Inspection Reports for Westmont of La Mesa
9000 Murray Dr, La Mesa, CA 91942, United States, CA, 91942
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, reflecting generally good compliance with regulations. The most recent report from August 20, 2025, was clean with no deficiencies observed. Earlier reports identified some issues including substantiated neglect related to delayed medical attention, resident abuse by staff resulting in bruising, failure to report incidents timely, and a medication administration error; these were isolated and addressed with staff termination or corrective actions. There was also a substantiated deficiency during a COVID-19 outbreak in 2022 related to improper mask use by staff. Overall, the facility’s record shows improvement over time, with recent inspections consistently free of deficiencies.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 125
Capacity: 164
Deficiencies: 0
Aug 20, 2025
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements and facility conditions.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited. All safety equipment and required postings were in place, and staff and client records were complete and properly stored.
Report Facts
Capacity: 164
Census: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Benjie Doctolero | Operations Specialist | Met with during inspection and exit interview |
| Amy Rodgers | Licensing Program Analyst | Conducted the inspection and signed the report |
| Angelica Boyles | Licensing Program Analyst | Conducted the inspection |
| Kimberly Garcia | Administrator/Director | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 164
Deficiencies: 0
Aug 18, 2025
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 07/11/2023 alleging neglect resulting in serious bodily injury and failure to provide timely medical care to a resident.
Findings
The investigation found that although the resident suffered a fall and a subsequent hip fracture, the facility staff provided appropriate care and supervision, including timely medical attention and hospice involvement. Interviews with residents and outside sources confirmed adequate care and supervision. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
Complaint alleged neglect resulting in serious bodily injury and failure to provide timely medical care. The allegation was unsubstantiated after investigation including record reviews, interviews, and observations.
Report Facts
Companion hours reduction: 8
Resident interviews: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Benjie Doctolero | Operation Specialist | Met with investigator during the visit and acknowledged receipt of report and licensee rights. |
| Kimberly Garcia | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 164
Deficiencies: 0
Sep 26, 2024
Visit Reason
The visit was conducted in response to an incident self-reported by the licensee involving missing personal belongings of a resident, which was reported via an SOC341 on 2024-09-17.
Findings
The Licensing Program Analyst conducted an unannounced case management visit, interviewed staff, reviewed facility records, and found no deficiencies during the inspection.
Complaint Details
The complaint involved missing personal belongings of Resident #1 from their apartment. The apartment was thoroughly searched, and local law enforcement and the Ombudsman were notified. No deficiencies were substantiated during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Sabrina Priesman | Executive Director | Met with the Licensing Program Analyst during the visit. |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 164
Deficiencies: 1
Jun 19, 2024
Visit Reason
The investigation was conducted due to a complaint alleging neglect that contributed to a resident's death and failure to follow reporting requirements.
Findings
The allegation of neglect contributing to the resident's death was unsubstantiated after review of records and interviews. However, the allegation regarding failure to complete required reporting for a resident's fall, hospitalization, and death was substantiated, with the facility failing to submit required Unusual Incident/Injury and Death Reports.
Complaint Details
The complaint alleged neglect that contributed to a resident's death and failure to follow reporting requirements. The neglect allegation was unsubstantiated, but the reporting requirements allegation was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report 1 out of 120 resident fall, hospitalization, or death which poses a potential health, safety or personal rights risk to persons in care. | Type B |
Report Facts
Resident fall not reported: 1
Facility capacity: 164
Census: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| David Armour | Administrator | Facility administrator named in the report. |
| Sabrina Priesman | Executive Director | Met with Licensing Program Analyst during investigation and involved in exit interviews. |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 164
Deficiencies: 1
Jun 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff failed to seek timely medical attention for a resident.
Findings
The investigation substantiated that the facility delayed medical attention for one resident who expressed pain for five days following a fall, which posed an immediate health and safety risk. The resident was eventually diagnosed with a fractured pelvis after being transported to the hospital.
