Deficiencies (last 5 years)
Deficiencies (over 5 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
170% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
76% occupied
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 103
Capacity: 135
Deficiencies: 0
Date: Nov 25, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations including inadequate care and supervision, lack of planned activities, improper facility maintenance, failure to report incidents, noncompliance with admission agreements, and staff retaliation against residents.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found the allegations to be unsubstantiated, with no deficiencies observed or cited. The facility had adequate staffing coverage, maintained the memory care unit properly, and conducted resident assessments and incident reporting as required.
Report Facts
Capacity: 135
Census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sheryl Bravo | Administrator | Facility designated Administrator not present due to health concerns |
| Marcy Borland | Business Officer Manager | Facility representative who met with the Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 135
Deficiencies: 0
Date: Nov 25, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff were not meeting residents' toileting, nutritional, bathing needs, leaving residents soiled for extended periods, and failing to provide adequate supervision to a fall-risk resident.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found the allegations to be unsubstantiated, with no deficiencies observed or cited. Staff coverage and resident care practices were reviewed and found to meet required standards, including adequate staffing levels and proper resident assessments.
Report Facts
Census: 103
Total Capacity: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sheryl Bravo | Administrator | Facility designated Administrator, unavailable during visit due to health concerns |
| Marcy Borland | Business Officer Manager | Facility representative who met with the Licensing Program Analyst during the visit |
Inspection Report
Plan of Correction
Census: 103
Capacity: 135
Deficiencies: 2
Date: Jul 28, 2025
Visit Reason
The visit was an unannounced Plan of Correction (POC) follow-up conducted to verify correction of deficiencies cited during a prior annual visit on 2025-07-07.
Findings
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.
Deficiencies (2)
The facility shall be clean, safe, sanitary and in good repair at all times, including maintenance services and procedures for safety and well-being of residents, employees, and visitors.
Training requirements include an additional 20 hours annually, with specific hours for dementia care, postural supports, restricted health conditions, and hospice care, administered on the job or in classroom/online settings.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Bravo | 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 the exit interview. |
Inspection Report
Plan of Correction
Census: 103
Capacity: 135
Deficiencies: 2
Date: Jul 28, 2025
Visit Reason
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.
Findings
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.
Deficiencies (2)
The facility shall be clean, safe, sanitary and in good repair at all times, including maintenance services and procedures for safety and well-being of residents, employees and visitors.
Training requirements shall include an additional 20 hours annually, including dementia care training and specific training on postural supports, restricted health conditions, and hospice care.
Report Facts
Census: 103
Total Capacity: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Bravo | Administrator | Facility designated Administrator met during the visit and involved in interview |
| Charlie Yang | Licensing Program Analyst | Conducted the Plan of Correction visit |
Inspection Report
Annual Inspection
Census: 103
Capacity: 135
Deficiencies: 2
Date: Jul 7, 2025
Visit Reason
Unannounced annual inspection visit conducted to evaluate compliance with licensing requirements and facility operations.
Findings
The facility was generally found to be in compliance with most licensing requirements, including adequate food supply, medication security, and fire safety. However, two Type B deficiencies were cited related to maintenance and staff training records.
Deficiencies (2)
Kitchen cabinet drawers were in need of repair and a broken chair was set out in the memory care courtyard posing a potential health, safety, or personal rights risk.
Two out of seven facility personnel files did not contain initial/annual training hours, posing a potential health, safety, or personal rights risk.
Report Facts
Residents under hospice care: 10
Hospice waiver capacity: 25
Residents bedridden: 9
Fire clearance bedridden capacity: 10
Facility capacity: 135
Current census: 103
Personnel files reviewed: 7
Resident files reviewed: 7
Deficiencies cited: 2
POC due date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Bravo | Facility Administrator | Interviewed during inspection and named in plans of correction |
| Charlie Yang | Licensing Program Analyst | Conducted inspection and signed report |
| Liza King | Licensing Program Manager | Named as licensing program manager overseeing inspection |
Inspection Report
Annual Inspection
Census: 103
Capacity: 135
Deficiencies: 2
Date: Jul 7, 2025
Visit Reason
Unannounced annual inspection visit conducted to evaluate compliance with licensing requirements and facility operations.
Findings
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.
Deficiencies (2)
Kitchen cabinet drawers were in need of repair and a broken chair was set out in the memory care courtyard posing a potential health, safety or personal rights risk to persons in care.
Two out of seven facility personnel files did not contain initial/annual training hours as required, posing a potential health, safety or personal rights risk to persons in care.
Report Facts
Residents under hospice care: 10
Hospice waiver capacity: 25
Bedridden residents: 4
Bedridden resident fire clearance capacity: 10
Personnel files reviewed: 7
Personnel files missing training: 2
Deficiencies cited: 2
POC due date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Bravo | Facility Administrator | Facility designated Administrator interviewed and named in plan of correction statements |
| Charlie Yang | Licensing Program Analyst | Conducted inspection and authored report |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Plan of Correction
Census: 103
Capacity: 135
Deficiencies: 1
Date: Apr 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 visit on 2025-03-24.
Complaint Details
The visit was a follow-up on deficiencies cited from a prior complaint visit conducted on 2025-03-24.
Findings
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.
Deficiencies (1)
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Bravo | Administrator | Facility designated Administrator met and interviewed during the visit. |
| Charlie Yang | Licensing Program Analyst | Conducted the Plan of Correction visit. |
| Liza King | Licensing Program Manager | Named in the exit interview. |
Inspection Report
Plan of Correction
Census: 103
Capacity: 135
Deficiencies: 1
Date: Apr 10, 2025
Visit Reason
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.
Findings
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.
