Inspection Reports for Sequoia Springs Senior Living

The inspection was an unannounced Required-1 Year annual inspection to evaluate compliance with licensing requirements and ensure the health and safety of residents.

The facility was generally found to be in good condition with no immediate health or safety violations observed during the tour. However, deficiencies were cited related to staff training, medication administration errors, and improper medication storage practices.

An unannounced complaint investigation was conducted following a complaint received on 2025-08-01 regarding personal rights violations at the facility.

The investigation substantiated that the facility did not accept a resident back after hospital discharge, violating state laws protecting residents from involuntary transfers and discharges. The resident returned to the facility later receiving hospice care.

The complaint was substantiated based on the preponderance of evidence standard. The allegation involved personal rights violations related to refusal to accept a resident back after hospital discharge.

An unannounced complaint investigation was conducted based on a complaint received on 2025-07-31 alleging that facility staff did not dispense medications as prescribed and did not maintain accurate resident records.

The investigation substantiated that the facility staff failed to start a prescribed antibiotic medication on the correct date, resulting in a delay from 07/19/2025 to 07/21/2025. Another allegation regarding inaccurate resident records was found unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for failure to dispense medications as prescribed, specifically a delay in starting antibiotics for a resident. The allegation regarding inaccurate resident records was unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations including the administrator not responding timely to resident concerns and failure to report a resident fall.

The investigation substantiated that the administrator did not respond in writing to resident council concerns since January 2025, violating Health and Safety Code 1569.157. Another allegation regarding failure to report a resident fall was found unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was substantiated for the allegation that the administrator did not respond timely to resident concerns. The allegation that the facility did not report a resident fall was unsubstantiated.

The visit was an unannounced case management inspection conducted to review incident reports submitted by the facility regarding residents observed outside the facility without proper supervision.

The inspection found that the facility did not ensure the front exit door was monitored, posing an immediate health, safety, or personal rights risk to residents. Deficiencies were cited related to the lack of auditory or staff alert devices to monitor exits accessible to residents at risk for elopement.

The visit was triggered by incident reports of residents observed walking towards the grocery store without proper supervision, requiring staff intervention to return them safely to the facility.

An unannounced complaint investigation was conducted in response to an allegation that staff allowed a minor to administer medications at the facility.

The investigation found that children often participate in activities during summer months under supervision, but there was no evidence that children assisted with medications or activities of daily living. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff allowed a minor to administer medications. The allegation was investigated and found to be unsubstantiated.

An unannounced complaint investigation was conducted based on a complaint received on 07/22/2025 regarding allegations including the facility not allowing resident visitors, blocking a fire exit, and not following the menu.

The investigation substantiated the allegation that the facility prevented residents from having visitors of their choosing without prior notice, violating Health and Safety code. Other allegations regarding blocking a fire exit and menu compliance were found unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was substantiated for the allegation that the facility was not allowing resident visitors. The other allegations about blocking a fire exit and not following the menu were unsubstantiated.

An unannounced complaint investigation was conducted due to allegations that staff did not ensure the facility's alert system was properly operating and did not timely respond to residents' alerts.

The investigation found that the facility's call system was not fully operational; calls were received at the front desk but did not directly notify caregivers. After-hours response times often exceeded 20 minutes, posing a potential health and safety risk to residents.

The complaint was substantiated. Allegations included failure to ensure the alert system was properly operating and failure to timely respond to resident alerts.

The visit was an unannounced case management inspection conducted in response to an incident report submitted by the facility regarding a resident found outside the building with an unlocked door and disabled door alarm.

The inspection found that the door alarm had been left turned off by kitchen staff the day prior, allowing a resident to exit unsupervised. The facility updated procedures to ensure exit alarms are monitored and operational. No citations were issued during the visit.

The visit was an unannounced case management inspection conducted due to recent management changes at the facility.

The Licensing Program Analyst met with the new Executive Director Alma Peralta to discuss reporting requirements and management changes. No citations or deficiencies were issued during this visit.

An unannounced complaint investigation was conducted following a complaint received on 2025-01-17 regarding the licensee's failure to issue a refund to a resident's responsible party in a timely manner.

The investigation found that the licensee did not issue a refund to the resident's responsible party within the 15-day timeframe required by Title 22 regulation and the Health and Safety Code after the resident's personal belongings were removed. The allegation was substantiated.