Complaint Details
The complaint alleged that facility staff failed to seek timely medical attention for Resident 1 after a fall on January 18, 2023. The resident expressed pain for five days before being transported to the hospital and diagnosed with a fractured pelvis. The allegation was substantiated based on interviews and records.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee delayed medical attention for 1 of 126 residents who expressed pain for 5 days, posing an immediate health, safety, or personal risk to persons in care. | Type A |
Report Facts
Resident census: 126
Total capacity: 164
Deficiency count: 1
Plan of Correction due date: Jun 27, 2024
Days of delayed medical attention: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Simon Jacob | Licensing Program Manager | Oversaw the complaint investigation |
| Sabrina Priesman | Executive Director | Facility representative who received the report and plan of correction |
| Kimberly Garcia | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 164
Deficiencies: 1
Jun 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff pushed a resident causing a bruise.
Findings
The investigation found that staff member S2 treated resident R1 roughly, resulting in a quarter-size bruise on R1's upper right arm. The allegation was substantiated based on interviews, records review, and observations. Staff S2 was no longer employed at the facility as of June 8, 2023.
Complaint Details
The complaint was substantiated. The allegation involved staff pushing a resident causing a bruise. The investigation included interviews with staff and residents, records review, and a facility tour. Staff member S2 was found to have not applied elder abuse training and was terminated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident was free from abuse resulting in bruising, violating personal rights under CCR 87468.1(a)(3). | Type A |
Report Facts
Residents in care: 126
Licensed capacity: 164
Deficiency type count: 1
Plan of Correction due date: Jun 28, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the complaint investigation visit |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
| Kimberly Garcia | Administrator | Facility Administrator named in report |
| Sabrina Priesman | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 92
Capacity: 164
Deficiencies: 0
May 29, 2024
Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing regulations for the facility.
Findings
The facility was found to be clean, sanitary, and in good repair with no deficiencies observed or cited. All safety equipment and required documents were in place and functioning properly.
Report Facts
Facility capacity: 164
Census: 92
Hot water temperature: 112
Hot water temperature: 111
Hot water temperature: 112
Refrigerator temperature: 31
Freezer temperature: 0
Perishable food supply: 2
Non-perishable food supply: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the inspection and authored the report |
| Sabrina Priesman | Executive Director | Facility representative met during inspection and exit interview |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 92
Capacity: 164
Deficiencies: 1
May 29, 2024
Visit Reason
The visit was an unannounced case management follow-up regarding a self-reported incident where a resident's medication was not administered as ordered.
Findings
The licensee failed to ensure that Resident 1's medication was administered according to the physician's orders from May 12 through May 18, 2024, posing a potential health risk. The resident did not experience adverse effects, and the correct medication was delivered and administered starting May 19, 2024.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that Resident 1's medication was administered as ordered by the physician. | Type B |
Report Facts
Residents in care: 92
Total licensed capacity: 164
Deficiency count: 1
Plan of Correction due date: Jun 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the unannounced case management visit and cited the medication administration deficiency |
| Sabrina Priesman | Executive Director | Met with Licensing Program Analyst during the visit and participated in the exit interview |
| Simon Jacob | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 164
Deficiencies: 0
Apr 4, 2024
Visit Reason
The inspection visit was an unannounced case management visit conducted in response to a self-reported incident involving an unwitnessed fall of a resident on March 19, 2024.
Findings
During the visit, a Health and Safety check was conducted on the resident involved in the incident and facility records were reviewed. No deficiencies were cited at this time.
Complaint Details
The visit was triggered by a complaint/self-report regarding an incident where Resident 1 had an unwitnessed fall resulting in a change in condition. The resident initially refused hospital care but was sent to the hospital the following day for evaluation and treatment.
Report Facts
Capacity: 164
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the unannounced case management visit and inspection |
| Sheryl McCaskill | Operation Specialist | Met with Licensing Program Analyst during the visit and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 164
Deficiencies: 0
Jan 30, 2024
Visit Reason
The visit was an unannounced Case Management - Incident inspection conducted in response to an LIC624 Incident Report regarding Resident #1 eloping from the facility on 01/27/2024.