Deficiencies (1)
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Bravo | Administrator | Facility designated Administrator met and interviewed during the visit |
| Charlie Yang | Licensing Program Analyst | Conducted the Plan of Correction visit |
| Liza King | Licensing Program Manager | Named in the exit interview |
Inspection Report
Follow-Up
Census: 107
Capacity: 135
Deficiencies: 0
Date: Mar 24, 2025
Visit Reason
The visit was an unannounced case management follow-up to review several incidents, including death reports, recently submitted to the Community Care Licensing (CCL).
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Bravo | Administrator | Met during the visit and involved in discussion of incidents. |
| Charlie Yang | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Liza King | Licensing Program Manager | Named in the exit interview. |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 135
Deficiencies: 1
Date: Mar 24, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff did not transfer a resident properly and handled the resident in a rough manner.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Residents in all residential care facilities for the elderly shall have safe, healthful and comfortable accommodations, furnishings and equipment. This facility was found deficient due to improper transfer of a resident from wheelchair to bed, posing an immediate threat to health, safety, and personal rights.
Report Facts
Capacity: 135
Census: 107
Deficiencies cited: 1
Plan of Correction Due Date: Mar 25, 2025
Training Duration: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Bravo | Administrator | Facility representative met during investigation |
| Charlie Yang | Licensing Program Analyst | Investigator conducting complaint visit |
| Liza King | Licensing Program Manager | Manager overseeing complaint investigation |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 135
Deficiencies: 1
Date: Mar 24, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not transfer a resident properly and handled the resident in a rough manner.
Complaint Details
The complaint was substantiated based on evidence that staff did not properly assist the resident during transfer, leading to a fall and potential injury. The allegation was found valid by preponderance of evidence.
Findings
The investigation found that caregivers improperly assisted a resident during transfer, prompting the resident to stand despite inability to bear weight, resulting in a fall and staff pushing the resident onto the bed to prevent injury. The allegation was substantiated with deficiencies cited related to improper transfer techniques.
Deficiencies (1)
Improper transfer of a facility resident by staff from wheelchair onto bed, posing immediate threat to health, safety, and personal rights of residents.
Report Facts
Capacity: 135
Census: 107
Deficiencies cited: 1
Plan of Correction Due Date: Mar 25, 2025
Training duration: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sheryl Bravo | Administrator | Facility designated administrator met during investigation |
| Liza King | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Census: 107
Capacity: 135
Deficiencies: 0
Date: Mar 24, 2025
Visit Reason
The unannounced case management visit was conducted to follow up on several incidents, including death reports, that were recently submitted into Community Care Licensing (CCL).
Findings
The visit found that the referenced residents were under hospice care prior to passing away at the facility, with hospice agencies present and family informed. No deficiencies were observed or cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Bravo | Administrator | Facility designated Administrator met with Licensing Program Analyst during the visit. |
| Charlie Yang | Licensing Program Analyst | Conducted the case management visit and interview. |
| Liza King | Licensing Program Manager | Named in the exit interview. |
Inspection Report
Census: 107
Capacity: 135
Deficiencies: 0
Date: Mar 10, 2025
Visit Reason
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Bravo | Administrator | Facility designated Administrator met during the visit and interviewed. |
| Charlie Yang | Licensing Program Analyst | Conducted the case management visit. |
| Liza King | Licensing Program Manager | Named in the exit interview. |
Inspection Report
Census: 98
Capacity: 135
Deficiencies: 0
Date: Sep 25, 2024
Visit Reason
The case management visit was conducted to follow up and inquire about recent incident reports related to facility residents and their care.
Findings
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.
Report Facts
Census: 98
Total Capacity: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcy Borland | Business Office Manager | Facility designated representative interviewed during the visit |
| Sheryl Bravo | Administrator | Facility designated Administrator contacted regarding incident reports |
| Charlie Yang | Licensing Program Analyst | Conducted the case management visit |
| Liza King | Licensing Program Manager | Named in exit interview |
Inspection Report
Plan of Correction
Census: 98
Capacity: 135
Deficiencies: 3
Date: Aug 19, 2024
Visit Reason
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.
Findings
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.
Deficiencies (3)
All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks, verified by health screening.
Each resident's record shall contain at least the following information.
Each resident with dementia shall have an annual medical assessment and a reappraisal done at least annually, including reassessment of dementia care needs.
Report Facts
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheryl Bravo | Administrator | Met with Licensing Program Analyst during the inspection and named in relation to facility administration |
| Charlie Yang | Licensing Program Analyst | Conducted the Plan of Correction visit |
| Liza King | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 135
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff mishandled a resident's medication while in care.
Complaint Details
The complaint alleged that staff mishandled a resident's medication. The investigation concluded the allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
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.
Report Facts
Capacity: 135
Census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Liza King | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Sheryl Bravo | Facility designated Administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 135
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff mishandled a resident's medication while in care.
Complaint Details
The complaint alleged staff mishandled a resident's medication. The allegation was found to be unsubstantiated as there was insufficient evidence to prove the violation occurred.
Findings
The investigation found no evidence to substantiate the allegation. Interviews and document reviews showed the resident did not have a history of missed or mishandled medications, and no deficiencies were cited during the visit.
Report Facts
Capacity: 135
Census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sheryl Bravo | Facility Designated Administrator | Met with the evaluator during the investigation |
| Liza King | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 96
Capacity: 135
Deficiencies: 3
Date: Jul 17, 2024
Visit Reason
Unannounced annual inspection visit conducted to evaluate compliance with licensing requirements and facility operations.
Findings
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.
Deficiencies (3)
One out of eight facility personnel records was not properly cleared for TB by a licensed medical professional.
Seven out of eight facility resident files were incomplete, missing required forms and documents.