The complaint was substantiated based on the preponderance of evidence standard. The licensee failed to issue a refund to the resident's responsible party within the required timeframe after the resident's passing and removal of personal belongings.

The visit was an unannounced case management inspection conducted due to a report that the facility was having difficulty acquiring food items and was unable to report incidents as required.

The Licensing Program Analyst found that the facility had not had access to their computer records system since January 1 due to a new management company takeover. Handwritten documentation was being used for medications and incident reports. The facility food stores were within regulation, and food was being purchased locally while securing food vendors. No citations were issued during this inspection.

An unannounced complaint investigation was conducted following a complaint received on 2024-12-17 regarding staff behavior and handling of resident pendants.

The investigation found no preponderance of evidence to substantiate the allegations that staff made inappropriate comments or mishandled resident pendants. One incident involved a pendant being left off a resident for approximately 4 hours without issues.

The complaint involved allegations that staff made inappropriate comments regarding a resident and mishandled residents' pendants. The investigation was unsubstantiated due to lack of evidence.

The inspection was an unannounced Required-1 Year inspection conducted to ensure the health and safety of residents in care and to follow up on a previously reported incident involving medication errors.

The facility was generally found to be clean, well-maintained, and compliant with health and safety standards, with no immediate violations observed. However, deficiencies were noted related to medication administration errors and incomplete staff training documentation.

The inspection included a follow-up on an incident report submitted on 10/30/2024 regarding two medication errors that occurred on 10/24/2024 and 10/25/2024. Staff misread medication orders, and an investigation was conducted with staff retraining. This was a repeat violation within 12 months. An immediate civil penalty of $1000 was issued.

The visit was an unannounced case management follow-up to amend a prior complaint investigation regarding allegations that staff were restricting residents' access.

The complaint investigation found no evidence that staff restricted access to residents, but identified a safety issue where a new emergency gate code was changed without timely notification to staff or the Fire Department, posing an immediate safety risk. The code was subsequently changed again and all relevant parties were informed.

The visit was related to a complaint alleging staff restricted access to residents. The allegation was not substantiated, but a related safety issue was identified.

The inspection was an unannounced case management visit conducted in response to several unusual incident reports submitted by the facility, including medication errors and residents leaving the facility without staff assistance.

The inspection found repeated medication errors involving residents receiving incorrect medications or dosages, and incidents of residents wandering off or leaving the facility without staff knowledge. Immediate civil penalties were issued for repeated violations and deficiencies were cited related to medication assistance and resident safety.

The visit was complaint-related due to reports of medication errors and residents leaving the facility without staff assistance. It was noted this was the third violation in a 12-month period, resulting in an immediate civil penalty of $1000.

An unannounced complaint investigation was conducted in response to an allegation that facility staff failed to meet residents' care needs.

The investigation found a resident with feces on their body, a swollen ankle, and bruising on their eye. Emergency personnel were contacted and the resident was taken to the hospital. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint was unsubstantiated after investigation. The allegation was that facility staff failed to meet residents' care needs, but there was insufficient evidence to prove the violation occurred.

An unannounced complaint investigation was conducted in response to allegations that staff did not seek timely medical attention for a resident, made unauthorized changes to a resident's medical needs, and did not provide adequate care and supervision to residents.

The investigation found that a resident was found on the floor and emergency personnel were contacted immediately. The resident was hospitalized and returned under hospice care with updated care plans. There was insufficient evidence to substantiate the allegations, and therefore the complaint was unsubstantiated.

The complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.

An unannounced complaint investigation was conducted in response to allegations that staff were restricting access to residents and that staff did not have planned activities for the residents.

The investigation found that the courtyard gate in the memory care section was locked with a keypad lock to prevent casual use by staff, with the fire department having emergency access. The facility has an activity schedule and observed activities being conducted. There was no preponderance of evidence to substantiate the allegations, so they were deemed unsubstantiated.

The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.

An unannounced complaint investigation was conducted in response to allegations that the facility failed to meet a resident's care needs and failed to observe and report changes in the resident's condition.

The investigation found no evidence to support the allegations. Records showed the resident was able to manage their own needs with assistance only for bathing, and the facility documented changes in the resident's condition and notified the responsible party. The allegations were determined to be unsubstantiated.

The complaint was unsubstantiated based on records and interviews. Although the allegations may have occurred, there was not a preponderance of evidence to prove violations.