Findings
The resident was found unharmed outside the facility after eloping. The facility's delayed-egress doors were inspected and found operational. No deficiencies were cited, but two Technical Violations related to signage and reporting requirements were issued, along with Technical Assistance regarding electronic equipment for staff.
Complaint Details
The complaint involved Resident #1 eloping from the secured memory care section. The incident was substantiated by staff interviews and records. The resident was located unharmed in the parking lot after a door alarm was triggered.
Report Facts
Technical Violations issued: 2
Medication Technicians on duty: 2
Caregivers on duty: 4
Delayed-egress doors: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Garcia | Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Lizzette Tellez | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 164
Deficiencies: 0
Jan 4, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to determine the validity of allegations received on 2023-12-28 regarding odor control, assistance with incontinence needs, resident hygiene, and adequacy of food service.
Findings
The investigation found no evidence to substantiate the allegations. Staff were observed to maintain odor control, assist with incontinence needs, meet residents' hygiene needs, and provide adequate food service despite some residents choosing to skip meals.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to keep the facility free of odors, failure to assist residents with incontinence needs, failure to meet residents' hygiene needs, and inadequate food service. The investigation found no violations.
Report Facts
Census: 140
Total Capacity: 164
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Garcia | Director | Met with Licensing Program Analyst during the investigation and participated in exit interview |
| Renita Hall | Licensing Program Analyst | Conducted the complaint investigation visit |
| Denise Powell | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Census: 132
Capacity: 164
Deficiencies: 0
Sep 26, 2023
Visit Reason
The visit was an unannounced Case Management - Incident visit in response to an LIC624 Incident Report regarding a resident elopement.
Findings
The Licensing Program Analyst conducted a facility tour, reviewed records, and interviewed staff and the resident involved. The resident was found safe, staff followed the AWOL policy, and no deficiencies were cited during the visit.
Report Facts
Number of staff who retrieved resident: 3
Alert charting duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Garcia | Administrator | Met with Licensing Program Analyst during the visit and involved in the exit interview. |
| Jeunesse Holmes | Resident Services Director | Met with Licensing Program Analyst during the visit. |
| Riza Gloria Alvarez | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 164
Deficiencies: 0
Jul 26, 2023
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following allegations that a resident was being held against their will and was not allowed visitors.
Findings
The investigation included record reviews and interviews with staff and outside sources. The allegations were determined to be unsubstantiated as evidence showed the resident was not held against their will and was allowed visitors.
Complaint Details
The complaint alleged that Resident 1 was held against their will and not allowed visitors. The lawsuit related to the allegation was withdrawn. Interviews and records confirmed the resident was allowed visitors. The allegations were unsubstantiated based on the preponderance of evidence.
Report Facts
Capacity: 164
Census: 137
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Kimberly Garcia | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Capacity: 164
Deficiencies: 0
Jun 28, 2023
Visit Reason
The visit was an unannounced Case Management - Incident visit conducted in response to an LIC624 Incident Report regarding a resident eloping from the facility.
Findings
No deficiencies were cited or observed during the visit. The resident who eloped returned unharmed, and staff followed the written Absentee Notification Plan as required.
Report Facts
Facility capacity: 164
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Garcia | Executive Director | Met with Licensing Program Analyst during the visit and involved in exit interview |
| Alyssa Ramirez | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Simon Jacob | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 164
Deficiencies: 2
Feb 28, 2023
Visit Reason
The visit was conducted in response to a self-submitted SOC341 Report of Suspected Dependent Adult/Elder Abuse regarding incidents involving a staff member and a resident.
Findings
The investigation found that staff member S1 did not accord dignity to Resident #1 and subjected the resident to verbal abuse and inappropriate physical checks, leading to S1's termination. The resident was physically unharmed but had baseline disorientation and dementia.
