
Hot water temperature: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Sanders | Executive Director | Met with Licensing Program Analyst during inspection |
| Jami Koopman | Memory Care Director | Participated in exit interview |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection |
| Troy Ordonez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 108
Deficiencies: 0
Date: Feb 21, 2024
Visit Reason
The visit was an unannounced Case Management - Incident inspection to obtain information regarding an incident involving a missing bubble pack of oxycodone reported on 02/13/2024.
Complaint Details
The visit was triggered by a complaint related to a missing bubble pack of 30 oxycodone tablets delivered on 02/07/2024 and signed off by night shift staff. The facility reported the incident to the police and conducted an internal investigation.
Findings
The facility conducted an internal investigation, notified the police and the resident's primary care physician, and provided in-service training on narcotics handling. No deficiencies were cited at this time.
Report Facts
Medication quantity: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Sanders | Executive Director | Met with Licensing Program Analyst during the visit |
| Jami Koopman | Memory Care Director | Participated in exit interview |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection visit |
| Troy Ordonez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 108
Deficiencies: 0
Date: Oct 26, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that unskilled staff were administering medication to residents, specifically concerning the administration of Morphine to a hospice resident.
Complaint Details
The complaint alleged that staff who are not appropriately skilled professionals were administering medication, specifically Morphine, to residents. The investigation found no evidence to substantiate this claim, with multiple staff and hospice nurse statements confirming that only licensed nurses, hospice nurses, and trained family members administered Morphine.
Findings
The investigation included interviews with staff and review of relevant documentation. The allegation that unlicensed staff administered Morphine was found to be unsubstantiated based on statements from medication technicians, hospice nurse, and review of physician orders and medication administration policies.
Report Facts
Facility Capacity: 108
Census: 91
Number of Med Techs interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Condie | Executive Director | Met with Licensing Program Analyst during investigation and named in report |
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 108
Deficiencies: 0
Date: Oct 26, 2023
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted to obtain information regarding an incident reported on 09/25/2023 involving a missing bubble pack of 30 Tramadol 50mg from the narcotic drawer on 09/10/2023.
Complaint Details
The visit was triggered by a complaint/incident report regarding a missing narcotic medication. The incident was investigated internally and involved notification of the police and the resident's doctor. No deficiencies were cited.
Findings
The facility conducted an internal investigation, notified the police and relevant parties, and provided in-service training on narcotic count and medication room policies. No deficiencies were cited at the time of the visit.
Report Facts
Medication quantity missing: 30
Facility census: 91
Facility capacity: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Condie | Executive Director | Met with Licensing Program Analyst during inspection |
| Kathryn Nevin | Resident Care Director | Notified and conducted search of medication room during incident investigation |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection visit |
| Anthony Perez | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 108
Deficiencies: 0
Date: Sep 14, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations received on 2023-05-10 regarding staff not providing timely incontinence care, not attending to a vomiting resident timely, not redirecting a wandering resident, and not answering the facility door for visitors.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not providing timely incontinence care, not attending to a vomiting resident timely, not redirecting a wandering resident, and not answering the facility door for visitors. Interviews and record reviews did not support these allegations.
Findings
The investigation included interviews with facility staff and review of relevant documentation. All allegations were found to be unsubstantiated due to lack of preponderance of evidence supporting the claims.
Report Facts
Facility capacity: 108
Resident census: 89
Number of staff interviewed: 4
Memory Care Unit residents: 15
Incontinent residents: 6
Caregivers per shift: 2
Caregivers per night shift: 1
Door answering time: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Allison Lopez | Assistant Executive Director | Met with Licensing Program Analyst during investigation and provided interview statements |
Inspection Report
Complaint Investigation
Capacity: 108
Deficiencies: 0
Date: Aug 30, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-05-05 alleging insufficient staffing to meet residents' needs and staff verbal abuse towards residents.
Complaint Details
The complaint alleged insufficient staffing to meet residents' needs and staff verbally abusing residents. The investigation included interviews with six staff and four residents, review of staffing schedules, call logs, and resident pendant response times. The evidence did not support the allegations, resulting in an unsubstantiated finding.