An unannounced complaint investigation was conducted in response to allegations received on 2024-05-06 regarding inadequate care, supervision, and lack of a qualified administrator at the facility.

The investigation found that residents have the right to walk freely and staff were aware of resident locations and able to redirect them. The facility administrator position was vacant for about 30 days but oversight was maintained by corporate management and department heads. All staff had received emergency disaster plan training. The allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations including staff leaving feces-soiled linens in a resident's room for over a week and the facility being in disrepair.

The investigation substantiated that the facility did not ensure laundry was done in a timely manner, with resident laundry sometimes not completed for more than two weeks. The facility windows were found to be in disrepair, with many not operational or not closing properly. Other allegations related to oxygen use and care plan documentation were unsubstantiated.

The complaint investigation was substantiated for allegations related to laundry service delays and facility disrepair. Other allegations regarding portable oxygen and care plan documentation were unsubstantiated.

An unannounced complaint investigation visit was conducted in response to allegations received on 2024-02-05 regarding staff training, infection control, and facility disrepair.

The investigation found that the facility had documentation of required staff training, was following its infection control plan with proper precautions, and was not in disrepair. The allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations regarding staff training, infection control, and facility condition.

An unannounced complaint investigation was conducted due to an allegation that resident medication was not administered per regulation.

The investigation found that a resident did not receive medication as ordered because the medication was out of stock and the facility lacked a written procedure to ensure oversight for re-ordering medications. The allegation was substantiated and a repeat violation was noted with a civil penalty issued.

The complaint was substantiated based on the preponderance of evidence standard. The facility failed to administer medication as ordered and lacked procedures for medication re-ordering. A civil penalty of $250.00 was issued.

An unannounced complaint investigation was conducted in response to allegations that the facility failed to manage medication as prescribed by a physician and that staff did not meet residents' care needs.

The investigation substantiated that the facility failed to manage medications properly, including not having medications on hand and not reordering them timely, posing an immediate health risk. Additionally, the facility did not meet residents' care needs, including lack of showering and laundry assistance as outlined in care plans.

The complaint investigation was substantiated. Allegations included failure to manage medication as prescribed and failure to meet residents' care needs. An immediate civil penalty of $250 was issued for repeat medication management violations within 12 months.

Unannounced investigation of a complaint received on 2024-02-05 regarding facility mismanagement of medications and unmet resident care needs.

The investigation found that the facility did not reorder medications causing residents to be without needed medication, and residents did not receive showering or laundry assistance as outlined in care plans and admission agreements. These allegations were substantiated and citations issued.

Complaint investigation was substantiated regarding medication mismanagement and unmet resident care needs.

The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was not receiving wound care as needed.

The investigation found that the facility failed to follow up on physician orders to provide wound care, resulting in the resident's wound worsening and requiring hospitalization and surgery. Other allegations regarding hygiene care and transportation assistance were unsubstantiated due to lack of evidence.

The complaint was substantiated regarding failure to provide wound care, but unsubstantiated regarding failure to provide hygiene care and transportation assistance.

An unannounced complaint investigation was conducted in response to an allegation that the facility was incorrectly charging a resident for a pet they do not have at the facility.

The investigation found that the facility made a one-time billing error by charging a resident an additional sum of money, but the error was caught and refunded. The complaint was determined to be unfounded as the facility is not charging residents for pets.

The complaint was found to be unfounded, meaning the allegation was false, could not have happened, and/or was without a reasonable basis.

An unannounced complaint investigation was conducted in response to allegations that the facility is in disrepair.

The investigation found that several outside lights were not operational in August 2023 but were repaired by December 2023. Resident Council meeting notes did not reference lighting issues. The allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint was unsubstantiated after investigation. The facility was aware of lighting issues and took steps to repair them, but there was insufficient evidence to prove the alleged violations occurred.

An unannounced complaint investigation was conducted in response to allegations received on 2023-10-05 regarding staff not following the Power of Attorney, isolating a resident, lack of communication with the resident's responsible party, failure to transport resident to medical appointments, restricting visits, not providing admission agreements, and overcharging.

The investigation found that the resident was their own responsible party, was not isolated, and was free to move about. The facility provided transportation when needed, respected visitation preferences, provided admission agreements, and did not overcharge. The complaint was determined to be unsubstantiated as there was no preponderance of evidence to prove the allegations.

The complaint investigation was unsubstantiated, meaning the allegations were false, could not have happened, or lacked reasonable basis.

The visit was an unannounced continuation of the annual required inspection conducted on 11/20/2023 to evaluate compliance with regulations.

The facility was found to have current medication and physician orders, adequate staffing, and implemented a new procedure for monthly emergency drills. However, a deficiency was cited for failure to document completed emergency drills as required by regulation.

An unannounced annual required inspection of the licensed senior care facility was conducted to evaluate compliance with regulatory standards.

The facility was found to be clean and in good repair with proper safety measures in place, including unobstructed exits, proper storage of toxins, and functioning fire safety equipment. However, 3 of 5 staff records reviewed did not contain documentation of completed training hours as required, and the facility lacked documentation of completed disaster drills. Resident files could not be reviewed due to a computer system issue, requiring a return visit.

The visit was an unannounced office meeting to discuss possible financial concerns with the facility, including requests for current lease agreements, management/operating agreements, and staffing plans related to vacancies.

The report documents a meeting involving multiple management and council representatives to address financial concerns at the facility. No specific deficiencies or violations are detailed in the report.

The inspection was an unannounced Health and Safety inspection conducted to ensure the facility is staffed appropriately, staff are being paid, utilities are functioning, and food is plentiful. The visit was prompted by information that the licensee might be experiencing financial hardships.

No immediate health and safety concerns were observed during the visit. The facility had required amounts of food stored properly, utilities were functioning except for a non-operational exhaust fan above the stove which is scheduled for repair. No issues with staff paychecks were reported. Work on earthquake-damaged areas was ongoing.

An unannounced complaint investigation was conducted in response to an allegation of unlawful eviction at Sequoia Springs Senior Living Community.

The investigation found that the facility did not update care plans or staffing levels to address resident behaviors and failed to notify the resident's responsible party of incidents. The eviction notice lacked required information regarding the resident's right to contest the eviction and did not include the effective date of eviction. The allegation was substantiated and the eviction was rescinded.

The complaint investigation was substantiated based on the preponderance of evidence standard. The allegation involved unlawful eviction and failure to comply with eviction notice regulations.

An unannounced complaint investigation was conducted following allegations including inadequate supervision resulting in resident altercations, failure to follow reporting requirements, and a dementia resident having access to a lighter.

The investigation substantiated that staff did not provide adequate supervision to prevent a resident from hitting another, the facility failed to notify the responsible party and local Ombudsman of incidents, and a dementia resident had access to a lighter. Some allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was substantiated. Allegations included inadequate supervision leading to resident altercations, failure to follow reporting requirements, and a dementia resident having access to a lighter. The facility failed to notify the local Ombudsman and responsible party of incidents due to sending information to a wrong fax number and other notification lapses.

The visit was an office meeting held to discuss areas of concern with the operation of the facility, including staffing, reporting requirements, resident care plans, and staff training regarding resident behaviors.

The report notes that the Administrator on record is no longer with the company and requests submission of documentation for a new Administrator and the facility's entire Plan of Operation by 09/29/2023. The Technical Support Program was discussed and offered, with agreement from the Executive Director and Executive Nurse.

An unannounced complaint investigation was conducted in response to a complaint received on 07/06/2023 regarding insufficient staffing at the facility.

The investigation found that staffing levels were insufficient to meet resident needs, including memory care shifts with only one staff member scheduled. The allegation of insufficient staffing was substantiated, posing an immediate health, safety, or personal rights risk to residents.

The complaint was substantiated based on the preponderance of evidence standard after review of care plans, staffing schedules, and interviews. The allegation was insufficient staffing.

An unannounced complaint investigation was conducted in response to allegations received on 07/07/2023 regarding resident care concerns including unattended residents in wet clothing, facility malodor, and failure to meet residents' needs.

The investigation found that residents are regularly checked for wet clothing and additional cleanings are provided for resistant residents. The facility updated care plans as needed. There was insufficient evidence to substantiate the allegations, and the complaint was determined to be unsubstantiated.

The complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.

The inspection visit was conducted as a complaint investigation to assess the safety and security of the facility, specifically regarding access to potentially hazardous substances and unsecured areas.

The Licensing Program Analyst observed unsecured access to the laundry area containing toxic substances such as laundry detergent accessible to residents, as well as unsecured activities office and materials. These conditions posed an immediate health and safety risk to residents.