One out of eight facility resident records for persons diagnosed with dementia did not have an updated annual medical assessment.
Report Facts
Residents under hospice care: 10
Hospice waiver capacity: 25
Residents diagnosed with dementia: 21
Residents receiving home health services: 12
Personnel records reviewed: 8
Resident records reviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Liza King | Licensing Program Manager | Supervisor overseeing the inspection. |
| Sheryl Bravo | Facility Designated Administrator | Met with Licensing Program Analyst during inspection and involved in plan of correction. |
Inspection Report
Plan of Correction
Census: 96
Capacity: 135
Deficiencies: 0
Date: Apr 19, 2024
Visit Reason
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.
Findings
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.
Report Facts
Census: 96
Total Capacity: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Ware | Facility Designated Administrator | Met and interviewed 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
Census: 96
Capacity: 135
Deficiencies: 0
Date: Apr 19, 2024
Visit Reason
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Ware | Administrator | Facility designated Administrator interviewed during the visit. |
| Charlie Yang | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Liza King | Licensing Program Manager | Named in the exit interview. |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 135
Deficiencies: 1
Date: Mar 21, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Residents in all residential care facilities for the elderly shall have all of the following personal rights: to be accorded dignity in their personal relationships with staff, residents, and other persons. The facility was found deficient as staff made an inappropriate comment regarding a resident, posing an immediate threat to health, safety, and personal rights.
Report Facts
Capacity: 135
Census: 97
Deficiencies cited: 1
Plan of Correction Due Date: Due date was 03/22/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Liza King | Licensing Program Manager | Oversaw the complaint investigation |
| Morgan Ware | Facility Designated Administrator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 135
Deficiencies: 0
Date: Mar 21, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 135
Census: 97
Administrator Certificate Expiration: Jan 25, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheri Kimbro | Administrator | Facility designated Administrator whose certification was reviewed |
| Morgan Ware | Facility designated Administrator | Met with Licensing Program Analyst during the visit |
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Liza King | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 135
Deficiencies: 1
Date: Mar 21, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-01-22 alleging that a staff member made an inappropriate comment about a resident.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The allegation involved a staff member making an inappropriate comment about a resident. The staff member was suspended pending investigation and later allowed to return with a written warning.
Findings
The investigation substantiated the allegation that a facility staff person made an inappropriate comment regarding 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.
Deficiencies (1)
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This facility was found deficient as facility staff made an inappropriate comment regarding a resident, posing an immediate threat to health, safety, and personal rights.
Report Facts
Capacity: 135
Census: 97
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Morgan Ware | Facility Designated Administrator | Met with the Licensing Program Analyst during the investigation |
| Sheri Kimbro | Administrator | Facility administrator named in the report |
| Liza King | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 135
Deficiencies: 0
Date: Mar 21, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-01-29 regarding the facility's administration qualifications and infection control procedures.
Complaint Details
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 insufficient evidence to prove the alleged violations occurred.
Findings
The investigation found that the facility's designated Administrator's certification was valid and renewed, and infection control procedures related to COVID-19 quarantine and testing were properly followed. No incidents of protocol breaches were found, and the allegations were determined to be unsubstantiated.
Report Facts
Capacity: 135
Census: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheri Kimbro | Administrator | Facility designated Administrator whose certification was reviewed |
| Morgan Ware | Facility designated Administrator | Met with Licensing Program Analyst during the investigation |
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Liza King | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Census: 90
Capacity: 135
Deficiencies: 0
Date: Jan 10, 2024
Visit Reason
The visit was an unannounced case management follow-up on several Special Incident Reports related to resident falls.
Findings
No deficiencies were observed or cited during the case management visit. An interview was conducted with the facility administrator regarding recent falls.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheri Kimbro | Administrator | Interviewed during the case management visit regarding recent resident falls. |
Inspection Report
Plan of Correction
Census: 89
Capacity: 135
Deficiencies: 0
Date: Nov 27, 2023
Visit Reason
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Silva | Resident Services Director | Briefly interviewed 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: 89
Capacity: 135
Deficiencies: 0
Date: Nov 16, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff left medications unattended, making them accessible to residents.
Complaint Details
The complaint allegation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.
Findings
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.
Report Facts
Capacity: 135
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheri Kimbro | Administrator | Facility representative met during the investigation |
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Liza King | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 135
Deficiencies: 1
Date: Nov 16, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide personal assistance and care as needed by the resident during showers, resulting in two falls despite the resident being assessed as full assist.
Report Facts
Falls sustained: 2
Capacity: 135
Census: 89
Plan of Correction Due Date: Nov 17, 2023
Staff training duration: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sheri Kimbro | Administrator | Facility designated Administrator met during the investigation and involved in exit interview |
| Liza King | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 135
Deficiencies: 3
Date: Nov 16, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Staff persons handling residents roughly when assisting with Activities of Daily Living (ADLs), violating residents' dignity and respect.
Staff speaking inappropriately to residents when assisting with Activities of Daily Living (ADLs), violating residents' personal rights.
Staff failing to respond timely to call button activations, often exceeding 10 minutes, posing immediate threat to residents' health, safety, and personal rights.
Report Facts
Call button activations: 1156
Delayed responses: 176
Response delay percentage: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Sheri Kimbro | Administrator | Facility designated Administrator interviewed during the investigation and recipient of the report. |
| Liza King | Licensing Program Manager | Oversaw the licensing program and signed the report. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 135
Deficiencies: 0
Date: Nov 16, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-08-16 alleging that staff left medications unattended, making them accessible to residents.
Complaint Details
The complaint allegation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.