Findings
The investigation found the allegations to be unsubstantiated. Interviews with staff and residents indicated that residents' needs were being met and no verbal abuse was witnessed. Staffing levels were reviewed including a staffing ratio waiver and staff schedules, and response times to resident call pendants were generally reasonable.
Report Facts
Facility capacity: 108
Resident census: 26
Staff shifts: 3
Residents interviewed: 4
Staff interviewed: 6
Pendant response time: 20
Pendant response time: 54
Pendant response time: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Allison Lopez | Assistant Executive Director | Met with Licensing Program Analyst during the investigation |
| Nathan Condie | Administrator | Facility Administrator named in report header |
Inspection Report
Census: 87
Capacity: 108
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
The inspection visit was an unannounced Case Management - Health Checks to ensure the health and safety of residents in care.
Findings
The facility was toured including common areas, kitchen, residents' bedrooms and bathrooms. No immediate health, safety, or personal rights violations were observed. The facility was found to be in substantial compliance with no deficiencies cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison Lopez | Assistant Executive Director | Met with Licensing Program Analyst during the inspection and exit interview. |
| Sarena Keosavang | Licensing Program Analyst | Conducted the unannounced Case Management - Health Checks inspection. |
| Anthony Perez | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 108
Deficiencies: 0
Date: May 4, 2023
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted to obtain information regarding an incident reported on 04/25/2023 involving alleged rude and cussing behavior by a staff member towards residents.
Complaint Details
The complaint involved a report by resident R1 that staff member S1 was cussing and speaking rudely towards residents R1 and R2. A written and signed statement from R1 was received. The staff member was suspended and an investigation is pending.
Findings
The investigation included review of incident reports, physician's reports, assessments, and interviews with staff. At the time of the visit, no deficiencies were cited, and the staff member involved was suspended pending further investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison Lopez | Assistant Executive Director | Met with Licensing Program Analyst during the investigation and involved in the incident report process. |
| Nathan Condie | Administrator | Named as facility administrator in the report. |
| Sarena Keosavang | Licensing Program Analyst | Conducted the unannounced case management incident visit. |
| Anthony Perez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 86
Capacity: 108
Deficiencies: 0
Date: Mar 8, 2023
Visit Reason
The inspection visit was an unannounced Case Management - Health Checks to ensure the health and safety of residents in care.
Findings
No immediate health, safety, or personal rights violations were observed during the tour of the facility. The facility was found to be in substantial compliance with no deficiencies cited as a result of the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison Lopez | Assistant Executive Director | Met with Licensing Program Analyst during the inspection and exit interview. |
| Sarena Keosavang | Licensing Program Analyst | Conducted the unannounced Case Management - Health Checks inspection. |
| Anthony Perez | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 108
Deficiencies: 0
Date: Feb 10, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2022-10-04 alleging that staff did not adhere to a resident's admissions agreement.
Complaint Details
The complaint alleged that facility staff did not ensure to call the resident and conduct status checks twice daily as per the admission agreement. The investigation reviewed medical and care records, interviewed four staff members and the resident, and reviewed call logs showing frequent checks and timely responses. The allegation was determined to be unfounded.
Findings
The investigation found that the allegation was unfounded. The resident's needs were being met, staff conducted frequent status checks, and no deficiencies were cited during the visit.
Report Facts
Call log events: 80
Response time average (minutes): 7
Staff interviews: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Allison Lopez | Assistant Executive Director | Met with Licensing Program Analyst during the investigation |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 83
Capacity: 108
Deficiencies: 0
Date: Feb 9, 2023
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure health and safety compliance at the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison Lopez | Assistant Executive Director | Met with Licensing Program Analyst during inspection and assisted with infection control domain evaluation. |
| Sarena Keosavang | Licensing Program Analyst | Conducted the Required-1 Year Inspection and infection control domain evaluation. |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 108
Deficiencies: 1
Date: Dec 28, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 07/05/2022 regarding allegations that the facility did not refund as specified in the Admission Agreement and that the facility did not have adequate staffing to meet residents' needs.
