Inspection Report Summary
Most inspections found deficiencies primarily related to medication management, including missed or incorrect medication administration and incomplete narcotics documentation, as well as staffing concerns affecting resident care and supervision. Several complaint investigations were substantiated, resulting in civil penalties totaling up to $9,500 for serious issues such as failure to monitor a resident who suffered serious injury. The facility addressed many prior deficiencies through plans of correction, and the most recent inspection on October 10, 2025, found no deficiencies, indicating improvement. Earlier issues with staffing sufficiency and medication administration posed immediate risks but were later cleared. Some complaint investigations were unsubstantiated, showing that not all concerns raised were confirmed.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Census: 87
Capacity: 136
Deficiencies: 1
Oct 10, 2025
Visit Reason
The visit was an unannounced Plan of Correction (POC) follow-up conducted to verify correction of deficiencies cited from a prior complaint investigation on 2025-09-25.
Findings
No further deficiencies were observed or cited during this Plan of Correction visit. The facility provided a Plan of Correction clearance letter to the designated administrator.
Complaint Details
The visit was a follow-up on deficiencies cited from a prior complaint conducted on 2025-09-25.
Deficiencies (1)
| Description |
|---|
| A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gale Schmidt | Business Office Director | Facility designated representative met during the inspection. |
| Charlie Yang | Licensing Program Analyst | Conducted the Plan of Correction visit. |
| Liza King | Licensing Program Manager | Named in the exit interview. |
Inspection Report
Monitoring
Census: 92
Capacity: 136
Deficiencies: 0
Sep 25, 2025
Visit Reason
The visit was an unannounced case management visit conducted as a quarterly follow-up to increased monitoring requirements from a Non Compliance Conference held on 03/25/2024, focusing on medication errors, staffing concerns, reporting requirements, and medication training.
Findings
The inspection found that the facility had ongoing issues related to medication management, including missed medications and incomplete centrally stored medication logs. Staffing levels were generally adequate but with some concerns about care assistance coverage. Several resident incident reports related to falls were reviewed, with care plans updated accordingly. Citations were issued related to a complaint about medication mismanagement, but no citations resulted directly from this visit.
Complaint Details
The visit was related to a complaint regarding mismanagement of medications. Citations were issued in relation to this complaint, and findings from the visit were incorporated into that complaint. No citations were issued solely as a result of this visit.
Report Facts
Residents in facility: 92
Total licensed capacity: 136
Residents in memory care unit: 27
Residents receiving hospice care: 8
Falls for resident R1: 5
Falls for resident R4: 8
Missed medications for resident R7: 1
Missed medications for resident R8: 6
Controlled substance bottles reviewed: 12
Controlled substance counts completed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Facility Administrator present during inspection and exit interview |
| Afifa Kahn | Health and Wellness Director | Met with inspectors and participated in exit interview |
| Jocelyn Ning | Memory Care Director | Met with inspectors and participated in exit interview; involved in staffing and care assistance |
| Charlie Yang | Licensing Program Analyst | Conducted the inspection visit |
| Liza King | Licensing Program Manager | Conducted the inspection visit and reviewed findings |
| Krystall Moore | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Plan of Correction
Census: 97
Capacity: 136
Deficiencies: 1
Jul 14, 2025
Visit Reason
Unannounced Plan of Correction visit to follow up on deficiencies cited from a prior case management visit/Legal Non Compliance conducted on 2025-06-19 and to verify the Plan of Correction that was due.
Findings
The Plan of Correction visit found no further deficiencies; the previously cited deficiency regarding the lack of a plan for incidental medical and dental care and assistance with self-administered medications was addressed and cleared.