Findings
The investigation found that medications were stored in locked medication carts and handled by Medication Technicians according to facility policies. Interviews confirmed no medications were left accessible to residents. The allegation was found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 89
Total Capacity: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sheri Kimbro | Administrator | Facility representative met during the investigation |
| Liza King | Supervisor | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 135
Deficiencies: 1
Date: Nov 16, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-09-13 regarding inadequate assistance to a resident during showering, which resulted in a fall.
Complaint Details
The complaint was substantiated based on evidence that staff did not adequately assist a resident with showering, resulting in two falls. The resident was assessed as requiring full assistance at all times during showers.
Findings
The investigation substantiated that a resident requiring full assistance during showers experienced two falls due to inadequate staff assistance, posing an immediate threat to resident health, safety, and personal rights. No other similar incidents were documented for other residents.
Deficiencies (1)
Failure to provide personal assistance and care as needed by the resident during showers, resulting in two falls despite the resident being assessed as requiring full assistance.
Report Facts
Falls sustained: 2
Capacity: 135
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Sheri Kimbro | Administrator | Facility designated Administrator met during the investigation and named in findings. |
| Liza King | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 135
Deficiencies: 3
Date: Nov 16, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 10/30/2023 regarding staff handling residents roughly, not responding to call buttons, and speaking inappropriately to residents.
Complaint Details
The complaint was substantiated based on evidence and interviews. Allegations included rough handling of residents, failure to respond to call buttons timely, and inappropriate speech by staff. The investigation found a 15% rate of call button responses exceeding 10 minutes, with some exceeding one hour.
Findings
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 15% of responses exceeding 10 minutes, and spoke inappropriately to residents. These actions posed immediate threats to residents' health, safety, and personal rights.
Deficiencies (3)
Staff persons handling residents roughly when assisting with Activities of Daily Living (ADLs), posing an immediate threat to health, safety, and personal rights.
Staff speaking inappropriately to residents when assisting with Activities of Daily Living (ADLs), posing an immediate threat to health, safety, and personal rights.
Staff not responding in a timely manner to call button activations, often exceeding 10 minutes, posing an immediate threat to health, safety, and personal rights.
Report Facts
Call button activations: 1156
Delayed responses: 176
Response delay percentage: 15
Census: 89
Total capacity: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sheri Kimbro | Administrator | Facility representative interviewed during investigation |
| Liza King | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 84
Capacity: 135
Deficiencies: 0
Date: Jul 17, 2023
Visit Reason
Unannounced annual visit conducted to evaluate the facility's compliance with licensing requirements and overall conditions.
Findings
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.
Report Facts
Residents under home health care: 9
Residents under hospice care: 7
Facility capacity: 135
Current census: 84
Fire extinguisher inspection date: Apr 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheri Kimbro | Administrator | Facility designated Administrator met during inspection |
| Charlie Yang | Licensing Program Analyst | Conducted the inspection visit |
| Liza King | Licensing Program Manager | Named in report header and exit interview |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 135
Deficiencies: 0
Date: May 12, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations regarding the placement of dementia residents and provision of clothing to a resident.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 135
Census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Silva | Resident Services Director | Met during the investigation and interviewed regarding the allegations |
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sheri Kimbro | Administrator | Facility designated administrator unavailable during the visit |
| Liza King | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 135
Deficiencies: 0
Date: May 12, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Attempts to change residents out of soiled depends: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation. |
| Karen Silva | Resident Services Director | Met with investigators and provided information during the investigation. |
| Sheri Kimbro | Administrator | Facility designated administrator who was unavailable during the investigation. |
| Liza King | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 135
Deficiencies: 0
Date: May 12, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-01-12 regarding resident safety and care concerns at the facility.
Complaint Details
The complaint alleged that facility staff did not protect a resident from inappropriate touching by another resident, failed to supervise residents resulting in inappropriate interaction, and left a resident in soiled feces. The findings were unsubstantiated.
Findings
The investigation found the allegations unsubstantiated based on interviews and observations. No deficiencies were cited, and the behaviors observed were consensual and not aggressive. Attempts to address resident care issues were ongoing.
Report Facts
Capacity: 135
Census: 88
Attempts to change residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Kimberly Viarella | Licensing Program Analyst | Assisted in the complaint investigation |
| Karen Silva | Resident Services Director | Met with investigators during the visit and provided information |
| Sheri Kimbro | Administrator | Facility designated administrator unavailable during visit |
| Liza King | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 135
Deficiencies: 0
Date: May 12, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff do not place dementia residents in the memory care unit and that staff do not ensure residents are provided clothing.
Complaint Details
The complaint was unsubstantiated. Although some behaviors and issues were observed, there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found that dementia diagnosed residents were appropriately placed in the Assisted Living side and received compatible care. A resident (R1) was observed to sometimes be without proper clothing, but staff made efforts to assist while respecting the resident's rights. The allegations were found to be unsubstantiated and no deficiencies were cited.
Report Facts
Capacity: 135
Census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst / Evaluator | Conducted the complaint investigation |
| Kimberly Viarella | Licensing Program Analyst | Conducted the complaint investigation |
| Karen Silva | Resident Services Director | Met with investigators and provided information during the investigation |
| Sheri Kimbro | Facility Administrator | Designated administrator unavailable during investigation |
Inspection Report
Census: 90
Capacity: 135
Deficiencies: 0
Date: May 5, 2023
Visit Reason
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Silva | Facility Administrator | Met with Licensing Program Analyst during the visit and participated in exit interview. |
| Kimberly Viarella | Licensing Program Analyst | Conducted the unannounced case management visit and requested resident documents. |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Plan of Correction
Census: 86
Capacity: 135
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
Unannounced plan of correction visit conducted to clear a previously cited deficiency from a prior visit on 2023-01-18.
