Inspection Reports for The Commons at Union Ranch

The visit was an unannounced Plan of Correction (POC) follow-up conducted to verify correction of deficiencies cited during a prior annual inspection on 2025-07-07.

The facility completed the Plans of Correction and provided all required forms and documents. No further deficiencies were observed or cited during this Plan of Correction visit.

Unannounced annual inspection visit conducted to evaluate compliance with licensing requirements and facility operations.

The inspection found the facility generally compliant with licensing requirements but cited two Type B deficiencies related to maintenance and staff training. The kitchen cabinet drawers needed repair and a broken chair in the memory care courtyard posed a safety risk. Additionally, 2 of 7 personnel files lacked required training documentation.

This was an unannounced Plan of Correction visit to follow up on deficiencies cited from a prior complaint visit conducted on 2025-03-24. The visit was to verify the completion of the Plans of Correction that were due.

The facility completed the Plans of Correction and provided all required forms and documents. No further deficiencies were observed or cited during this Plan of Correction visit.

The visit was an unannounced case management follow-up to review several incidents, including death reports, recently submitted to the Community Care Licensing (CCL).

The hospice care involvement for two residents who passed away was confirmed, with responsible family and friends informed. No deficiencies were observed or cited during the visit.

Unannounced complaint investigation visit conducted due to allegations that staff did not transfer a resident properly and handled the resident in a rough manner.

The investigation found that two caregivers improperly assisted resident R1 during a transfer, prompting R1 to stand despite being unable to bear weight, resulting in a fall. One staff member pushed R1 onto the bed to prevent a fall to the floor. The complaint was substantiated with deficiencies cited related to improper transfer techniques.

The complaint was substantiated based on evidence that staff did not properly assist resident R1 during transfer, leading to a fall and improper handling. The allegation that staff handled the resident in a rough manner was found unsubstantiated.

The case management visit was conducted to follow up on several incidents, including death reports, that were recently submitted into the Community Care Licensing (CCL) system.

The visit found that three residents who passed away were under hospice care and that hospice agencies and responsible family members were informed. No deficiencies were observed or cited during the visit.

The case management visit was conducted to follow up and inquire about recent incident reports related to facility residents and their care.

The facility self-reported a medication error involving a resident's care and supervision. The facility addressed the issue by training and evaluating personnel responsible for medication handling and updating policies to prevent future errors. No deficiencies were observed or cited during the visit.

Unannounced Plan of Correction visit to follow up on deficiencies cited from a prior annual visit conducted on 07/17/2024 and to verify the Plans of Correction that were due.

The facility completed the Plans of Correction and provided all required forms and documents. No further deficiencies were observed or cited during this Plan of Correction visit.

The visit was an unannounced complaint investigation triggered by an allegation that staff mishandled a resident's medication while in care.

The investigation found no evidence to substantiate the allegation. Interviews and document reviews showed the resident did not have a history of missing or mishandled medications, and no deficiencies were cited during the visit.

The complaint alleged that staff mishandled a resident's medication. The investigation concluded the allegation was unsubstantiated due to lack of preponderance of evidence.

Unannounced annual inspection visit conducted to evaluate compliance with licensing requirements and facility operations.

The inspection identified deficiencies related to personnel health screening, incomplete resident records, and missing updated annual medical assessments for residents with dementia. The facility was found to have adequate food supply, locked medication carts, sufficient furnishings, and compliant fire extinguisher inspections.

The visit was an unannounced Plan of Correction (POC) follow-up to verify corrections of deficiencies cited during the last complaint visit on 2024-03-21.

No further deficiencies were observed or cited during this Plan of Correction visit. Proof of corrections was mailed to the licensing agency and plan of correction letters were provided to the facility administrator.

The visit was an unannounced Case Management visit to follow up on the most recent Special Incident Reports (SIRs) submitted from the facility regarding resident care and supervision.

A review of the submitted SIRs was conducted with the facility Administrator and Resident Services Director. No deficiencies were observed or cited during the visit.

The visit was an unannounced complaint investigation triggered by a complaint received on 2024-01-22 regarding a staff member making an inappropriate comment about a resident.

The investigation substantiated that a facility staff member made an inappropriate comment about a resident, which posed an immediate threat to the health, safety, and personal rights of residents. The staff member was suspended pending investigation and later allowed to return with a written warning.

The complaint was substantiated based on the preponderance of evidence standard. The allegation that staff made an inappropriate comment about a resident was found valid. The staff member received a written warning and was allowed to return to work.

The visit was an unannounced complaint investigation conducted in response to allegations received on 01/29/2024 regarding the facility's administration qualifications and infection control procedures.