Deficiencies (1)
| Description |
|---|
| A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by prior citation on 2025-06-19. |
Report Facts
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Facility designated Administrator met during inspection and received Plan of Correction clearance letter |
| Charlie Yang | Licensing Program Analyst | Conducted the Plan of Correction visit |
| Liza King | Licensing Program Manager | Named in exit interview |
Inspection Report
Monitoring
Census: 97
Capacity: 136
Deficiencies: 1
Jun 19, 2025
Visit Reason
Unannounced case management visit conducted as a quarterly visit following a Non Compliance Conference on 03/25/2024, with increased monitoring required. The visit focused on medication errors, staffing concerns, reporting requirements, medication training, and facility policies regarding assessments, monitoring of residents, change in condition, and medication errors.
Findings
The inspection found deficiencies related to medication administration, including missing or incorrect narcotics count entries, incomplete documentation, and medications not dispensed as prescribed, posing an immediate risk to resident health and safety. Caregiver task documentation was also incomplete or improperly filled out. A civil penalty of $1000 was assessed for a repeat violation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care plan was not developed as required; medication administration records had missing names/initials for narcotics counts, omitted or incorrect dates, and medications were not dispensed as prescribed, posing immediate risk to residents. | Type A |
Report Facts
Civil penalty amount: 1000
Narcotics count entries: 3
Narcotics count entries observed: 2
Total days with missing narcotics entries: 7
Census: 97
Total capacity: 136
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Facility designated Administrator met during inspection and named in appeal rights and civil penalty notification |
| Charlie Yang | Licensing Program Analyst | Conducted inspection, named in report and findings |
| Liza King | Licensing Program Manager | Named in report and findings |
Inspection Report
Plan of Correction
Census: 97
Capacity: 136
Deficiencies: 1
Jun 19, 2025
Visit Reason
Unannounced Plan of Correction visit to follow up on deficiencies cited from a prior complaint visit conducted on 2025-04-28 and to verify the Plan of Correction that was due.
Findings
No further deficiencies were observed or cited during the Plan of Correction visit. The prior deficiencies related to ensuring incontinent residents are checked during known incontinent periods, including night time.
Deficiencies (1)
| Description |
|---|
| Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Met with Licensing Program Analyst during Plan of Correction visit. |
| Charlie Yang | Licensing Program Analyst | Conducted the Plan of Correction visit. |
| Liza King | Licensing Program Manager | Named in exit interview. |
Inspection Report
Plan of Correction
Census: 93
Capacity: 136
Deficiencies: 1
Apr 28, 2025
Visit Reason
Unannounced Plan of Correction visit to follow up on deficiencies cited from a prior complaint visit conducted on 2025-02-21 and to verify the Plan of Correction that was due.
Findings
The prior deficiencies related to the lack of a plan for incidental medical and dental care and assistance with self-administered medications were addressed. No further deficiencies were observed during this Plan of Correction visit.
Complaint Details
The visit was a follow-up on deficiencies cited from a prior complaint visit conducted on 2025-02-21.
Deficiencies (1)
| Description |
|---|
| A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by prior citation on 02/21/2025. |
Report Facts
Census: 93
Total Capacity: 136
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Facility designated Administrator met during the inspection and involved in interview |
| Charlie Yang | Licensing Program Analyst | Conducted the Plan of Correction visit |
| Liza King | Licensing Program Manager | Named in exit interview |
Inspection Report
Monitoring
Census: 93
Capacity: 136
Deficiencies: 0
Apr 28, 2025
Visit Reason
The visit was an unannounced Case Management follow-up to a report concerning a facility resident requiring care and supervision related to a Restricted Health Condition.
Findings
The review confirmed that the facility had an appropriate care plan in place with trained individuals involved, and no deficiencies were observed or cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Met with Licensing Program Analyst during the inspection and involved in care plan review. |
| Charlie Yang | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Liza King | Licensing Program Manager | Named in the exit interview. |
Inspection Report
Monitoring
Census: 92
Capacity: 136
Deficiencies: 1
Feb 21, 2025
Visit Reason
The visit was an unannounced case management visit conducted as a quarterly monitoring visit following a Non Compliance Conference held on 2024-03-25, with a focus on medication errors, staffing concerns, reporting requirements, medication training, and facility policies regarding assessments, monitoring of residents, change in condition, and medication errors.