Findings
No deficiencies were observed or cited during this plan of correction visit. Proof of correction was submitted and cleared by the Licensing Program Analyst.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheri Kimbro | Administrator | Facility designated Administrator met during the visit. |
| Charlie Yang | Licensing Program Analyst | Conducted the plan of correction visit. |
| Stephenie Doub | Licensing Program Manager | Named in exit interview. |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 135
Deficiencies: 1
Date: Jan 18, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to follow assistance and care needs of residents as indicated in their pre-admission appraisal for assistance in meals, food allergies, and eating, presenting an immediate threat to health, safety, and personal rights.
Report Facts
Capacity: 135
Census: 86
Deficiency Type: 1
Plan of Correction Due Date: Jan 25, 2023
Training Duration: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sheri Kimbro | Facility Administrator | Facility representative interviewed during investigation and recipient of findings |
| Stephenie Doub | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 135
Deficiencies: 0
Date: Jan 18, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Complaint Control Number: 27-AS-20221109143103
Capacity: 135
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sheri Kimbro | Administrator | Facility designated administrator met during the investigation |
| Stephenie Doub | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 135
Deficiencies: 1
Date: Jan 18, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2022-11-04 regarding the facility staff failing to follow a resident's modified dietary restriction.
Complaint Details
The complaint was substantiated based on the preponderance of evidence standard. The allegation that facility staff failed to follow a resident's modified dietary restriction was confirmed.
Findings
The investigation found that a resident with a documented peanut allergy was given peanut butter cookies, resulting in an allergic reaction requiring immediate medical care. The facility was found deficient for allowing a known food allergy to be violated, posing an immediate threat to resident health and safety.
Deficiencies (1)
Failure to follow assistance and care needs of residents as indicated in their pre-admission appraisal for assistance in meals, food allergies, and eating, presenting an immediate threat to health, safety, and personal rights.
Report Facts
Census: 86
Total Capacity: 135
Plan of Correction Due Date: Jan 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sheri Kimbro | Administrator | Facility representative involved in the investigation and exit interview |
| Stephenie Doub | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 135
Deficiencies: 0
Date: Jan 18, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff failed to keep a resident clean and dry from incontinence.
Complaint Details
The complaint allegation was found to be unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.
Findings
The investigation found that the resident was independent in toileting and grooming at admission, and there was insufficient evidence to substantiate the allegation. No deficiencies were observed or cited.
Report Facts
Census: 86
Total Capacity: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sheri Kimbro | Administrator | Facility administrator met during the investigation |
| Stephenie Doub | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 135
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff were not following COVID protocols at the facility.
Complaint Details
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.
Findings
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.
Report Facts
COVID positive cases: 6
Days since last COVID positive case: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Sheri Kimbro | Facility designated Administrator who was interviewed during the investigation. | |
| Stephenie Doub | Licensing Program Manager | Named in the report as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 135
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff were not following COVID protocols.
Complaint Details
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.
Findings
The investigation found that the facility followed all COVID mitigation and infection control protocols, including masking, isolation of positive individuals, and adherence to Public Health Orders. The complaint was determined to be unfounded with no deficiencies observed or cited.
Report Facts
COVID positive cases: 6
Days since last COVID positive case: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Sheri Kimbro | Facility Administrator | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 135
Deficiencies: 0
Date: Oct 27, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint alleging uncleared staff providing care and supervision.
Complaint Details
Complaint was investigated and found to be unfounded; allegations were false, could not have happened, or were without reasonable basis.
Findings
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.
Report Facts
Census: 87
Total Capacity: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Sheri Kimbro | Facility designated Administrator met during the investigation. | |
| Diana Borza | Administrator | Named as facility administrator in report header. |
| Stephenie Doub | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 135
Deficiencies: 0
Date: Oct 27, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint alleging that uncleared staff were providing care and supervision.
Complaint Details
Complaint was investigated and found to be unfounded; allegations were false or without reasonable basis.
Findings
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.
Report Facts
Capacity: 135
Census: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sheri Kimbro | Facility designated Administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 135
Deficiencies: 0
Date: Sep 29, 2022
Visit Reason
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.
Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
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.
Report Facts
Prescribed medications: 14
PRN medications: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sheri Kimbro | Facility Designated Administrator | Met with Licensing Program Analyst during investigation |
| Stephenie Doub | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 135
Deficiencies: 1
Date: Sep 29, 2022
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff were not following a physician's order to discontinue medication.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to follow the discontinuance notice for a prescribed medication provided by the attending physician, posing an immediate threat to the health, safety, and personal rights of residents.
Report Facts
Census: 87
Total Capacity: 135
Plan of Correction Due Date: Oct 6, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Sheri Kimbro | Facility Designated Administrator | Met with Licensing Program Analyst during the investigation and received appeal rights |
| Stephenie Doub | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 135
Deficiencies: 0
Date: Sep 29, 2022
Visit Reason
Unannounced complaint investigation conducted in response to allegations that the facility was not following the prescribed diabetic diet for a resident, not administering medications as ordered, and that staff were not properly trained.
Complaint Details
The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found that the facility was compliant with dietary and medication administration requirements, and staff were properly trained. The allegations were determined to be unsubstantiated with no deficiencies observed or cited.
Report Facts
Medications prescribed: 14
PRN medications: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sheri Kimbro | Facility Designated Administrator | Met with the Licensing Program Analyst during the investigation |
| Stephenie Doub | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 135
Deficiencies: 1
Date: Sep 29, 2022
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff were not following a physician's order to discontinue medication.
Complaint Details
The complaint was substantiated based on the preponderance of evidence that staff did not follow the physician's order to discontinue medication.