Complaint Details
The complaint investigation was substantiated regarding failure to refund as specified in the Admission Agreement. The allegation about inadequate staffing was unsubstantiated due to lack of sufficient evidence.
Findings
The complaint that the facility did not refund the responsible party as specified in the Admission Agreement was substantiated, with evidence showing the facility initially failed to provide the refund but later issued a refund of $4625. The allegation regarding inadequate staffing to meet residents' needs was unsubstantiated based on interviews, staff schedules, and level of care assessments.
Deficiencies (1)
Licensee did not adhere to admission agreement and did not provide refund to resident's responsible party, posing a potential health and safety risk to resident in care.
Report Facts
Capacity: 108
Census: 73
Refund amount: 4625
Late fee: 75
Monthly rate: 4495
Monthly rate: 3500
Monthly rate: 950
Days absent: 18
Days for pro-rated credit: 14
Days refunded: 3
Residents in Villa: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Allison Lopez | Assistant Executive Director (AED) | Met with Licensing Program Analyst during investigation and provided statements |
| Debra Duval | Administrator | Facility administrator named in report header |
| Rayna Gabriel | Business Office Director (BOD) | Provided statements regarding refund and resident move-out |
| S3 | Staff member who assisted resident R1 and confirmed staffing details | |
| S1 | Facility staff who provided statements about staffing and care | |
| S2 | Facility staff who provided statements about staffing and care |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 108
Deficiencies: 1
Date: Dec 8, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 04/13/2022 regarding allegations of resident neglect including not being changed, strong urine odor in bedroom, lack of re-evaluation for change of condition, lack of medical attention, and over medication.
Complaint Details
The complaint investigation was substantiated for the allegation that a resident was not changed and the bedroom smelled of urine. The investigation found that staff did not consistently change the resident's incontinence briefs, resulting in strong urine odor. Other allegations including resident not re-evaluated for change of condition and resident did not receive medical attention were unfounded. The allegation that the resident was over medicated was unsubstantiated.
Findings
The complaint investigation substantiated that a resident was not kept clean and dry, resulting in a strong urine odor in the resident's bedroom, posing a potential health and safety risk. Other allegations regarding lack of re-evaluation for change of condition and lack of medical attention were found to be unfounded. The allegation of over medication was unsubstantiated due to lack of evidence.
Deficiencies (1)
Failure to ensure incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence.
Report Facts
Capacity: 108
Census: 61
Deficiencies cited: 1
Plan of Correction Due Date: Dec 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Allison Lopez | Assistant Executive Director | Met with Licensing Program Analyst during inspection and provided statements |
| Kathryn Nevin | Memory Care Director | Provided statements regarding resident's condition and medication |
Inspection Report
Monitoring
Census: 61
Capacity: 108
Deficiencies: 0
Date: Dec 8, 2022
Visit Reason
The visit was an unannounced Case Management - Health Checks inspection conducted to ensure the health and safety of residents in care.
Findings
The Licensing Program Analyst toured the facility and observed residents participating in activities. No immediate health, safety, or personal rights violations were found, and the facility was found to be in substantial compliance with no deficiencies cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allison Lopez | Assistant Executive Director | Met with Licensing Program Analyst during the inspection. |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Anthony Perez | Licensing Program Manager | Named in the report header. |
Inspection Report
Census: 73
Capacity: 108
Deficiencies: 0
Date: Sep 1, 2022
Visit Reason
The inspection visit was an unannounced Case Management - Health Checks to ensure the health and safety of residents in care.
Findings
No immediate health, safety, or personal rights violations were observed during the tour of the facility. The facility was found to be in substantial compliance with no deficiencies cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debra Duval | Executive Director | Met with Licensing Program Analyst during the inspection and exit interview. |
| Sarena Keosavang | Licensing Program Analyst | Conducted the unannounced Case Management - Health Checks inspection. |
| Anthony Perez | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 108
Deficiencies: 0
Date: Aug 17, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-02-02 regarding multiple allegations of inadequate care and supervision at Meadow Oaks of Roseville.
