Inspection Reports for Vine Ridge at Cloverdale

The inspection was an unannounced annual case management continuation visit to evaluate compliance with licensing requirements at Vine Ridge Senior Living Facility.

The inspection found deficiencies related to staff training documentation, specifically one staff member lacking proof of annual training and another with incomplete training hours. All other staff and resident documentation were found to be in compliance, and medications were properly stored and documented.

The inspection was an unannounced 1-Year Required annual inspection of Vine Ridge Senior Living Facility to evaluate compliance with licensing requirements.

The facility was generally clean, orderly, and compliant with safety and operational standards, including emergency preparedness and environmental conditions. One deficiency was cited for a staff member not having completed the required Guardian Background Clearance prior to employment. Additionally, flooring in the memory care unit was found to be in disrepair and will be cited under a separate complaint. The annual inspection was not completed and will continue at a later date.

The inspection was a Required - 1 Year unannounced visit to evaluate the licensed assisted living community, including the memory care unit, for compliance with state regulations.

The facility was found to be clean, orderly, and compliant with all reviewed requirements including resident and staff records, emergency plans, infection control, and medication storage. No deficiencies were cited during the visit.

An unannounced complaint investigation was conducted in response to allegations received on 2024-07-10 regarding resident injury, inadequate care and supervision, soiled clothing neglect, unsafe environment, and unsafe transfer methods at Vine Ridge Senior Living Facility.

The investigation found no preponderance of evidence to substantiate any of the allegations. Each complaint, including resident injury, inadequate care and supervision, neglect of continence care, unsafe environment, and unsafe transfer methods, was determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included resident injury due to falls, inadequate supervision, neglect of continence care, unsafe environment due to recliners left open, and unsafe transfer methods. Interviews, record reviews, and observations did not support these allegations.

The inspection was an unannounced complaint investigation conducted in response to allegations that the facility did not have a certified administrator and that staff were not properly trained.

The investigation found that the acting administrator did not have a current administrator certificate but had applied and was pending certification. An interim certified administrator was present part-time. The allegation regarding staff training was unsubstantiated as records and interviews showed staff had required training and sufficient coverage.

The complaint investigation was unsubstantiated. The allegation that the facility did not have a certified administrator was partially true but pending certification and interim coverage was provided. The allegation that staff were not properly trained was unsubstantiated due to lack of evidence.

The visit was an unannounced case management inspection conducted to cite deficiencies discovered during a prior complaint investigation.

The licensee failed to notify the Department in writing within thirty days of hiring a new administrator in December 2023, which is a regulatory violation and a potential risk to resident health and safety.

Deficiencies were cited based on a complaint investigation regarding failure to notify the Department of administrator change within the required timeframe.

An unannounced annual required inspection of the facility was conducted to evaluate compliance with regulations and licensing requirements.

The facility was found to be clean, in good repair, and compliant with safety and food storage regulations. However, five out of five staff records reviewed did not contain documentation of completed training records as required, posing a potential health, safety, or personal rights risk to persons in care.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-07-03 regarding failure to reassess resident needs and overcharging for care services.

The investigation substantiated that the facility overcharged a resident due to lack of documented reassessment following a significant change in condition as indicated by a physician's report. Another allegation regarding failure to provide timely copies of records was found to be unfounded.

The complaint investigation was substantiated for overcharging a resident due to failure to reassess care needs after a significant change in condition. The allegation that staff did not provide resident with a copy of records in a timely manner was found to be unfounded.

The inspection was an unannounced complaint investigation conducted in response to multiple allegations including failure to follow Covid protocols, failure to follow resident's care plan, reporting requirements, and neglect/lack of supervision resulting in resident elopement.

The complaint that the facility was not following Covid protocols was substantiated with observation of staff not wearing masks. The allegations that staff were not following a resident's care plan and reporting requirements were unsubstantiated. The allegation of neglect/lack of supervision resulting in resident elopement was found to be unfounded with no deficiencies cited.

The complaint investigation addressed allegations of failure to follow Covid protocols, failure to follow resident's care plan, failure to meet reporting requirements, and neglect/lack of supervision resulting in resident elopement. The Covid protocol allegation was substantiated; the care plan and reporting allegations were unsubstantiated; and the neglect/elopement allegation was unfounded.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-09-22 regarding removal of resident's personal belongings without consent and denial of entry to a resident's visitor.

The investigation found the allegations unsubstantiated due to lack of preponderance of evidence. Staff removed moldy food items from a resident's room per facility policy, and the visitor in question did not physically attempt entry, so no denial occurred. No deficiencies were cited.

The complaint alleged that the facility removed a resident's personal belongings without consent and did not allow entry to a resident's visitor. The findings were unsubstantiated, meaning there was insufficient evidence to prove the allegations.

The inspection was an unannounced annual required inspection focused on infection control procedures and practices at the facility.

The facility generally maintained infection control practices including PPE supply, signage, and staff mask use. However, a deficiency was cited related to the elopement of a memory care resident, indicating a failure to meet safety measures for residents with dementia.

Unannounced Plan of Correction visit to amend a prior report and review submitted corrections related to personnel requirements and basic services violations cited on August 31, 2022.

The Licensing Program Analyst observed compliance with the required corrections and cleared the deficiency related to basic services. No deficiencies were cited during this inspection.

Unannounced Plan of Correction visit to verify that previously cited deficiencies were corrected.

The facility corrected all deficiencies cited on August 19, 2022, including repairs to the delayed egress door, exterior door locking mechanism, and a leaking pipe causing ceiling discoloration. No deficiencies were cited during this visit.

The inspection was an unannounced complaint investigation visit triggered by allegations of insufficient staffing, resident needs not being met, and administrator qualifications.

The complaint allegations of insufficient staffing and resident needs not being met were substantiated, with evidence showing staffing shortages impacting resident care. The allegation regarding administrator qualifications was unsubstantiated, with the administrator found qualified despite having to perform caregiving duties due to staffing shortages.

The complaint investigation was substantiated for allegations of insufficient staffing and resident needs not being met, meaning the allegations were valid based on the preponderance of evidence. The allegation regarding administrator qualifications was unsubstantiated.

An unannounced complaint investigation was conducted regarding an allegation that the facility retaliated against a whistleblower by terminating their employment.

The investigation found the allegation to be unsubstantiated as there was insufficient evidence to prove retaliation occurred. Interviews indicated that three employees voluntarily terminated their employment by walking off the job. No deficiencies were cited.

The complaint alleged that the facility retaliated against a whistleblower by terminating their employment. The allegation was found unsubstantiated due to lack of preponderance of evidence.

Unannounced complaint investigation visit conducted to investigate allegations regarding delayed egress doors and gates in the Memory Care area.

Concerns were found that exterior gates in the Memory Care outdoor area do not alarm when pressed and staff are not notified via phone application when these gates are opened. One of three gates has a lock on the latch. The local fire department was called to address the gates and will provide additional information. No deficiencies were cited.

Complaint investigation visit revealed concerns about delayed egress doors and gates in Memory Care, specifically that exterior gates do not alarm and staff are not notified when gates are opened.

Unannounced complaint investigation visit conducted due to allegations that the facility did not follow their Covid Mitigation Plan, was not safe, sanitary and in good repair, and failed to ensure proper fingerprint clearance and association of individuals.

The investigation substantiated that the facility failed to follow their Covid Mitigation Plan, including failure to notify residents and responsible parties of Covid positive cases and failure to test all staff and residents. The facility was also found not safe and in good repair due to malfunctioning delayed egress doors and evidence of plumbing leaks. The allegation regarding improper fingerprint clearance and association was unsubstantiated.

Complaint was substantiated for failure to follow Covid Mitigation Plan and unsafe, unsanitary conditions. The fingerprint clearance allegation was unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-05-03 alleging failure to ensure resident's personal rights, retention of a resident with a prohibited condition, and failure to meet resident's care needs.

The complaint that the facility failed to ensure resident's personal rights was substantiated, with evidence that a resident entered other residents' rooms and took their clothes. The allegations that the facility retained a resident with a prohibited condition and failed to meet resident's care needs were unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for failure to ensure resident's personal rights. The allegations regarding retention of a resident with a prohibited condition (staph infection) and failure to meet resident's care needs (weeping wounds and rash) were unsubstantiated.

An unannounced complaint investigation was conducted regarding an allegation that the facility administrator was not qualified due to not having an administrator certificate.

The investigation found that the complaint was unfounded. The previous administrator had left, and the acting administrator and licensee both hold active administrator certificates and are in the process of completing the change of administrator paperwork.

The complaint alleged that the facility administrator was not qualified due to not having an administrator certificate. The complaint was found to be unfounded.

The inspection was conducted as a Case Management follow-up on an incident where a resident in Memory Care eloped the facility and staff did not respond to the delayed egress alarm.

The facility was found deficient for not having an adequate number of direct care staff to support residents, resulting in a resident eloping and staff failing to respond to the delayed egress alarm, posing an immediate risk to resident health and safety.

The visit was complaint-related, following up on an incident where a Memory Care resident eloped the facility and staff failed to respond to the delayed egress alarm. The complaint was substantiated by interview and document review.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-01-27 alleging insufficient staffing and multiple resident care concerns at Vine Ridge at Cloverdale facility.

The complaint of insufficient staffing was substantiated, indicating staff shortages leading to delayed or unmet resident needs. Other allegations including improper feeding, medication mishandling, unsafe and unsanitary conditions, resident fall, unmet incontinence and laundry needs, and failure to follow resident care plans were unsubstantiated due to lack of sufficient evidence.

The complaint investigation was substantiated for insufficient staffing, meaning the allegation was valid based on the preponderance of evidence. Other allegations related to resident feeding, medication handling, facility sanitation, resident fall, incontinence care, laundry services, and adherence to care plans were unsubstantiated.

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

The facility demonstrated compliance with infection control practices including PPE availability, staff mask usage, and cleaning protocols. No deficiencies were cited during this inspection.

The visit was an unannounced follow-up to verify proof of correction for a citation issued on 2021-09-16 that required staff training.

The Licensing Program Analyst met with the administrator who provided proof of completion of the required staff training. The citation issued on 2021-09-16 was cleared and no new citations were issued during this visit.

Unannounced complaint investigation visit conducted due to multiple allegations including insufficient care and supervision resulting in injury, failure to seek timely medical attention, failure to address changes in resident condition, failure to meet resident care needs, violation of personal rights, and failure to report incidents as required.

The investigation found the initial allegations unsubstantiated based on staff, resident, and family interviews, observations, and record reviews indicating appropriate care and reporting. However, a separate substantiated finding was made regarding hazardous products being accessible to residents and lack of staff training on this issue.

The complaint investigation was unannounced and addressed multiple allegations including insufficient care, failure to seek timely medical attention, failure to address changes in resident condition, failure to meet resident care needs, violation of personal rights, and failure to report incidents. The initial allegations were found unsubstantiated, but the allegation regarding hazardous products accessibility and staff training was substantiated.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 06/28/2021 regarding facility cleanliness, mitigation plan adherence, medication log accuracy, and medication dispensing practices.

The investigation found that the facility was clean, the mitigation plan was being followed, and medication administration and record keeping complied with regulations. There was no preponderance of evidence to support the allegations, so they were unsubstantiated. However, a related allegation about medication accessibility to residents was substantiated in a prior complaint received on 06/16/2021.

The complaint investigation addressed allegations that facility staff did not keep the facility clean, were not following their mitigation plan, were not keeping accurate medication logs, and were not dispensing medications as prescribed. These allegations were found to be unsubstantiated. However, the allegation that facility staff did not ensure medications were inaccessible to residents was substantiated in a separate complaint #21-AS-202106160-85247 received on 06/16/2021.

Unannounced follow-up visit to verify correction of citations issued on 2021-09-16, specifically regarding staff training in medical and dental care.

No deficiencies were cited during this visit. The administrator reported that all but one staff member have completed the required training, with the remaining staff expected to complete it upon return from approved leave.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/16/2021 regarding staff training, medication storage, and maintenance of the centrally stored medication log.

The investigation substantiated that staff were not properly trained and medication was not stored inaccessible to residents, posing immediate risks. However, the allegation regarding the centrally stored medication log not being maintained was unsubstantiated.

The complaint investigation was substantiated for allegations that staff were not trained and medication was not stored inaccessible to residents. The allegation that the centrally stored medication log was not maintained was unsubstantiated.