Findings
The inspection found deficiencies related to medication administration, including missing required names/initials for narcotics counts, omitted or incorrect dates, and medications not dispensed as prescribed, posing an immediate risk to residents. A civil penalty of $250 was assessed for a repeat violation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care: Required names/initials for narcotics counts were missing, dates were omitted or incorrect, and medications were not dispensed as prescribed, posing an immediate risk to residents. | Type A |
Report Facts
Civil penalty amount: 250
Number of resident files reviewed: 10
Number of residents in memory care unit: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Facility designated Administrator met during inspection and named in relation to appeal rights and findings |
| Lakena Touch | Medication Technician | Interviewed during tour of memory care unit medication room |
| Charlie Yang | Licensing Program Analyst | Conducted the inspection and signed the report |
| Liza King | Licensing Program Manager | Named as supervisor and licensing program manager |
Inspection Report
Follow-Up
Census: 89
Capacity: 136
Deficiencies: 1
Feb 6, 2025
Visit Reason
Unannounced case management visit conducted to follow up on a substantiated allegation from a prior complaint investigation regarding failure to provide care and supervision.
Findings
The Department determined that the facility failed to monitor a resident (R1), resulting in serious bodily injury requiring hospitalization and rehabilitation. A civil penalty of $9,500 was issued in addition to a prior immediate penalty of $500.
Complaint Details
The visit was a follow-up to a substantiated complaint investigation concluded on January 17, 2024, which found the facility failed to provide care and supervision to Resident (R1). The complaint was substantiated and resulted in an immediate civil penalty and further penalties for serious bodily injury.
Deficiencies (1)
| Description |
|---|
| Failure to monitor Resident (R1) to ensure their general health, safety, and well-being, resulting in serious bodily injury. |
Report Facts
Civil penalty amount: 9500
Immediate civil penalty amount: 500
Facility capacity: 136
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Facility designated Administrator met during inspection and named in findings |
| Charlie Yang | Licensing Program Analyst | Conducted the inspection visit |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager in report |
Inspection Report
Plan of Correction
Census: 93
Capacity: 136
Deficiencies: 1
Dec 23, 2024
Visit Reason
Unannounced Plan of Correction visit conducted to follow up on deficiencies cited from a prior complaint visit on 2024-12-12 and to verify the Plan of Correction that was due.
Findings
No further deficiencies were observed or cited during this Plan of Correction visit. The previously cited deficiency related to staffing sufficiency and competency was addressed and cleared.
Complaint Details
The visit was a follow-up on deficiencies cited from a prior complaint visit conducted on 2024-12-12.
Deficiencies (1)
| Description |
|---|
| Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs, including sufficient support staff for personal assistance, care, and other facility operations. |
Report Facts
Census: 93
Total Capacity: 136
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Facility Administrator | Met with Licensing Program Analyst during the Plan of Correction visit. |
| Charlie Yang | Licensing Program Analyst | Conducted the Plan of Correction visit. |
| Liza King | Licensing Program Manager | Named in the exit interview. |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 136
Deficiencies: 0
Dec 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate an allegation that the licensee does not ensure enough staff are present to prevent inappropriate interaction between residents.
Findings
The investigation found that residents R1 and R2, both with cognitive impairments, had a mutual, non-forced relationship seeking comfort from each other. The allegation was found to be unsubstantiated with no deficiencies observed or cited.
Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.
Report Facts
Capacity: 136
Census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Facility designated Administrator met during the investigation |
| Charlie Yang | Licensing Program Analyst | Investigator who conducted the complaint visit |
| Liza King | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Plan of Correction
Census: 93
Capacity: 136
Deficiencies: 3
Dec 12, 2024
Visit Reason
Unannounced Plan of Correction visit to follow up on deficiencies cited from a prior annual visit conducted on 2024-10-17 and to verify the Plan of Correction that was due.
Findings
No further deficiencies were observed or cited during the Plan of Correction visit. The previously cited deficiencies related to staffing with CPR training, medication administration per physician orders, and resident record documentation were addressed.