Complaint Details
The complaint was substantiated based on staff interviews and personnel records. S1 denied the allegations, but three co-workers corroborated the events. S1 was placed on administrative leave and subsequently terminated on 2023-02-09.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee’s staff (S1) did not accord dignity to 1 of 121 residents (R1), posing a potential personal rights risk. | Type B |
| Licensee staff (S1) did not ensure 1 of 121 residents (R1) was free from abuse, posing a potential personal rights risk. | Type B |
Report Facts
Residents present: 121
Total licensed capacity: 164
Deficiency count: 2
Plan of Correction due date: Mar 30, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management visit and investigation |
| Lizzette Tellez | Licensing Program Manager | Supervised the licensing evaluation |
| Mayra Rodriguez | Business Office Director | Met with Licensing Program Analyst during visit and exit interview |
| Eva Amorim | Compass Rose (Memory Care) Director | Met with Licensing Program Analyst during visit |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 164
Deficiencies: 0
Nov 30, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 08/11/2022 regarding staff not following care plans, exposing residents to toxic chemicals, leaving residents in soiled diapers, and not treating residents with dignity.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Interviews, observations, and records review indicated that care plans were followed, no toxic chemicals were observed, residents were not left in soiled diapers, and residents were treated with dignity.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not following care plans, exposing residents to toxic chemicals, leaving residents in soiled diapers, and not treating residents with dignity. Evidence did not support these claims.
Report Facts
Capacity: 164
Census: 134
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Armour | Executive Director | Met with during investigation and exit interview |
| Liliana Silveira | Licensing Program Analyst | Conducted complaint investigation |
| Denise Powell | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 133
Capacity: 164
Deficiencies: 0
Sep 27, 2022
Visit Reason
An unannounced Required 1-Year Visit was conducted to evaluate the facility's compliance with licensing requirements, including infection control measures.
Findings
No deficiencies were cited or observed during the inspection. The facility was found to be in compliance with infection control protocols and other regulatory requirements.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Armour | Director | Met with Licensing Program Analysts during the inspection and discussed the purpose of the visit. |
Inspection Report
Complaint Investigation
Census: 138
Capacity: 164
Deficiencies: 1
Aug 1, 2022
Visit Reason
The visit was a case management follow-up to discuss a deficiency observed during a complaint investigation visit conducted on August 1, 2022, related to staff not properly wearing face masks during the COVID-19 outbreak.
Findings
During the complaint investigation, multiple staff were observed not wearing face masks properly or at all, posing a potential health and personal rights risk to residents. The facility had approximately 28 residents with active COVID-19 diagnoses during the period. A deficiency was cited for failure to accord safe, healthful, and comfortable accommodations to all 138 residents in care.
Complaint Details
The visit was complaint-related, triggered by observations of staff not wearing face masks properly during a COVID-19 outbreak. The complaint was substantiated by observations during the visit.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personal Rights of Residents in All Facilities: Failure to accord safe, healthful and comfortable accommodations, furnishings and equipment, posing a potential health and personal rights risk to persons in care. | Type B |
Report Facts
Residents with active COVID-19 diagnoses: 28
Census: 138
Total Capacity: 164
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Armour | Executive Director | Met with during the visit and discussed mask-wearing deficiencies; involved in exit interview and plan of correction. |
| Jessica Mallory | Resident Services Director | Present during the County of San Diego Healthcare Associated Infection team assessment. |
Inspection Report
Routine
Capacity: 164
Deficiencies: 0
Jul 28, 2022
Visit Reason
The Department conducted an announced Case Management visit to provide technical assistance and to evaluate the facility's COVID-19 screening, testing, disinfection processes, and staff’s use of personal protective equipment.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst and Healthcare Associated Infection nurse toured the facility, interacted with staff, and interviewed the licensee.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Domingo | Licensing Program Analyst | Conducted the announced Case Management visit. |
| Elizar Perez | Nurse Contractor, RN, BSN, PHN | Accompanied the Licensing Program Analyst during the visit. |
| David Armour | Executive Director | Licensee interviewed during the visit. |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 164
Deficiencies: 0
Apr 29, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that residents were not provided with bed linen.