Complaint Details
The complaint included allegations that staff did not assist residents with hygiene needs, failed to provide adequate incontinence care, left residents unattended, did not provide adequate food service, residents sustained pressure sores due to lack of care, and that the facility was in disrepair. All allegations were found unsubstantiated based on interviews, documentation review, and observations.
Findings
The investigation found all allegations unsubstantiated after interviews with staff, review of resident records, and facility observations. The facility was found to provide adequate hygiene assistance, incontinence care, food service, and maintenance, with no evidence of residents being left unattended or sustaining pressure sores due to neglect.
Report Facts
Number of facility staff interviewed: 5
Number of resident records reviewed: 4
Number of kitchen staff interviewed: 2
Number of care staff interviewed: 3
Number of residents referenced in incontinence care allegation: 4
Visit start time: 15
Visit end time: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debra Duval | Executive Director | Met with Licensing Program Analyst during complaint investigation and provided statements |
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation visit |
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager on report |
| Dale Garrett | Maintenance Director | Provided statements regarding facility maintenance and repairs |
Inspection Report
Census: 71
Capacity: 108
Deficiencies: 0
Date: Jun 9, 2022
Visit Reason
The inspection visit was an unannounced Case Management - Health Checks to ensure the health and safety of residents in care.
Findings
No immediate health, safety, or personal rights violations were observed during the tour of the facility. The facility was found to be in substantial compliance and no deficiencies were cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debra Duval | Executive Director | Met with Licensing Program Analyst during the inspection visit. |
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection visit. |
| Anthony Perez | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 108
Deficiencies: 0
Date: Apr 7, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2021-10-13 regarding inadequate staffing, non-adherence to COVID protocols, and improper notice of resident rate increase.
Complaint Details
The complaint investigation addressed allegations that the facility did not have adequate staffing, staff were not adhering to COVID protocols, and the facility raised a resident's rate without proper notice. All allegations were found to be unsubstantiated or unfounded after review of interviews, documentation, and timecards.
Findings
The investigation found all allegations to be unsubstantiated or unfounded. Staffing levels were supported by agency staff and timecards, COVID protocol adherence was confirmed, and proper notice of rate increase was documented with signed agreements.
Report Facts
Resident census: 67
Total capacity: 108
Resident count per caregiver: 30
Rate increase amount: 5265
Previous rate amount: 1895
Notice date: Apr 22, 2021
Agreement signed date: Apr 30, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Debra Duval | Executive Director | Facility representative interviewed during investigation |
| Samantha Murphy | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 66
Capacity: 108
Deficiencies: 0
Date: Feb 15, 2022
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure compliance with health and safety standards.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debra Duval | Executive Director | Met with Licensing Program Analyst during inspection and explained the purpose of the visit. |
| Sarena Keosavang | Licensing Program Analyst | Conducted the Required-1 Year Inspection and infection control domain evaluation. |
| Anthony Perez | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 108
Deficiencies: 2
Date: Jan 21, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint received on 12/18/2020 alleging resident physical abuse and failure to treat residents with dignity and respect.
Complaint Details
The complaint was substantiated regarding physical abuse of a resident by staff member S2 twisting R1's wrist and verbal abuse towards residents including calling a resident 'stupid and dumb'. Staff S2 was suspended and later resigned. Other allegations about hygiene assistance and food service were unsubstantiated.
Findings
The investigation substantiated allegations that a staff member physically abused a resident by twisting their wrist and verbally abused residents, failing to treat them with dignity and respect. Other allegations regarding hygiene assistance and food service were found unsubstantiated.
Deficiencies (2)
Residents were not free from punishment, humiliation, intimidation, abuse, or other punitive actions such as withholding residents’ money or interfering with daily living functions.
Residents were not accorded dignity in their personal relationships with staff, residents, and other persons.
Report Facts
Capacity: 108
Census: 66
Number of interviewed staff for abuse allegations: 5
Number of interviewed residents for food service allegation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Debra Duval | Executive Director | Facility representative met during the investigation |
| Samantha Murphy | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 108
Deficiencies: 0
Date: Dec 2, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that a resident obtained a pressure injury at the facility due to neglect.