Deficiencies (3)
| Description |
|---|
| The facility shall employ and schedule sufficient staff to ensure at least one staff member with CPR and first aid training is on duty at all times. |
| Facility staff designated by the licensee shall assist residents with self-administration of nonprescription PRN medication according to physician's written orders. |
| Each resident's record shall contain required information. |
Report Facts
Census: 93
Total Capacity: 136
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Facility designated Administrator met during the visit and involved in interview |
| Charlie Yang | Licensing Program Analyst | Conducted the Plan of Correction visit |
| Liza King | Licensing Program Manager | Named in exit interview |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 136
Deficiencies: 0
Dec 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations regarding improper isolation of residents, lack of toiletries in restrooms, and inadequate facility cleanliness and sanitation.
Findings
The investigation found the allegations to be unsubstantiated with no deficiencies observed or cited. The facility had adequate supplies in restrooms and appropriate infection control policies and staff training were in place.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 136
Census: 93
Training hours: 41
PPE and Infection Control training hours: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Facility designated Administrator met during the investigation |
| Charlie Yang | Licensing Program Analyst | Investigator who conducted the complaint visit |
| Liza King | Licensing Program Manager | Manager overseeing the licensing program |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 136
Deficiencies: 1
Dec 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations regarding staff training, medication administration, timely medication ordering, and staff retaliation against residents.
Findings
The investigation found the allegations of inadequate staff training, medication administration errors, untimely medication ordering, and staff retaliation to be unsubstantiated except for the allegation that there were not enough staff to provide care and supervision, which was substantiated. The facility was found deficient in staffing levels posing an immediate threat to resident health and safety.
Complaint Details
The complaint investigation was triggered by allegations received on 09/25/2024 concerning inadequate staff training, medication administration errors, untimely medication ordering, staff retaliation, and insufficient staffing. The allegation of insufficient staffing was substantiated, while the others were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This facility did not maintain adequate staffing for all shifts at all times. | Type A |
Report Facts
Facility census: 93
Total capacity: 136
Total facility personnel: 30
Caregivers: 24
Medication Technicians: 6
Training hours: 41
PPE and Infection Control training hours: 2
Residents self-managing medications: 29
Caregivers on AM shift: 11
Caregivers on PM shift: 10
Caregivers on NOC shift: 4
Medication Technicians on AM shift: 4
Medication Technicians on PM shift: 3
Medication Technicians on NOC shift: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Facility designated Administrator met during the investigation |
| Charlie Yang | Licensing Program Analyst | Investigator who conducted the complaint visit |
| Liza King | Licensing Program Manager | Manager overseeing the licensing program |
Inspection Report
Annual Inspection
Census: 96
Capacity: 136
Deficiencies: 3
Oct 17, 2024
Visit Reason
Unannounced annual visit conducted on 10/17/2024 to evaluate compliance with licensing requirements and facility operations.
Findings
The inspection found deficiencies related to staff training in First Aid, incomplete narcotic medication documentation, and missing required forms in resident files. Plans of correction were submitted with due dates for compliance.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Three out of ten facility personnel files did not have updated First Aid Training. | Type A |
| Narcotic counts were incomplete and documentation errors were found for medication dispensing days. | Type A |
| All ten resident files were missing required forms and documents. | Type B |
Report Facts
Residents under hospice care: 6
Residents receiving home health services: 10
Hospice waiver capacity: 15
Personnel files reviewed: 10
Resident files reviewed: 10
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Facility designated Administrator mentioned in relation to inspection and certification |
| Asha Prasad | Business Office Director | Facility designated representative met during inspection and involved in exit interview |
| Charlie Yang | Licensing Program Analyst | Conducted the inspection and authored the report |
| Liza King | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Monitoring
Census: 96
Capacity: 136
Deficiencies: 0
Oct 17, 2024
Visit Reason
Unannounced case management visit conducted to follow up on quarterly visits required since the last visit on 2024-07-25, monitoring compliance with staffing, medication errors, audits, reporting, training, and facility policies.