Findings
The investigation found the allegation to be unsubstantiated. Interviews with residents and staff, as well as a facility tour, confirmed that linens were sufficiently available, laundered regularly, and stored properly.
Complaint Details
The complaint was unsubstantiated based on interviews and facility tour. Although the allegation may have been valid, there was not a preponderance of evidence to prove the violation occurred.
Report Facts
Capacity: 164
Census: 137
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation and facility tour |
| David Armour | Executive Director | Facility representative met during the investigation |
| Simon Jacob | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 164
Deficiencies: 0
Apr 29, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations regarding failure to take universal precautions to prevent the spread of scabies and improper use of PPE equipment.
Findings
The investigation found that the facility staff followed the prescribed treatment protocol for scabies and used PPE properly. Due to lack of corroborating evidence, the allegations were determined to be unsubstantiated.
Complaint Details
The complaint involved allegations that facility staff failed to take universal precautions to prevent the spread of scabies and did not use PPE equipment properly. The investigation included interviews and record reviews and concluded the allegations were unsubstantiated.
Report Facts
Capacity: 164
Census: 137
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Armour | Executive Director | Met with during investigation and named in report |
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation |
| Simon Jacob | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Routine
Census: 124
Capacity: 164
Deficiencies: 0
Sep 30, 2021
Visit Reason
The visit was an announced Case Management visit focused on evaluating the facility's COVID-19 screening, testing, disinfection processes, and staff use of personal protective equipment.
Findings
No deficiencies were cited during the visit. The team provided technical assistance and conducted brief tours and staff interviews.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Armour | Executive Director | Met with during the visit and named in the report narrative. |
| Lean Alhambra | Resident Services Director | Met with during the visit and named in the report narrative. |
| Dang Nguyen | Licensing Program Analyst | Conducted the announced Case Management visit. |
| Jennifer West | Nurse Contractor | Accompanied the Licensing Program Analyst during the visit. |
| Elizar Perez | Nurse Contractor | Accompanied the Licensing Program Analyst during the visit. |
Inspection Report
Annual Inspection
Census: 109
Capacity: 164
Deficiencies: 0
Jul 21, 2021
Visit Reason
An unannounced Required 1-Year Visit was conducted to evaluate the facility's compliance, including review of the COVID-19 Mitigation Plan and infection control measures.
Findings
The Licensing Program Analyst conducted a tour and observation of residents and infection control practices. No deficiencies were cited during this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Armour | Executive Director | Met with Licensing Program Analyst to discuss the purpose of the visit and during exit interview. |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 164
Deficiencies: 1
Jun 14, 2021
Visit Reason
An unannounced complaint investigation was conducted due to allegations of neglect resulting in an unwitnessed fall and loss of consciousness of a resident, as well as other allegations including neglect of personal hygiene, isolation, and improper medication management.
Findings
The investigation substantiated neglect related to inadequate supervision leading to an unwitnessed fall and subsequent decline in the resident's condition. Other allegations regarding incontinence care, personal hygiene, isolation, and medication management were found to be unsubstantiated due to lack of corroborating evidence.
Complaint Details
The complaint investigation was triggered by allegations that facility staff left Resident (R1) unsupervised resulting in an unwitnessed fall and loss of consciousness. Additional allegations included neglect of incontinence care, personal hygiene, isolation, and improper medication management. The neglect allegation was substantiated, while the others were unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to provide necessary supervision to residents, resulting in neglect of a high-risk resident leading to an unwitnessed fall. | Type A |
Report Facts
Capacity: 164
Census: 107
Plan of Correction Due Date: Jul 12, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Armour | Executive Director | Met with during investigation and named in findings related to supervision deficiencies |
| Debbie Correia | Licensing Program Analyst | Conducted the complaint investigation |
Report
February 29, 2024
File
report_21_374604079_inx20_2024-02-29.pdf
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