Complaint Details
The complaint alleged that a resident obtained a pressure injury at the facility due to neglect. The investigation was unsubstantiated based on records review, staff interviews, and medical documentation.
Findings
The investigation found no documentation or evidence supporting the allegation of neglect causing a pressure injury. Staff interviews and medical records indicated the resident had a history of skin fragility but no pressure injuries were observed or documented. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 108
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation |
| Melissa Parks | Licensing Program Analyst | Arrived at the facility with Sarena Keosavang to deliver complaint findings |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
| Debra Duval | Facility representative met during the investigation | |
| Samantha Murphy | Administrator | Facility Administrator |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 108
Deficiencies: 1
Date: Dec 2, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2020-10-26 alleging lack of supervision resulting in resident wandering away from the facility and failure to notify resident's authorized representative of change in health condition and failure to seek timely medical attention for resident.
Complaint Details
The complaint investigation was triggered by allegations that a resident (R1) was able to leave the facility without staff knowledge due to lack of supervision, and that staff failed to notify the resident's authorized representative of a change in health condition and did not seek timely medical attention. The allegation of lack of supervision was substantiated, while the allegations regarding notification and medical attention were unsubstantiated.
Findings
The investigation substantiated the allegation that lack of supervision resulted in a resident wandering away from the facility, posing an immediate threat to the resident's health and safety. Another allegation regarding failure to notify the resident's authorized representative and failure to seek timely medical attention was found to be unsubstantiated.
Deficiencies (1)
Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided, and such changes are documented and brought to the attention of the resident's physician and responsible person.
Report Facts
Capacity: 108
Census: 41
Deficiencies cited: 1
Plan of Correction Due Date: Dec 3, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debra Duval | Executive Director | Met with Licensing Program Analysts during complaint investigation |
| Allison | Resident Care Director | Interviewed regarding resident's level of care and supervision |
| Sarena Keosavang | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Melissa Parks | Licensing Program Analyst | Conducted complaint investigation |
| Anthony Perez | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Annual Inspection
Census: 72
Capacity: 108
Deficiencies: 0
Date: Oct 20, 2021
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure health and safety compliance at the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed during the inspection. No deficiencies were cited as a result of the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the inspection and met with the Executive Director. |
| Debra Duval | Executive Director | Met with Licensing Program Analyst during the inspection. |
| Anthony Perez | Licensing Program Manager | Named in the exit interview section of the report. |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 108
Deficiencies: 0
Date: Jul 27, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that staff did not ensure a resident's colostomy bag was changed.
Complaint Details
The complaint alleged that resident R1 was not receiving assistance with their colostomy bag. Investigations included review of medical and care assessments indicating R1 could self-manage, interviews with R1's spouse and staff confirming R1's ability and need for reminders, and the fact that R1 had passed away prior to the investigation. The allegation was unsubstantiated.
Findings
The allegation was found to be unsubstantiated after review of resident records, interviews with the resident's spouse and facility staff, and consideration of the resident's ability to self-manage the colostomy bag. No evidence supported the claim that staff failed to assist the resident.
Report Facts
Facility capacity: 108
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melana Llopis | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Maribeth Senty | Licensing Program Manager | Named in report as Licensing Program Manager |
| Debra Duval | Administrator | Facility administrator met with during investigation |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 108
Deficiencies: 0
Date: Jun 16, 2021
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2020-10-19 alleging that staff did not assist a resident with hygiene needs and would not allow a resident to have a visitor.
Complaint Details
The complaint alleged that staff did not assist resident R1 with hygiene needs and did not allow R1 to have visitors. The investigation included record reviews, staff and family interviews, and observation of visitor guidelines. The allegations were determined to be unsubstantiated due to insufficient evidence.
Findings
The investigation found that the resident was able to self-manage grooming and colostomy care with some assistance and reminders, and that visitor guidelines were in compliance with state regulations. Due to lack of sufficient evidence, the allegations were found to be unsubstantiated.
