Inspection Reports for
Vienna at Santianna – Memory Care

The complaint investigation was unsubstantiated based on interviews with staff and residents, review of facility records, and direct observations. No evidence supported the allegations.

The investigation found all complaints against the staff to be unsubstantiated. Interviews, record reviews, and observations confirmed that residents were provided meals, floors were cleaned, hazardous items were not accessible, trash was properly disposed of, and call light response times were within acceptable limits. The facility ceased operations on or about November 26, 2025.

The complaint was unsubstantiated. The investigation included unannounced visits, interviews with staff and the resident, and records review. The resident confirmed satisfaction with the facility's response and compensation. The elevator repair was timely and did not prevent resident mobility.

The investigation found that the facility addressed the air conditioning issues by providing portable units and that the resident misunderstood thermostat use. The elevator was out of service for about two weeks but was repaired promptly, with another elevator remaining operational. The resident's hospitalization was due to co-morbidities unrelated to room temperature. Overall, the allegations were unsubstantiated.

The complaint alleged that staff mishandled Resident 1 (R1). The investigation included unannounced visits, interviews, and records review. Staff and the responsible party denied the allegation, and R1 was unable to provide details due to cognitive impairment. The allegation was determined to be unsubstantiated.

The investigation found no evidence to corroborate the allegation of rough handling by staff. Interviews with staff, residents, and the responsible party, as well as records review, indicated that the allegation was unsubstantiated due to lack of proof.

The complaint investigation was unsubstantiated. Despite allegations of multiple issues, the Department found no preponderance of evidence to prove violations occurred. The allegations included failure to report elopement, lack of drills, untrained registry staff, neglect of care, census unawareness, and outdated service plans.

The investigation found no substantiated violations related to the allegations. Staff and records confirmed no elopement incidents, regular emergency drills, trained registry staff, adequate personal care, accurate census tracking, and updated service plans for residents with condition changes. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The facility was found to be clean, safe, and in good repair with no pathway obstructions. Bathrooms and showers were in working order, hazardous materials and medications were securely stored, fire safety equipment was compliant, and required postings were observed. The facility had adequate food supplies and approved fire inspection status. No deficiencies were identified during this visit.

The report documents the administrator's participation in the COMP II interview process, confirming knowledge of licensing laws and regulations. No specific deficiencies or violations are listed in the report.

The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All required safety equipment, furnishings, and supplies were present and in working order.

The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All required safety equipment, furnishings, and supplies were present and in working order. Confidential records were properly stored and licensing postings were observed.

The visit was complaint-related due to self-reported incidents involving resident falls, elopements, and medication issues. No deficiencies were found, and no substantiation status was stated.

A wellness check was completed with no health or safety issues identified. No deficiencies were cited or observed during this unannounced case management visit.

No health or safety issues were identified during the wellness check, and no deficiencies were cited or observed on this date.

The complaint was unsubstantiated. Allegations included failure to prevent resident elopement and failure to arrange psychiatric care. Investigation included record reviews and interviews, concluding the allegations were unsubstantiated.

The investigation found no preponderance of evidence to prove the alleged violations occurred. Resident 1 was followed by staff during exit seeking behavior, was not left unsupervised, and was provided emergency medical care. There was no known history of exit seeking or aggressive behaviors requiring psychiatric care prior to the incident.

The complaint alleged that the licensee failed to prevent Resident 1 from eloping and failed to arrange psychiatric medical care. The allegations were found to be unsubstantiated based on interviews, record reviews, and observations.

The investigation found no preponderance of evidence to substantiate the allegations. Resident 1 was followed by staff during an exit attempt, was not left unsupervised, and was provided emergency medical care. There was no known history of exit seeking or aggressive behaviors requiring psychiatric care prior to the incident.

The visit was complaint-related due to incidents of Resident 1 and Resident 2 suffering falls with injury. No deficiencies were found, indicating no substantiated violations.

The Licensing Program Analyst interviewed staff and residents, conducted a wellness check, and found no health or safety issues. No deficiencies were cited or observed during this visit.

The visit was complaint-related due to self-reported incidents of Resident 1 and Resident 2 suffering falls with injury. No deficiencies were found.

The Licensing Program Analyst conducted interviews and a wellness check, finding no health or safety issues and no deficiencies cited or observed during the visit.