The visit was complaint-related and involved observations of unsecured toxic substances and unsecured areas accessible to residents. The report does not explicitly state substantiation status.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 07/06/2023 regarding failure to protect residents, unmet resident needs, and facility cleanliness and disrepair.

The investigation substantiated multiple allegations including failure to update care plans and staffing after resident assaults, failure to administer physician-ordered medication for three consecutive days, and facility cleanliness and maintenance issues such as dirty carpets and flaking ceiling paint. Some allegations related to facility construction impacting resident activities were unsubstantiated.

The complaint investigation was substantiated. Allegations included failure to protect residents, unmet resident needs, and facility disrepair. The investigation found evidence supporting these allegations, including repeated resident assaults without care plan updates, medication errors, and facility maintenance issues.

The visit was an unannounced case management visit conducted by the Licensing Program Analyst to review records and discuss regulations regarding background checks and resident councils.

No citations were issued during this visit. The Licensing Program Analyst requested submission of specific documents including LIC 500, staff schedules for June, and actual worked staff hours for June by 07/17/2023.

The inspection was an unannounced complaint investigation visit triggered by allegations including the facility not answering the phone after hours and concerns about resident grooming, linen provision, room cleanliness, kitchen floor cleanliness, and safeguarding of personal belongings.

The allegation that the facility does not answer the phone after hours was substantiated, with evidence showing the cordless phone for after-hours calls was not working, posing a potential risk to residents. Other allegations regarding grooming, linen, room cleanliness, kitchen floor cleanliness, and safeguarding personal belongings were investigated but found unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was substantiated for the allegation that the facility does not answer the phone after hours. Other allegations related to resident grooming, linen provision, room cleanliness, kitchen floor cleanliness, and safeguarding personal belongings were unsubstantiated.

An unannounced complaint investigation was conducted in response to allegations that facility staff were not meeting the care needs of residents and were not serving residents food in a timely manner.

The Licensing Program Analyst found no evidence to support that meals were served late and interviews did not support the allegations. There was not a preponderance of evidence to prove the alleged violations occurred, therefore the allegations were unsubstantiated.

The complaint investigation was unsubstantiated as there was insufficient evidence to prove the allegations that staff were not meeting care needs or serving food timely.

An unannounced complaint investigation was conducted regarding an allegation that staff used alcohol to persuade a resident while in care.

The investigation found that the resident was provided alcohol as part of an agreed celebration with their conservator, supported by a physician's order. Interviews and observations indicated the resident was not intoxicated and the alcohol was not used to weaken their resolve. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint alleged staff used alcohol to persuade a resident while in care. The allegation was unsubstantiated after investigation.

An unannounced complaint investigation was conducted in response to allegations that a resident eloped from the facility and that the facility failed to keep the building and grounds safe and sanitary.

The investigation found no preponderance of evidence to substantiate the allegations. Staff interviews and document reviews indicated residents were accompanied by staff when leaving the facility, and the facility promptly addressed damage from an earthquake and a broken sewer pipe.

The complaint was unsubstantiated based on the investigation findings and evidence reviewed.

An unannounced complaint investigation was conducted in response to allegations including a resident room without heat for 2 days and unlawful eviction.

The investigation found that the facility lost electrical power due to an earthquake, and the heating system was not supported by the emergency generator. Portable heaters and blankets were provided, and staff conducted frequent resident checks. Documentation regarding a waiver of in-room meal costs was missing, leading to an eviction notice that was later rescinded with a revised plan agreed upon. The allegations were unsubstantiated due to insufficient evidence.

The complaint investigation was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations did or did not occur.

The inspection was an unannounced complaint investigation visit triggered by an allegation of lack of supervision resulting in multiple falls at the facility.

The investigation found that Resident 1 had multiple falls from December through January without updated care plans or service appraisals for staff to follow. The allegation was substantiated based on the preponderance of evidence, indicating a failure to update resident appraisals and care plans, posing a potential health and safety risk.

The complaint was substantiated. The allegation was lack of supervision resulting in multiple falls. The investigation included record reviews and staff interviews, concluding that care plans and appraisals were not updated following multiple falls of Resident 1.

The inspection was an unannounced complaint investigation visit triggered by allegations including the facility operating without an Administrator, an uncleared adult working with residents, and inadequate feeding of residents.

The allegation that the facility was operating without an Administrator was substantiated due to the Administrator not being present a sufficient number of hours to ensure compliance. The allegation regarding an uncleared adult working was unsubstantiated as the individual was escorted at all times and did not provide care. The allegation that residents were not adequately fed was unsubstantiated as the kitchen closure was temporary and residents received appropriate meals.

The complaint investigation was substantiated for the allegation that the facility was operating without an Administrator present for sufficient hours. The allegations that an uncleared adult was allowed to work and that residents were not adequately fed were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff left a resident soiled for an extended period of time.

The investigation found no evidence to support the allegation that a resident was left soiled for an extended period. Interviews and record reviews indicated the resident was assisted multiple times during the night, and the allegations were determined to be unsubstantiated.

The complaint alleged that staff left a resident soiled for an extended period. The investigation was unannounced and conducted by Licensing Program Analyst Christopher Arnhold. Based on interviews and records, the allegation was unsubstantiated due to lack of evidence.

An unannounced investigation was conducted in response to a complaint alleging that staff did not keep residents' authorized persons informed about the resident's care.

The investigation found that residents were tested for COVID on 2022-12-16 and responsible parties were notified accordingly. Although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations occurred, and therefore the allegation was unsubstantiated.

The complaint was unsubstantiated based on the investigation findings.

An unannounced complaint investigation was conducted in response to an allegation that the facility failed to meet residents' care needs.

The investigation found that the facility met the needs of residents in care. Although incidents of a resident causing self-harm occurred, the facility followed physician orders and emergency protocols. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint was unsubstantiated after investigation. The allegation was that the facility failed to meet residents' care needs, but evidence did not prove violations occurred.

An unannounced annual required infection control inspection was conducted to evaluate the infection control procedures and practices of the facility.

The facility was found to be clean, with all exits free from obstruction, properly charged fire extinguishers, secure medications, and adequate PPE supplies. No deficiencies or citations were found during the inspection.

Unannounced complaint investigation visit conducted in response to allegations that staff did not provide timely assistance to residents, did not follow the food menu, and did not provide adequate food service, as well as an allegation that staff were not CPR trained to assist residents from choking.

The investigation found that staff did provide timely assistance to residents, the meal options were consistent with recommended dietary allowances, and the facility always had at least one staff person on duty with CPR and first aid training. The allegations were determined to be unsubstantiated with no citations issued.

The complaint was investigated and found to be unsubstantiated, meaning the allegations were false, could not have happened, or lacked reasonable basis.

The visit was an unannounced case management inspection conducted in response to an incident report submitted regarding a resident's skin tear and subsequent medical treatment.

The facility followed all required reporting procedures related to the incident, including notifying involved parties. No citations were issued.

The visit was triggered by a complaint/incident report about a resident who sustained a skin tear on 04/20/2022, had redness and swelling observed on 04/29/2022, was hospitalized on 05/03/2022, and returned to the facility on 05/09/2022. The facility's handling of the incident was reviewed and found compliant.

The inspection was an unannounced Annual Required infection control inspection focusing on the Infection Control procedures and practices of the facility.

The facility was found to be clean, with all exits free from obstruction, and proper storage of toxins and medications. Fire extinguishers were charged and inspected within the last 12 months. The facility had an approved Covid Mitigation plan and adequate PPE supplies. No deficiencies or citations were found during the inspection.

The visit was a case management inspection conducted due to an incident where a resident received medication that was not prescribed to them on 2020-05-27.

The Licensing Program Analyst met with the Executive Director, reviewed the incident, confirmed staff retraining and physician notification, and found the facility to be following regulations with no citations issued.

The incident involved a medication error where a resident received medication not prescribed. The staff involved no longer works at the facility. The facility retrained staff and notified the physician. Resident was placed on alert charting for observation. No citations were issued.

The visit was an unannounced complaint investigation conducted due to an allegation that the facility was refusing to take back residents from the hospital.

The investigation found that although the facility had been hesitant in the past to accept residents back from the hospital unless they were at baseline, currently the facility accepts residents back as long as they meet regulatory requirements. The allegation was determined to be unsubstantiated.

The complaint alleged that the facility was refusing to take back residents from the hospital. The allegation was unsubstantiated based on interviews and evidence gathered during the investigation.

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