Findings
The visit found that all required items were monitored and maintained in compliance. A medication error was reported by the facility, a medication audit was completed, incident reports were received, and facility policies were provided. The case management visit was conducted in conjunction with the required annual visit, with all deficiencies addressed and cited on the annual LIC 809-D.
Report Facts
Census: 96
Total Capacity: 136
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Asha Prasad | Business Office Director | Met and interviewed during the visit |
| Charlie Yang | Licensing Program Analyst | Conducted the inspection visit |
| Liza King | Licensing Program Manager | Named in exit interview |
Inspection Report
Routine
Census: 98
Capacity: 136
Deficiencies: 3
Jul 25, 2024
Visit Reason
The visit was an unannounced case management quarterly visit to follow up on staffing concerns, medication errors, medication audit, reporting requirements, medication training, and facility policies regarding assessments, monitoring of residents, change in condition, and medication errors.
Findings
The inspection found that Resident 1 was administered the wrong dosage of Metoprolol from June 6, 2024, to July 9, 2024, with missing medication administration record signatures and no caregiver notes. Resident 2's assessments were not updated to reflect significant health changes, including wound care needs. Deficiencies were cited related to medication administration and assessment documentation, posing immediate and potential health and safety risks.
Severity Breakdown
Type A: 1
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Resident 1 was administered the wrong Metoprolol dosage from 06/06/24 to 07/09/2024, posing an immediate health and safety risk. | Type A |
| Medication Administration Records (MARs) for Metoprolol on Feb 07, May 23, and May 25, 2024, were missing staff signatures, posing a potential health and safety risk. | Type B |
| Resident 2's assessments were not maintained, did not document significant health changes, and were not signed by responsible parties, posing an immediate health and safety risk. | Type B |
Report Facts
Civil penalty amount: 1000
Capacity: 136
Census: 98
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Liza King | Licensing Program Manager | Supervisor overseeing the inspection. |
| Andrea Armstrong | Administrator | Facility administrator met during the inspection. |
Inspection Report
Census: 98
Capacity: 136
Deficiencies: 0
Jul 23, 2024
Visit Reason
The visit was an unannounced case management quarterly visit to follow up on staffing concerns, medication errors, medication audit, reporting requirements, medication training, and facility policies regarding assessments and monitoring of residents.
Findings
No deficiencies were cited at the time of the visit. The Licensing Program Analyst reviewed seven resident files and conducted interviews related to medication errors and will follow up on these files at a later time.
Report Facts
Resident files reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Facility administrator met during the inspection |
| Avelina Martinez | Licensing Program Analyst | Conducted the case management visit and follow-up |
| Liza King | Licensing Program Manager | Named in report signature section |
Inspection Report
Census: 98
Capacity: 136
Deficiencies: 0
Jul 23, 2024
Visit Reason
An unannounced post continuation required inspection was conducted to ensure compliance with Title 22 regulations.
Findings
The Licensing Program Analyst inspected the physical plant and conducted staff interviews. No deficiencies were cited during this continuation post licensing visit.
Report Facts
Hospice waiver approved: 15
Bedridden capacity: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the inspection and staff interviews |
| Andrea Armstrong | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Original Licensing
Census: 92
Capacity: 136
Deficiencies: 4
Jun 3, 2024
Visit Reason
An unannounced post licensing inspection visit was conducted to ensure compliance with Title 22 regulations and to complete the post licensing visit process.
Findings
The facility was found not in compliance with Title 22 regulations due to deficiencies including lack of first aid training for staff, failure to conduct required fire drills, and medication administration errors involving morphine sulfate. Plans of correction were required for these deficiencies.