The complaint was unsubstantiated after investigation. Allegations included staff sleeping on duty, failure to follow resident care plans, and unclean resident rooms. Evidence did not support these claims.

The investigation found no evidence to substantiate the allegations. Staff interviews, resident and outside source interviews, records review, and direct observations indicated that staff did not sleep on duty, resident care plans were followed, and resident rooms were maintained clean.

The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All required safety, sanitation, and licensing standards were met during the inspection.

The Licensing Program Analyst conducted interviews and a wellness check, identifying no health or safety issues. No deficiencies were cited during the visit.

The facility was found to be clean, sanitary, and in good repair with no deficiencies cited. All required safety equipment, furnishings, and supplies were present and in working order.

The complaint alleged staff slept on duty resulting in lack of supervision, failure to follow a resident's care plan regarding hourly checks, and failure to keep resident rooms clean. The investigation concluded these allegations were unsubstantiated based on interviews, observations, and records.

The investigation found no evidence to substantiate the allegations. Staff interviews, resident interviews, outside source interviews, records review, and direct observations all indicated that staff met resident needs, followed care plans, and maintained clean resident rooms.

The Licensing Program Analyst interviewed staff and residents, conducted a wellness check, and found no health or safety issues. No deficiencies were cited during the visit.

The complaint alleged that the Licensee did not address concerns regarding door egress, resulting in injury. The allegation was found to be unsubstantiated based on interviews, observations, and records review.

The investigation found that while the doors were heavy and closed quickly, the Licensee had been actively addressing the issue since November 2023 through contractor adjustments and communication with residents. Evidence did not support that the Licensee failed to make efforts to correct the problem, resulting in the allegation being unsubstantiated.

The complaint was unsubstantiated. Allegations included failure to maintain resident hygiene and failure to assist with medical care for a pressure sore. Evidence showed attempts to provide care and communication with the physician, with no proof of violation.

The investigation found that the resident frequently refused showers, but staff made regular attempts and communicated with the family to improve consent. Staff were aware of the pressure sore, communicated with the resident's physician, and received medication orders after the resident moved out. The allegations were unsubstantiated based on interviews, observations, and records review.

The complaint alleged that the Licensee did not address concerns regarding door egress, resulting in injury. The allegation was found to be unsubstantiated after investigation.

The investigation found that while the doors were heavy and closed quickly, resulting in a prior minor injury, the Licensee had been actively addressing the issue since November 2023 through contractor adjustments and communication with residents. The allegation was unsubstantiated based on interviews, observations, and records review.

The complaint was unsubstantiated. Allegations included failure to maintain resident hygiene and failure to assist with medical care for a pressure sore. Evidence showed attempts to provide care and communication with the resident's physician. The pressure sore was at a low stage and treated prior to resident transfer.

The investigation found that the resident frequently refused showers, staff communicated with the family and made scheduling adjustments, and staff made regular attempts to provide care. The pressure sore was monitored and treated with prescribed barrier cream after the resident had moved out. The allegations were unsubstantiated based on interviews, observations, and records review.

The complaint alleged neglect resulting in unexplained bruising on Resident 1. The allegation was found to be unsubstantiated after investigation including staff and outside source interviews, records review, and observations.

The investigation included interviews, record reviews, and observations, concluding that there was no preponderance of evidence to substantiate the allegation of neglect. The bruising was noted to be related to the resident's agitation episodes and no evidence of staff abuse or neglect was found.

The complaint alleged neglect resulting in unexplained bruising of a resident. The allegation was unsubstantiated based on interviews, observations, records review, and outside investigations.

The investigation found no corroboration or evidence to support the allegation of neglect causing unexplained bruising. Interviews, records review, and outside source investigations did not substantiate the complaint, and the allegation was determined to be unsubstantiated.

The complaint was unsubstantiated based on interviews, records review, and outside source corroboration. The allegations included failure to follow physician's orders, obtaining Home Health services without consent, and denying Home Health agency access. Evidence showed consent was obtained and care was provided by the Home Health agency.

The investigation found that the facility staff could not provide the wound care as it was not a medical facility, but assisted the resident in obtaining Home Health services which provided the care. The resident had signed consent for the Home Health agency care. No evidence was found that the Home Health agency was denied access to the resident. The allegations were unsubstantiated.

The complaint was unsubstantiated after investigation, which included unannounced visits, record reviews, and interviews with staff and outside sources. The allegations regarding failure to follow physician's orders, unauthorized Home Health service provider, and denial of Home Health agency access were not supported by evidence.

The investigation found that the licensee did not provide wound care directly because it was not a medical facility but assisted the resident in obtaining Home Health services, with signed consent from the resident. The Home Health agency was allowed access to provide care, and no evidence supported the allegations. Therefore, all allegations were unsubstantiated.

The complaint alleged lack of supervision resulting in a resident AWOL. The allegation was found to be unsubstantiated based on evidence from interviews, observations, and records review.

The investigation included unannounced visits, record reviews, staff interviews, and direct observations. It was found that the resident exited through a door that did not latch properly and the door alarm was deactivated by staff. However, all other doors were functioning properly and staff responded promptly when alarms sounded. The allegation was determined to be unsubstantiated.

The complaint alleged lack of supervision resulting in a resident AWOL. The allegation was found to be unsubstantiated after investigation.

The investigation found that the resident exited through a door that did not completely latch after being opened by staff, and the door alarm was deactivated by a staff member assisting an outside individual. However, all other delayed egress doors were functioning properly and staff responded promptly when alarms sounded. The allegation was unsubstantiated based on interviews, observations, and records review.

The complaint investigation was unsubstantiated. Allegations included failure to ensure a family council was generated, denial of authorized representative access, and staff not meeting minimum qualifications. Evidence did not support these claims, and the allegations were dismissed.

The investigation found no evidence to substantiate the allegations that staff failed to assist in creating a family council or denied authorized representative access to the facility. The Licensee provided required information about family councils and restricted access to a disruptive individual only to protect other residents' rights. The allegation that staff did not meet minimum qualifications was also found to be unfounded based on approved equivalent experience documentation.

The complaint investigation addressed allegations that staff did not assist with the creation of a Family Council upon request and that staff denied an authorized representative access to a resident. The investigation included multiple unannounced visits, interviews with staff, residents, and outside sources, and records review. The findings concluded the allegations were unsubstantiated.

The investigation found no preponderance of evidence to support that the Licensee prohibited the formation of a Family Council or denied an authorized representative access to the facility. The allegations were determined to be unsubstantiated based on interviews, records review, and observations.

The complaint was unsubstantiated after investigation including interviews, observations, and records review. Allegations included unsupervised resident wandering and a gate in disrepair; both were found unsupported by evidence.

The investigation found no evidence to substantiate the allegations. The resident was observed to be independent and able to ambulate without supervision, and the facility gate was found to be in good repair with ongoing upgrades in progress.

The complaint was unsubstantiated after investigation, which included interviews, record reviews, and direct observations. Allegations involved resident supervision and facility gate safety.

The investigation found no evidence to substantiate the allegations. The resident was observed to be independent and did not require supervision, and the facility gate was found to be in good repair with ongoing upgrades in progress.

The investigation found no preponderance of evidence that staff failed to observe the resident or that lack of supervision caused the elopement. No deficiencies were cited for this incident.

The resident was found unharmed and no deficiencies were cited related to the incident. The delayed egress doors operated correctly except for an inconsistent self-closing mechanism on one door, which did not constitute a violation. Staff had been retrained on elopement policies and responded promptly to alarms during testing.

The investigation was triggered by a complaint incident report about Resident #1's fall and subsequent medical care. The complaint was not substantiated as timely emergency care was arranged.

No deficiencies were cited related to the incident, and no deficiencies were identified during the visit. A Technical Violation/Education was delivered regarding reporting requirements.

The complaint involved a resident eloping from the secured memory care unit. The incident was self-reported by the licensee. The investigation found no substantiated deficiencies or staff neglect.

The resident was found unharmed and no deficiency was cited. The investigation found no evidence of staff neglect or lack of supervision. The delayed egress doors functioned correctly except for an inconsistent self-closing mechanism on one door, which was not a violation. Staff were retrained on elopement policies.

The complaint involved an incident where Resident #1 fell and initially refused emergency transport but later was taken to the ER and diagnosed with lumbar spine fractures. The investigation found no preponderance of evidence that the licensee failed to arrange timely emergency medical care.

No deficiencies were identified or cited during the visit. The facility timely notified the physician and responsible person, kept the resident under observation, and arranged emergency care appropriately. A Technical Violation/Education was delivered regarding reporting requirements.

Complaint alleging the facility had not conducted an emergency drill was investigated and found to be unfounded.

The investigation found the complaint to be unfounded. Records and interviews confirmed that multiple emergency drills and preparedness trainings had been conducted since April 2022. The complaint was dismissed after an exit interview with the Executive Director.

The complaint alleging the facility had not conducted an emergency drill was investigated and found to be unfounded, meaning the allegation was false and without reasonable basis.

The investigation found the complaint to be unfounded. Records and interviews confirmed that multiple emergency drills and emergency preparedness trainings had been conducted since April 2022.

The complaint was investigated and found to be unfounded based on observations and interviews with the Executive Director. The Community Care Licensing poster and Ombudsman poster were both present but not exactly as alleged.

The investigation found that the Community Care Licensing poster was posted near the main entrance down a hallway and the Long-Term Care Ombudsman poster was posted in the residents' activity room. There was insufficient evidence to support the allegations, and the complaint was deemed unfounded.

The complaint was investigated and found to be unfounded based on observations and interviews. The allegations regarding missing posters were not supported by evidence.

The investigation found that the Community Care Licensing poster was posted near the main entrance down a hallway and the Ombudsman poster was posted in the residents' activity room. There was insufficient evidence to support the allegations, and the complaint was deemed unfounded.

The complaint alleged that the facility elevator was not maintained in good repair. The investigation included interviews with staff, residents, and maintenance personnel, as well as review of maintenance records and invoices. The allegation was found unsubstantiated.

The investigation found that only one elevator was out of service at a time, often reserved for movers during resident move-ins, with proper signage and maintenance contracts in place. The allegation was deemed unsubstantiated based on observations, interviews, and record reviews.

The complaint alleged that the facility elevator was not maintained in good repair. The investigation included interviews with staff, residents, and outside sources, as well as review of maintenance records and observations. The allegation was found unsubstantiated.

The investigation found that while there were operational issues with one elevator in September 2022, the facility maintained regular elevator maintenance and inspections. Only one elevator was out of service at a time, and the other was available for resident use. The allegation was deemed unsubstantiated based on observations, interviews, and record review.

The complaint was unsubstantiated based on direct observations, staff interviews, and records review. The alleged sewage leak was determined to be groundwater from a cable box crack, not sewage, and lighting was confirmed to be sufficient and functional.

The investigation found no evidence of a sewage leak or unsanitary conditions in the parking garage, and the lighting in the garage was observed to be operable and adequate. Both allegations were determined to be unsubstantiated.

The complaint was unsubstantiated after investigation. Allegations included unsanitary conditions due to a sewage leak and inadequate lighting in the parking garage. Evidence showed no sewage leak and adequate lighting.

The investigation found no evidence of a sewage leak in the parking garage; the leak was determined to be ground water from a cable box crack, which was sealed. The lighting in the parking garage was found to be operable and adequate with LED lights. Both allegations were unsubstantiated.

During the visit, the team interviewed the Regional Operations Specialist and Maintenance Director and conducted a walk-through of the facility. No deficiencies were cited during the visit.

During the visit, the team interviewed facility staff and conducted a walk-through of the facility. No deficiencies were cited during this assessment visit.

The facility was found to be clean, sanitary, and in good repair with no obstructions or slip hazards. All resident rooms, common areas, and equipment were inspected and found adequate. The facility fire clearance was granted, and safety measures such as locked medication storage and operational signal systems were confirmed.

The facility was found to be clean, sanitary, and in good repair with no obstructions or slip hazards. Hot water temperatures were within acceptable ranges, and the facility had sufficient space and equipment for resident activities and safety measures including locked medication storage and operational signal systems. Fire clearance was granted, approving the facility for 226 elderly residents.

The applicant and administrator successfully completed the Component II evaluation, confirming understanding of facility operation, staff qualifications, program policies, and application requirements. No clients were in care at the time of the evaluation.

The applicant and administrator successfully completed Component II of the licensing process, demonstrating understanding of facility operation, staff qualifications, program policies, and compliance requirements. No clients were in care at the time of the evaluation.