Findings
The investigation found that a prescribed medication, Benazepril HCL (Lotensin) 5 mg, was still being dispensed despite a physician's discontinuance order faxed to the facility. This was due to communication and filing issues with the faxed order, resulting in the medication technicians not seeing the discontinuance notice for six days.
Deficiencies (1)
Failure to follow the discontinuance notice for a prescribed medication provided by the attending physician, posing an immediate threat to the health, safety, and personal rights of residents.
Report Facts
Capacity: 135
Census: 87
Plan of Correction Due Date: Oct 6, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sheri Kimbro | Facility Designated Administrator | Met with the Licensing Program Analyst during the investigation and received appeal rights |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 135
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to complaints alleging insufficient staffing and lack of laundry service to residents.
Complaint Details
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.
Findings
The allegations were substantiated; however, no new deficiencies were cited as they had been recorded in a previous complaint with the same allegations.
Report Facts
Capacity: 135
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sherri Kimbro | Facility designated administrator met during the investigation | |
| Stephenie Doub | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 135
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
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.
Complaint Details
The complaint was substantiated based on the investigation conducted by Licensing Program Analyst Charlie Yang during the unannounced visit on 2022-08-04.
Findings
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.
Report Facts
Capacity: 135
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sherri Kimbro | Facility designated administrator met during the investigation | |
| Diana Borza | Administrator | Facility administrator named in the report |
| Stephenie Doub | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 135
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations including inadequate food service and stolen residents' belongings.
Complaint Details
The complaint was substantiated following the investigation conducted on 08/04/2022 by Licensing Program Analyst Charlie Yang.
Findings
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.
Report Facts
Capacity: 135
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sherri Kimbro | Facility designated Administrator met during the investigation | |
| Diana Borza | Administrator | Facility Administrator named in the report header |
| Stephenie Doub | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 135
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
Unannounced follow-up complaint visit conducted to investigate allegations including insufficient staffing and lack of laundry service to residents.
Complaint Details
The complaint was substantiated. Allegations included insufficient staffing and failure to provide laundry service to residents.
Findings
The investigation was completed and the allegations were substantiated; however, no new deficiencies were cited as these issues had been recorded in a previous complaint.
Report Facts
Capacity: 135
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sherri Kimbro | Facility Designated Administrator | Met with the Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 135
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
Unannounced follow-up complaint visit conducted to investigate allegations that staff were not responding to pull cords timely and residents were not getting showers due to lack of staff.
Complaint Details
The complaint was substantiated based on the investigation conducted by Licensing Program Analyst Charlie Yang on 08/04/2022.
Findings
The investigation was completed and the allegations were substantiated; however, no new deficiencies were cited as these issues had been recorded in a previous complaint with the same allegations.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Sherri Kimbro | Facility Designated Administrator | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 135
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
The visit was an unannounced follow-up complaint investigation conducted to revise the complaint report to reflect changes made to the allegations received on 12/20/2021.
Complaint Details
The complaint involved allegations that staff were not providing adequate food service for residents and that residents' belongings were stolen. The investigation substantiated these allegations.
Findings
The allegations were substantiated; however, no new deficiencies were cited as they had been recorded in a previous complaint with the same allegations.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Sherri Kimbro | Facility Designated Administrator | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Annual Inspection
Census: 91
Capacity: 135
Deficiencies: 0
Date: Jul 20, 2022
Visit Reason
Unannounced annual visit conducted to evaluate the facility's compliance with licensing requirements.
Findings
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.
Report Facts
Food supply review: 7
Food supply review: 2
Hot water temperature range: 105
Hot water temperature range: 120
Fire extinguisher inspection date: Apr 6, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheri Kimbro | Facility Designated Administrator | Briefly interviewed during the inspection |
| Charlie Yang | Licensing Program Analyst | Conducted the inspection |
| Arielle Pascua | Licensing Program Analyst | Conducted the inspection |
| Stephenie Doub | Licensing Program Manager | Named in report header and exit interview |
Inspection Report
Plan of Correction
Census: 95
Capacity: 135
Deficiencies: 0
Date: May 11, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 135
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Silva | Facility Designated Administrator | Met during the visit and received plan of correction letters |
| Charlie Yang | Licensing Program Analyst | Conducted the inspection visit |
| Arielle Pascua | Licensing Program Analyst | Conducted the inspection visit |
| Stephenie Doub | Licensing Program Manager | Named in the exit interview |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 135
Deficiencies: 3
Date: Apr 25, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to provide personal assistance and care as needed by residents including dressing, eating, bathing, and medication assistance as indicated in pre-admission appraisals.
Insufficient facility personnel to provide necessary services to meet resident needs, including personal assistance and care.
Failure to safeguard residents' cash resources, personal property, and valuables resulting in thefts and losses.
Report Facts
Census: 95
Total Capacity: 135
Call response time: 30
Plan of Correction Due Date: May 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Stephenie Doub | Licensing Program Manager | Oversaw the complaint investigation |
| Sheri Kimbro | Facility Designated Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 135
Deficiencies: 2
Date: Apr 25, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Facility did not meet the requirement for personal assistance and care as needed by residents, including assistance with eating and hygiene, presenting a potential threat to residents' health, safety, and personal rights.
Facility failed to safeguard residents' cash resources, personal property, and valuables, evidenced by reports of thefts and losses.
Report Facts
Census: 95
Total Capacity: 135
Response Time: 30
Plan of Correction Due Date: May 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Stephenie Doub | Licensing Program Manager | Oversaw the complaint investigation |
| Sheri Kimbro | Facility Designated Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 135
Deficiencies: 2
Date: Apr 25, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Facility personnel were insufficient in numbers and competence to provide necessary services, including timely response to residents' activation of pendants.
Facility did not meet the requirement for providing personal assistance and care as indicated in residents' pre-admission appraisals, including hygiene care and showers.
Report Facts
Response time: 20
Response time: 30
Capacity: 135
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Stephenie Doub | Licensing Program Manager | Oversaw the complaint investigation and signed the report. |
| Sheri Kimbro | Facility Designated Administrator | Met with the Licensing Program Analyst during the investigation and was involved in the exit interview. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 135
Deficiencies: 2
Date: Apr 25, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to address allegations including insufficient staffing and failure to provide laundry services to residents.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Facility personnel were insufficient in numbers and did not respond timely to residents' activation of their pendants, posing an immediate threat to residents' health, safety, and personal rights.
Facility did not meet the requirement for providing personal assistance and care including proper hygiene and laundry service as indicated in residents' pre-admission appraisals.
Report Facts
Census: 95
Total Capacity: 135
Response Time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Stephenie Doub | Licensing Program Manager | Oversaw the complaint investigation |
| Sheri Kimbro | Facility Designated Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 135
Deficiencies: 3
Date: Apr 25, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-11-18 regarding staff not meeting residents' hygiene needs, feeding residents, safeguarding personal belongings, and responding to call buttons in a timely manner.
Complaint Details
The complaint investigation was substantiated for allegations of neglect in hygiene care, feeding assistance, safeguarding personal belongings, and delayed response to call buttons. The allegation of staff making inappropriate comments was unsubstantiated.
Findings
The investigation substantiated that due to staff shortages, residents' hygiene needs and feeding assistance were neglected, personal belongings were not properly safeguarded resulting in thefts, and staff did not respond to call buttons in a timely manner with delays up to 30 minutes. Another allegation regarding inappropriate comments by staff was found unsubstantiated. Several deficiencies were cited related to personal care, staffing sufficiency, call response times, and safeguarding residents' belongings.
Deficiencies (3)
Failure to provide personal assistance and care as needed by residents, including dressing, eating, bathing, and medication assistance as indicated in pre-admission appraisals.
Insufficient staff to properly respond to residents' activation of pendants in a timely manner, posing an immediate threat to health, safety, and personal rights.
Failure to safeguard residents' cash resources, personal property, and valuables, evidenced by reports of thefts and losses.
Report Facts
Capacity: 135
Census: 95
Call response time: 30
Plan of Correction Due Date: May 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sheri Kimbro | Facility Designated Administrator | Met with evaluator during investigation and named in findings |
| Diana Borza | Administrator | Named as facility administrator |
| Stephenie Doub | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 135
Deficiencies: 2
Date: Apr 25, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including staff not present to assist residents, inadequate food service, and theft of residents' belongings and money.
Complaint Details
The complaint was substantiated based on evidence including interviews, call logs showing delayed staff response times, incident reports, and police reports regarding theft of residents' belongings and money.
Findings
The investigation substantiated the allegations that residents needing assistance with eating were neglected due to staff shortages, response times to resident calls for assistance were delayed up to 30 minutes, and residents' personal belongings and money were reported stolen or missing while under facility care.
Deficiencies (2)
Failure to provide personal assistance and care as needed by residents, including assistance with eating and hygiene, as indicated in pre-admission appraisals.
Failure to safeguard residents' cash resources, personal property, and valuables entrusted to the facility, evidenced by reports of thefts and losses.
Report Facts
Census: 95
Total Capacity: 135
Response time: 30
Plan of Correction Due Date: May 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sheri Kimbro | Facility Designated Administrator | Met with investigator during complaint visit |
| Stephenie Doub | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 135
Deficiencies: 2
Date: Apr 25, 2022
Visit Reason
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.
Complaint Details
The complaint was substantiated based on evidence that staff did not respond timely to pull cords and residents were not receiving showers due to lack of staff. The preponderance of evidence standard was met.
Findings
The investigation found that due to a shortage of staff, residents' hygiene needs were neglected, including lack of showers and assistance with activities of daily living. Staff response times to resident call pendants were delayed, sometimes up to 20-30 minutes, posing a threat to residents' health, safety, and personal rights. The allegations were substantiated.
Deficiencies (2)
Facility personnel were insufficient in numbers and not competent to provide necessary services, resulting in delayed response to residents' activation of pendants.
Facility did not provide basic services including personal assistance and care as indicated in residents' pre-admission appraisals, specifically hygiene care and showers.
Report Facts
Census: 95
Total Capacity: 135
Response Time: 20
Response Time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sheri Kimbro | Facility Designated Administrator | Met with Licensing Program Analyst during investigation |
| Diana Borza | Administrator | Named as facility administrator in report header |
| Stephenie Doub | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 135
Deficiencies: 2
Date: Apr 25, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations including insufficient staffing and failure to provide laundry service to residents.
Complaint Details
The complaint investigation was substantiated for allegations of insufficient staffing and failure to provide laundry service, with evidence showing delayed staff response times and neglected laundry care. The allegations of unsafe environment and failure to report COVID cases were unsubstantiated.
Findings
The investigation substantiated that facility staff did not respond timely to residents' calls for assistance, sometimes taking up to 20-30 minutes, and that laundry services were neglected due to staffing shortages. Another complaint regarding unsafe environment and failure to report COVID cases was found unsubstantiated.
Deficiencies (2)
Facility personnel were insufficient in numbers and did not respond timely to residents' activation of their pendants, posing an immediate threat to residents' health, safety, and personal rights.
Facility failed to provide proper hygiene care and laundry service as indicated in residents' pre-admission appraisals, presenting a potential threat to residents' health, safety, and personal rights.