Report Facts
Complaint Control Number: 27-AS-20201019113838
Capacity: 108
Census: 63
Baths per week: 2
Grooming reminders per week: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melana Llopis | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Kevin Mknelly | Licensing Program Manager | Named as Licensing Program Manager on report |
| Debra Duval | Administrator | Met with Licensing Program Analyst during investigation |
| Jasmine Ridenour | Administrator | Named as Administrator of the facility |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 108
Deficiencies: 0
Date: May 28, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-09-24 alleging facility disrepair and staff misconduct including not safeguarding resident's personal belongings, causing injury to a resident, and turning off call buttons.
Complaint Details
The complaint was investigated and found to be unsubstantiated. Allegations included staff not safeguarding resident's personal belongings, staff causing injury to a resident, and staff turning off call buttons. Interviews with staff and review of relevant documents including incident reports and call pendant logs were conducted. No preponderance of evidence was found to prove the alleged violations occurred.
Findings
The investigation found all allegations to be unsubstantiated. The facility was observed to be in good repair, and interviews and document reviews did not support the allegations. Recommendations were made to improve documentation such as creating a supply log for residents' personal belongings.
Report Facts
Facility capacity: 108
Census: 65
Complaint received date: Sep 24, 2020
Investigation visit date: May 28, 2021
Investigation visit start time: 1310
Investigation visit end time: 1330
Number of staff interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jasmine Ridenour | Executive Director | Met during investigation and provided statements regarding facility operations and documentation |
| Debra Duval | Met during investigation and spoke with Licensing Program Analyst | |
| S1 | Caregiver | Interviewed regarding call button system and unplugging allegations |
| S2 | Caregiver | Interviewed regarding personal belongings and call button system |
| S3 | Caregiver | Interviewed regarding call button system and response times |
| Sarena Keosavang | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Anthony Perez | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Capacity: 108
Deficiencies: 0
Date: May 26, 2021
Visit Reason
Licensing Program Analysts arrived unannounced to conduct a case management visit related to an ongoing investigation involving an alleged perpetrator held by the facility.
Findings
The facility is currently holding out the alleged perpetrator while performing an investigation. Licensing Program Analysts are awaiting more facts and determined that the case needs further investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Perez | Licensing Program Manager | Named as Licensing Program Manager overseeing the case management visit. |
| Jacob Williams | Licensing Program Analyst | Named as Licensing Program Analyst involved in the case management visit. |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 108
Deficiencies: 1
Date: May 8, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2020-12-17 regarding facility conditions.
Complaint Details
The complaint alleged that the facility was in despair, specifically noting that light bulbs were not working in one of the bathrooms in the Memory Care unit, making it difficult for staff and residents to see. The complaint was substantiated after investigation.
Findings
The complaint was substantiated due to non-working light bulbs in the Memory Care unit bathroom and hallway, posing a potential health and safety risk to residents. The facility agreed to correct the deficiency by replacing the light bulbs.
Deficiencies (1)
Hallway light bulbs and bathroom light bulbs located in the Memory Care unit were out and not working, posing a potential health and safety risk to residents.
Report Facts
Capacity: 108
Census: 63
Deficiency due date: May 14, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation and telephone contact with the facility |
| Debra Duval | Executive Director | Facility representative met during the investigation and exit interview |
| Samantha Murphy | Administrator | Previous Executive Director who was unaware of the light bulb issue |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 108
Deficiencies: 2
Date: Apr 26, 2021
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 08/12/2020 regarding medication administration and communication issues at the facility.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not administer medication per physician's order and failed to inform the authorized representative to renew the physician's order. The allegation that staff did not provide adequate food service was unsubstantiated.
Findings
The investigation substantiated that staff did not administer a resident's medication per physician's orders on multiple dates and failed to inform the authorized representative to renew the physician's order. Another allegation regarding inadequate food service was found to be unsubstantiated.
Deficiencies (2)
Medication was not given to resident R1 and not documented on the Medication Administration Records per facility policy.