The investigation found that the facility's designated Administrator's certification was valid and renewed, and that infection control procedures related to COVID-19 quarantine and testing were properly followed. The allegations were determined to be unsubstantiated with no deficiencies cited.

The complaint alleged that the facility did not have a qualified Administrator and that staff did not follow procedures to prevent the spread of illness. The findings were unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.

The visit was an unannounced case management follow-up on several Special Incident Reports related to resident falls.

No deficiencies were observed or cited during the case management visit. An interview was conducted with the facility administrator regarding recent falls.

Unannounced Plan of Correction visit to verify the plan of corrections required to be completed and submitted for deficiencies cited and due by 11/23/2023.

The visit confirmed the submission and verification of the plan of correction letters for previously cited deficiencies. A copy of the Plan of Correction letters was left with the facility representative.

The visit was an unannounced complaint investigation conducted in response to an allegation that staff left medications unattended, making them accessible to residents.

The investigation found that medications were stored securely in locked medication carts and there were no reports or evidence of medications being left accessible to residents. The allegation was determined to be unsubstantiated and no deficiencies were cited.

The complaint allegation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.

The inspection was an unannounced complaint investigation visit conducted due to a complaint received on 09/13/2023 regarding inadequate assistance to a resident during showering, resulting in a fall.

The investigation found that a resident, designated as full assist for showers, experienced two falls while showering despite requiring a dedicated caregiver present at all times. The allegation was substantiated, indicating a failure in providing adequate personal assistance and care during showers.

The complaint was substantiated based on evidence that the facility failed to adequately assist a resident during showering, leading to two falls. The resident required a caregiver present at all times during showers but did not receive this level of care.

The inspection was an unannounced complaint investigation visit triggered by allegations of rough handling of residents, failure to respond to call buttons, and inappropriate staff communication with residents.

The investigation substantiated the allegations that staff often became frustrated and handled residents roughly during care activities, failed to respond timely to call button activations with many responses exceeding 10 minutes or even one hour, and spoke inappropriately to residents. These deficiencies posed immediate threats to residents' health, safety, and personal rights.

The complaint was substantiated based on evidence and interviews. The complaint involved allegations of rough handling of residents, delayed response to call buttons, and inappropriate communication by staff. The investigation found a 15 percent rate of call button responses exceeding 10 minutes, with some responses exceeding one hour.

Unannounced annual visit conducted to evaluate the facility's compliance with licensing requirements and overall conditions.

The facility was toured including resident areas, kitchen, medication storage, and exterior grounds. All observed areas were maintained in compliance with no deficiencies cited during this annual visit.

An unannounced complaint investigation visit was conducted in response to allegations regarding the placement of dementia residents and provision of clothing to a resident.

The investigation found that dementia diagnosed residents were appropriately placed in the Assisted Living side and that staff made efforts to ensure residents were clothed, although one resident occasionally appeared without proper attire due to behavioral issues. The allegations were found to be unsubstantiated with no deficiencies cited.

The complaint involved allegations that staff did not place dementia residents in the memory care unit and did not ensure a resident was provided clothing. The findings were unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-01-12 regarding staff not protecting residents from inappropriate touching, lack of supervision, and leaving a resident in soiled feces.

The investigation found that the alleged inappropriate touching between residents was consensual and not aggressive or forced. Some residents were resistant to staff intervention when changing soiled depends, but attempts were ongoing to address this. The allegations were determined to be unsubstantiated and no deficiencies were cited during the visit.

The complaint was unsubstantiated. Although the allegations may have happened or were valid, there was not a preponderance of evidence to prove the alleged violations occurred.

An unannounced case management visit was conducted as part of an ongoing investigation involving a resident (R1). The Licensing Program Analyst requested various resident documents including physician's report, admissions agreements, needs and appraisal, incident reports, ID emergency contact, and charting notes/daily notes.

The Licensing Program Analyst conducted the visit, reviewed requested documents, and completed an exit interview with the facility administrator. A copy of the report was provided to the facility.

Unannounced plan of correction visit conducted to clear a previously cited deficiency from a prior visit on 2023-01-18.

No deficiencies were observed or cited during this plan of correction visit. Proof of correction was submitted and cleared by the Licensing Program Analyst.

An unannounced complaint investigation visit was conducted to investigate an allegation that facility staff failed to follow a resident's modified dietary restriction related to a peanut allergy.

The investigation found that the facility allowed a resident with a documented peanut allergy to consume peanut butter cookies, resulting in the resident suffering allergic symptoms requiring immediate medical care. The allegation was substantiated and the facility was found deficient in meeting the residents' care needs related to food allergies.