Severity Breakdown
Type A: 2
Type B: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Four out of five staff did not have first aid training by a qualified agency. | Type B |
| The last fire drill was conducted on 12/29/2023, which is not within the required three-month interval. | Type B |
| Facility staff did not follow resident's morphine orders; medication was not administered as noted on the controlled drug record and MAR. | Type A |
| A med-tech signed off on morphine administration when it was not administered, resulting in medication being unaccounted for and controlled medication count being off. | Type A |
Report Facts
Capacity: 136
Census: 92
Plan of Correction Due Date: Jun 17, 2024
Plan of Correction Due Date: Jun 10, 2024
Plan of Correction Due Date: Jul 3, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the inspection and medication audit |
| Liza King | Licensing Program Manager | Supervisor and Licensing Program Manager overseeing the inspection |
| Andrea Armstrong | Administrator/Director | Facility Administrator holding current certificate |
| Asha Prasad | Facility representative met during inspection and toured facility |
Inspection Report
Follow-Up
Census: 96
Capacity: 136
Deficiencies: 0
Apr 26, 2024
Visit Reason
The visit was an unannounced case management follow-up to review incident reports involving falls with injuries received on February 7, 2024 and February 24, 2024.
Findings
No deficiencies were cited during this visit. The Licensing Program Analyst requested documentation related to the incidents for further review and will follow up at a later date.
Report Facts
Incident report dates: Incidents occurred on February 7, 2024 and February 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Facility Administrator | Met with Licensing Program Analyst during the visit |
| Avelina Martinez | Licensing Program Analyst | Conducted the case management visit |
| Liza King | Licensing Program Manager | Named in the report header |
Inspection Report
Census: 87
Capacity: 136
Deficiencies: 0
Mar 25, 2024
Visit Reason
The visit was an Informal Non-Compliance Conference (NCC) conducted due to legal/non-compliance issues including complaint investigations, medication errors, staffing concerns, and reporting requirements.
Findings
No deficiencies were cited at this visit. The facility has been cited six times in the past year with four A citations and two B citations related to care and supervision, incidental reporting, and medical issues. The facility agreed to submit documentation and updated policies by 03/29/2024 to achieve continued compliance.
Complaint Details
Complaint Number 27-AS-20231107162650 regarding Lack of Care and Supervision was discussed during the Non-Compliance Conference.
Report Facts
Citations in last year: 6
Capacity: 136
Census: 87
Deadline for submissions: Mar 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Facility representative present at the Non-Compliance Conference |
| Liza King | Licensing Program Manager | Licensing Program Manager present and signed the report |
| Avelina Martinez | Licensing Program Analyst | Licensing Program Analyst present and signed the report |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 136
Deficiencies: 1
Mar 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-12-15 regarding medication administration, care and supervision, and adherence to resident's signed admission agreement.
Findings
The investigation substantiated that the facility failed to administer medications to resident 1 (R1), posing an immediate health and safety risk, resulting in a $1,000 civil penalty. The allegation that the facility failed to provide care and supervision was unsubstantiated due to lack of evidence. The complaint that the facility did not adhere to the resident's signed admission agreement was found to be unfounded.
Complaint Details
The complaint investigation was substantiated for failure to administer medications to resident 1, resulting in a civil penalty of $1,000. The allegation of failure to provide care and supervision was unsubstantiated. The allegation regarding non-adherence to the signed admission agreement was unfounded.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not ensure staff were administering medications to resident 1, posing an immediate health and safety risk. | Type A |
Report Facts
Civil penalty amount: 1000
Refund amount: 2292.92
Medication management acuity points: 30
Billable points: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Andrea Armstrong | Administrator | Facility administrator met with Licensing Program Analyst during the investigation. |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Follow-Up
Census: 85
Capacity: 136
Deficiencies: 3
Jan 17, 2024
Visit Reason
The visit was an unannounced case management follow-up to address deficiencies learned during a prior complaint investigation related to medication administration and reporting requirements.
Findings
The facility failed to properly administer medications to residents R1, R2, and R3, including missed doses and administration of wrong medications. Additionally, the facility did not submit required incident reports related to medication errors and did not maintain medication administration records (MARs) properly, posing immediate and potential health and safety risks.
Complaint Details
The follow-up visit was triggered by a complaint investigation (27-AS-20231114094113) which revealed missing Hydrocodone tablets for resident R1, missed medication doses in November 2023, and administration of wrong medications to residents R2 and R3. The complaint investigation substantiated deficiencies in medication administration and reporting.