Facility did not notify the resident's authorized representative of change in physician’s order.
Report Facts
Capacity: 108
Census: 61
Missed medication dates: 5
Number of interviewed staff: 5
Number of interviewed residents: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Anthony Perez | Licensing Program Manager | Oversaw the complaint investigation |
| Debra Duval | Executive Director | Facility representative interviewed during investigation |
| Jasmine Ridenour | Prior Executive Director | Provided statement regarding communication practices with resident's authorized representative |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 108
Deficiencies: 1
Date: Feb 15, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-02-10 regarding a malodorous resident room.
Complaint Details
The complaint was substantiated. The allegation was that a resident's room was malodorous. The investigation found that basic services were not provided as required, and the allegation was substantiated based on the preponderance of evidence standard.
Findings
The Licensing Program Analyst determined that a resident's room was malodorous and that basic services, including house cleaning, were not provided as required, posing a potential health and safety risk. The allegation was substantiated based on observations and evidence.
Deficiencies (1)
Failure to provide basic services including house cleaning for one resident, posing a potential health and safety risk.
Report Facts
Capacity: 108
Census: 69
Deficiency Type: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pheej Cheng | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Debra Duval | Administrator | Facility administrator met during the investigation |
| Rayna L Bryson | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 108
Deficiencies: 0
Date: Feb 1, 2021
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to a complaint received on 07/16/2020 regarding personal rights concerns related to COVID-19 exposure and staff working conditions.
Complaint Details
The complaint alleged that staff member S1 was required to work a full shift despite expressing concerns about being COVID-19 positive and symptoms. The investigation found that S1 was exposed to COVID-19, tested positive on 7/3/2020, and the facility acted by removing S1 from work for several days. The allegation was unsubstantiated.
Findings
The investigation found that staff member S1 was instructed to work despite concerns of COVID-19 exposure, but after testing positive, the facility took appropriate action by not scheduling S1 to return to work for several days. The complaint was determined to be unsubstantiated due to insufficient evidence of a violation.
Report Facts
Complaint received date: Jul 16, 2020
Complaint investigation visit date: Feb 1, 2021
Facility capacity: 108
Facility census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jasmine Ridenour | Executive Director | Named in relation to complaint findings and investigation |
| Laura Benson | Interim Executive Director | Met with Licensing Program Analyst during investigation |
| Sarena Keosavang | Licensing Program Analyst | Conducted the complaint investigation |
| Anthony Perez | Licensing Program Manager | Named in report as Licensing Program Manager |
| Samantha Murphy | Assistant Executive Director | Named in relation to complaint findings |
| Josh Allen | Nurse Consultant | Provided guidance on staff exposure to COVID-19 |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 108
Deficiencies: 1
Date: Dec 2, 2020
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2020-04-10 regarding allegations that the facility raised fees without giving proper notice to the responsible party, charged residents for services not provided, and did not do a reappraisal prior to raising care level fees.
Complaint Details
The complaint investigation was based on three allegations: 1) Facility raised fees without giving proper notice to responsible party (substantiated), 2) Facility charged resident for services not provided (unsubstantiated), and 3) Facility did not do a reappraisal prior to raising care level fees (unfounded).
Findings
The investigation substantiated that the facility raised fees without giving proper notice to the responsible party, citing a deficiency for failure to provide written notice of rate increase within two business days after initially providing services at the new level of care. The allegation that the facility charged residents for services not provided was unsubstantiated, as services billed were refunded. The allegation that the facility did not do a reappraisal prior to raising care level fees was unfounded, as a reappraisal was completed prior to raising fees.
Deficiencies (1)
§1569.657 Rate increase due to change in level of resident care; notice - The licensee did not provide the resident and the resident’s representative written notice of the rate increase within two business days after initially providing services at the new level of care.
Report Facts
Capacity: 108
Census: 65
Deficiency count: 1
Plan of Correction Due Date: Dec 16, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danyle Wolter | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Laura Munoz | Licensing Program Manager | Oversaw the complaint investigation |
| Samantha Murphy | Executive Director | Facility representative met during the investigation |
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