The complaint was substantiated based on evidence that a resident with a known peanut allergy was given peanut butter cookies, causing allergic reaction and requiring immediate medical care.

The inspection was an unannounced complaint investigation visit conducted to address an allegation that facility staff failed to keep a resident clean and dry from incontinence.

The investigation found the allegation to be unsubstantiated as there was insufficient evidence to prove the alleged violation occurred. No deficiencies were observed or cited during the visit.

The complaint allegation was that facility staff failed to keep a resident clean and dry from incontinence. The allegation was found to be unsubstantiated after review of resident records and interviews.

The visit was an unannounced complaint investigation conducted in response to allegations that staff were not following COVID protocols at the facility.

The investigation found that the facility followed all COVID mitigation and infection control protocols, including masking, isolation of positive cases, and adherence to Public Health Orders. The complaint was determined to be unfounded with no deficiencies observed or cited during the visit.

The complaint alleged that staff were not following COVID protocols. The investigation found the complaint to be unfounded, meaning the allegations were false or without reasonable basis.

Unannounced complaint investigation visit conducted in response to a complaint alleging uncleared staff providing care and supervision.

The complaint was found to be unfounded after investigation, meaning the allegations were false or without reasonable basis. No deficiencies were observed or cited during the complaint visit.

Complaint was investigated and found to be unfounded; allegations were false, could not have happened, or were without reasonable basis.

Unannounced complaint investigation visit conducted due to allegations that the facility was not following the prescribed diabetic diet for a resident, not administering medications as ordered, and staff were not properly trained.

The investigation found that the facility staff were aware of the resident's dietary needs and prepared meals accordingly, medications were properly documented and administered with no discrepancies, and staff were properly trained in medication handling. The allegations were found to be unsubstantiated with no deficiencies observed or cited.

The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.

An unannounced complaint investigation was conducted due to an allegation that staff were not following a physician's order to discontinue medication.

The investigation substantiated that a discontinued medication, Benazepril HCL (Lotensin) 5 mg, was still being dispensed due to a communication and filing issue with the discontinuance fax. This posed an immediate threat to residents' health, safety, and personal rights.

The complaint was substantiated based on evidence that medication technicians continued dispensing a discontinued medication due to a delay in receiving the discontinuance fax. The allegation was found valid by the preponderance of evidence standard.

Unannounced complaint investigation visit conducted due to complaints alleging insufficient staffing and lack of laundry service to residents.

The allegations were substantiated; however, no new deficiencies were cited as they had been recorded in a previous complaint with the same allegations.

The complaint was substantiated. Allegations included insufficient staffing and failure to provide laundry service to residents. No new deficiencies were cited since these issues were previously recorded.

Unannounced complaint investigation visit conducted due to complaints received on 2022-01-12 regarding staff not responding timely to pull cords and residents not getting showers due to lack of staff.

The investigation was completed and the allegations were substantiated; however, no new deficiencies were cited as these issues were previously recorded in a prior complaint.

The complaint was substantiated based on the investigation conducted by Licensing Program Analyst Charlie Yang during the unannounced visit on 2022-08-04.

Unannounced complaint investigation visit conducted in response to allegations including inadequate food service and stolen residents' belongings.

The investigation was completed and the allegations were substantiated; however, no new deficiencies were cited as they had been recorded in a previous complaint with the same allegations.

The complaint was substantiated following the investigation conducted on 08/04/2022 by Licensing Program Analyst Charlie Yang.

Unannounced annual visit conducted to evaluate the facility's compliance with licensing requirements.

No deficiencies were observed or cited during the annual visit. Facility areas including living, dining, kitchen, resident rooms, restrooms, memory care unit, and exterior grounds were toured and found to be in compliance. Fire extinguishers were inspected and in compliance.

Unannounced plan of correction visit conducted to clear deficiencies cited on several complaints filed on 01/14/2022, 01/12/2022, 12/20/2021, and 11/18/2021.

The visit focused on verifying correction of previously cited deficiencies related to multiple complaints. Plan of correction letters were generated and provided to the facility administrator.

The visit was related to complaints filed on 01/14/2022, 01/12/2022, 12/20/2021, and 11/18/2021. The purpose was to clear deficiencies cited from these complaints.

The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations including neglect of residents' hygiene needs, feeding assistance, safeguarding of personal belongings, and timely response to call buttons.

The investigation substantiated that due to staff shortages, residents' hygiene and feeding needs were neglected, personal belongings were not properly safeguarded resulting in thefts, and staff did not respond timely to residents' call buttons, with some waits exceeding 30 minutes. Another allegation regarding inappropriate staff comments was found unsubstantiated.