Severity Breakdown
Type A: 1
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as needed, resulting in missed and incorrect medication administration to residents R1, R2, and R3. | Type A |
| Failure to maintain medication administration records (MARs) for residents R1, R2, and R3. | Type B |
| Failure to submit required incident reports related to medication errors, posing a potential health and safety risk to resident R1. | Type B |
Report Facts
Medication tablets missing: 1
Medication prescription tablets: 112
Census: 85
Total capacity: 136
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Armstrong | Administrator | Met with Licensing Program Analyst during the visit |
| Avelina Martinez | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Liza King | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 136
Deficiencies: 2
Jan 17, 2024
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2023-11-07 regarding alleged failure to provide care and supervision and failure to seek timely medical care for a resident.
Findings
The investigation substantiated that Resident 1 (R1) was found on the floor for an undetermined amount of time with injuries due to lack of monitoring and timely medical attention. The facility was short staffed during the AM shift and failed to provide basic care services, posing an immediate health and safety risk to R1. Another allegation regarding failure to provide care as identified on the care plan was unsubstantiated.
Complaint Details
The complaint was substantiated based on evidence that the facility failed to provide care and supervision and failed to seek timely medical care for Resident 1, who was found on the floor with injuries after being unmonitored for hours. The allegation that the facility failed to provide care as identified on the care plan was unsubstantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not ensure R1 was monitored daily, resulting in R1 being found on the ground unable to get up for hours due to lack of monitoring/basic services. | Type A |
| Facility failed to immediately telephone 9-1-1 after an injury or circumstance resulting in an imminent threat to R1's health. | Request Denied Type A |
Report Facts
Civil penalty: 500
Capacity: 136
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Eugenia Smith | Administrator | Named as facility administrator during investigation. |
| Andrea Armstrong | Facility representative met with Licensing Program Analyst during investigation. | |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 136
Deficiencies: 0
Jan 17, 2024
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations including staff stealing resident's medication and the facility charging visitors for liquor.
Findings
The investigation found no missing controlled medication during the audit and no evidence that staff were stealing medication. The facility was incorrectly charging a resident for a meal not ordered but was reviewing and would reimburse if needed. There was no evidence that the resident was charged for alcoholic beverages, and the admission agreement allowed alcohol purchase. The allegations were unsubstantiated due to insufficient evidence.
Complaint Details
Complaint investigation was unsubstantiated. Allegations included staff stealing medication and improper charges for liquor. Evidence did not support the allegations.
Report Facts
Controlled drug administration records reviewed: 8
Capacity: 136
Census: 85
Incorrect charge amount: 12.93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Avelina Martinez | Licensing Program Analyst | Conducted the complaint investigation and audit |
| Eugenia Smith | Administrator | Facility administrator involved in review of incorrect charges |
| Andrea Armstrong | Facility staff met with during the investigation | |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Original Licensing
Census: 88
Capacity: 136
Deficiencies: 0
Oct 4, 2023
Visit Reason
An announced pre-licensing visit was conducted to evaluate the facility for licensure.
Findings
The facility was found to be in good condition with no objections to licensure at this time. Observations included proper medication storage, no obstruction of emergency exits, and appropriate food storage.
Report Facts
Residents receiving hospice services: 7
Ambulatory residents: 76
Non-ambulatory residents: 12
Bedridden residents: 0
Hot water temperature: 108
Hot water temperature: 107
Refrigerator temperature: 39
Freezer temperature: -2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Campbell | Licensing Program Analyst | Conducted the pre-licensing visit and observations |
| Victoria Brown | Licensing Program Analyst | Conducted the pre-licensing visit and observations |
| Andrea Armstrong | Administrator | Accompanied the licensing analysts during the facility tour |
| Terry Evans | Vice President of Operations | Representative for applicant Oakmont Senior Living of Lodi, OPCO LLC; Oakmont MG LLC |
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