Report Facts
Census: 95
Total Capacity: 135
Response Time: 20
Response Time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Yang | Licensing Program Analyst | Conducted the complaint investigation |
| Sheri Kimbro | Facility Designated Administrator | Met with evaluator during investigation |
| Stephenie Doub | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Capacity: 135
Deficiencies: 0
Date: Oct 22, 2021
Visit Reason
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Freudenthal | Facility Designated Administrator | Met with Licensing Program Analyst during the visit and responsible for signing the report. |
| Charlie Yang | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Kristy Trausch | Conducted the exit interview with tips and recommendations related to COVID. | |
| Stephenie Doub | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 95
Capacity: 135
Deficiencies: 0
Date: Jul 7, 2021
Visit Reason
Unannounced annual visit conducted as a required 1-year inspection to evaluate compliance with licensing regulations.
Findings
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.
Report Facts
Residents under hospice care: 9
Licensed hospice capacity: 15
Fire extinguisher inspection date: Apr 13, 2021
Food storage review periods: 2
Food storage review periods: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Freudendahl | Interim Executive Director | Met during inspection and interviewed |
| Charlie Yang | Licensing Program Analyst | Conducted inspection |
| Tirzah Hubbard | Licensing Program Analyst involved in inspection | |
| Stephenie Doub | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 135
Deficiencies: 1
Date: May 3, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that staff did not give resident medications.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure medications ordered for residents are given as prescribed, posing an immediate health and safety risk.
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Stephenie Doub | Licensing Program Manager | Named in relation to the investigation and report. |
| Maureen Bradley | Administrator | Facility administrator met during the inspection. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 135
Deficiencies: 1
Date: May 3, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not give resident medications.
Complaint Details
The complaint was substantiated based on records and interviews. The allegation that staff did not give resident medications was confirmed. The facility did not provide medications on January 5th and 6th, 2021, and failed to notify the physician, hospice, or licensing department.
Findings
The investigation substantiated that staff did not provide prescribed medications to a resident on January 5th and 6th, 2021, and failed to report this to the resident's physician, hospice, or the licensing department. This posed an immediate health and safety risk to residents.
Deficiencies (1)
Failure to ensure medications ordered for residents are given as prescribed, posing an immediate health and safety risk.
Report Facts
Census: 90
Total Capacity: 135
Deficiencies cited: 1
Plan of Correction Due Date: May 4, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Albert Johnson | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Maureen Bradley | Administrator | Facility administrator met during inspection and named in report |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 135
Deficiencies: 1
Date: Apr 8, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide personal assistance and care as needed by the resident, specifically a two person assist during transfers, resulting in a resident fall and fractured hip.
Report Facts
Capacity: 135
Census: 92
Plan of Correction Due Date: Apr 13, 2021
Plan of Correction Completion Date: Apr 30, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bruce Jacobs | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Maureen Bradley | Executive Director | Facility representative met during investigation and involved in findings discussion |
| Liza King | Licensing Program Manager | Oversaw complaint investigation and signed report |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 135
Deficiencies: 1
Date: Apr 8, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 2020-11-17 alleging neglect resulting in a resident sustaining a fracture, insufficient and untrained staff, and unmet resident incontinence needs.
Complaint Details
The complaint was substantiated regarding neglect causing a resident's fracture. Other allegations about staffing and incontinence care were unsubstantiated.
Findings
The investigation substantiated that a resident sustained a hip fracture due to neglect when only one staff member assisted during a two-person transfer. Other allegations regarding insufficient staffing and unmet incontinence needs were found to be unsubstantiated. A deficiency was cited related to failure to provide personal assistance as required by the resident's care plan.
Deficiencies (1)
Failure to provide personal assistance and care as needed by the resident, specifically a two person assist during transfers was not followed, resulting in a resident fall and fractured hip.
Report Facts
Capacity: 135
Census: 92
Plan of Correction Due Date: Apr 13, 2021
Plan of Correction Completion Date: Apr 30, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Bradley | Executive Director | Spoke with Licensing Program Analyst regarding investigation findings and was present during inspection |
| Bruce Jacobs | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 135
Deficiencies: 0
Date: Apr 2, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Facility capacity: 135
Census: 92
Wound size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bruce Jacobs | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Maureen Bradley | Executive Director | Facility administrator met during investigation |
| Liza King | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 135
Deficiencies: 0
Date: Apr 2, 2021
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 11/30/2020 regarding allegations that a resident sustained a wound due to neglect and that the facility was not following doctor's orders.
Complaint Details
The complaint investigation was unannounced and involved interviews, site inspections, and record reviews. The allegations were found to be without reasonable basis and were determined to be unfounded.
Findings
The investigation found that the resident sustained a minor skin tear likely caused by her wheelchair, which was treated according to the doctor's order. The facility followed the doctor's orders in a timely manner, and there was no evidence of neglect. The allegations were determined to be unfounded.
Report Facts
Facility capacity: 135
Census: 92
Skin tear size: 1
Date complaint received: 11302020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bruce Jacobs | Licensing Evaluator | Conducted the complaint investigation and delivered findings |
| Maureen Bradley | Executive Director | Facility representative met during investigation |
| Liza King | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 135
Deficiencies: 0
Date: Mar 25, 2021
Visit Reason
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.
Complaint Details
The complaint investigation was unsubstantiated as the evidence did not prove the alleged violations occurred.
Findings
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.
Report Facts
Capacity: 135
Census: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bruce Jacobs | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Maureen Bradley | Executive Director | Facility administrator met during investigation |
| Liza King | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 135
Deficiencies: 0
Date: Mar 19, 2021
Visit Reason
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.
Complaint Details
The complaint investigation was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred.
Findings
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.
Report Facts
Capacity: 135
Census: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bruce Jacobs | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Maureen Bradley | Executive Director | Facility administrator met during the investigation |
| Liza King | Licensing Program Manager | Manager overseeing the licensing program |
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