The complaint investigation was substantiated for neglect of hygiene and feeding assistance, failure to safeguard personal belongings, and untimely response to call buttons. The allegation of inappropriate staff comments was unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-12-20 regarding staff not assisting residents, inadequate food service, and theft of residents' belongings and money.

The investigation substantiated that residents needing assistance with eating were neglected due to staff shortages, staff response times to resident calls for assistance were delayed up to 30 minutes, and residents' personal belongings and money were reported stolen or missing. Several incident and police reports were filed.

The complaint was substantiated based on evidence that staff were not present to assist residents, did not provide adequate food service, and residents' belongings and money were stolen. The preponderance of evidence standard was met.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not responding to pull cords timely and residents were not getting showers due to lack of staff.

The investigation substantiated the allegations, finding that due to staff shortages, residents' hygiene needs were neglected and staff did not respond timely to call pendants, with some response times exceeding 30 minutes.

The complaint was substantiated based on evidence that staff response times to resident calls were delayed up to and beyond 30 minutes, and residents were not receiving required hygiene care due to staff shortages.

The inspection was an unannounced complaint investigation visit conducted to address allegations including insufficient staffing and failure to provide laundry services to residents.

The investigation substantiated that facility staff did not respond timely to resident calls for assistance, sometimes taking up to 30 minutes, and that laundry services were neglected due to staff shortages. Another complaint regarding unsafe environment and COVID reporting was found unsubstantiated.

The complaint investigation was substantiated for allegations of insufficient staffing and failure to provide laundry services, with evidence showing delayed response times up to 30 minutes and neglected laundry care. The allegations regarding unsafe environment and failure to report COVID cases were unsubstantiated.

The visit was an unannounced case management visit conducted in response to a recent increase in COVID-related resident and personnel cases at the facility.

A tour of the facility was conducted and an exit interview was held with recommendations related to reducing the number of COVID cases. No specific deficiencies or violations were cited in the report.

Unannounced annual visit conducted as a required 1-year inspection to evaluate compliance with licensing regulations.

The facility was toured including common areas, resident bedrooms, restrooms, medication rooms, kitchen, and exterior grounds. No deficiencies were observed or cited during the visit. Fire extinguishers were inspected and necessary forms were requested to be updated.

Unannounced complaint investigation visit conducted due to an allegation that staff did not give resident medications.

The investigation substantiated that staff did not provide prescribed medications to resident R1 on January 5th and 6th, 2021, and failed to report this to the physician, hospice, or the Department. This posed an immediate health and safety risk to residents.

The complaint was substantiated. Staff did not give resident medications on January 5th and 6th, 2021, and did not report this to the resident's physician, hospice, or the Department.

The inspection was an unannounced complaint investigation triggered by a complaint received on 2020-11-17 alleging that a resident sustained a fracture due to neglect.

The investigation substantiated that a resident suffered a severe fall resulting in a fractured hip due to insufficient staff assistance during transfer, violating care plan requirements. Other allegations regarding staff training and sufficiency were found unsubstantiated.

The complaint investigation was substantiated for the allegation that a resident sustained a fracture due to neglect. The investigation found that only one staff member assisted the resident during a transfer when two were required, leading to the fall and injury. Other allegations about staff training and sufficiency were unsubstantiated.

An unannounced complaint investigation visit was conducted following a complaint received on 11/30/2020 alleging neglect resulting in a resident wound and failure to follow doctor's orders.

The investigation found that the resident sustained a minor skin tear likely caused by her wheelchair, which was observed and treated according to the doctor's order. The facility followed the doctor's orders in a timely manner, and no evidence of neglect was found. The allegations were determined to be unfounded.

The complaint alleged that a resident sustained a wound due to neglect and that the facility was not following doctor's orders. The investigation concluded these allegations were unfounded.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 11/24/2020 regarding staff abuse, rough handling of residents, and insufficient staffing.

The investigation found insufficient evidence to substantiate the allegations of abuse, rough handling of residents, or insufficient staffing. Interviews, records, and site inspections did not support the complaints, resulting in an unsubstantiated finding.

The complaint investigation was unsubstantiated as the evidence did not prove the alleged violations occurred.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-11-10 alleging staff yelled at a resident and that food was not of adequate quality.

The investigation found insufficient evidence to substantiate the allegations. Conflicting statements and lack of witness support led to the conclusion that staff did not yell at the resident. Regarding food quality, residents expressed dissatisfaction during tray service but no evidence proved inadequate food quality, and satisfaction improved once dining resumed.

The complaint investigation was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred.