Inspection Reports for
Westmont of La Mesa

9000 Murray Dr, La Mesa, CA 91942, United States, CA, 91942

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 1.8 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

55% better than California average
California average: 4 deficiencies/year

Deficiencies per year

8 6 4 2 0
2021
2022
2023
2024
2025

Census

Latest occupancy rate 76% occupied

Based on a August 2025 inspection.

Occupancy over time

60 90 120 150 180 Jun 2021 Aug 2022 Jul 2023 Feb 2024 Sep 2024 Aug 2025

Inspection Report

Annual Inspection
Census: 125 Capacity: 164 Deficiencies: 0 Date: 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
NameTitleContext
Benjie DoctoleroOperations SpecialistMet with during inspection and exit interview
Amy RodgersLicensing Program AnalystConducted the inspection and signed the report
Angelica BoylesLicensing Program AnalystConducted the inspection
Kimberly GarciaAdministrator/DirectorFacility administrator named in the report

Inspection Report

Complaint Investigation
Census: 134 Capacity: 164 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Companion hours reduction: 8 Resident interviews: 3

Employees mentioned
NameTitleContext
Amy DomingoLicensing Program AnalystConducted the complaint investigation and authored the report.
Simon JacobLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation.
Benjie DoctoleroOperation SpecialistMet with investigator during the visit and acknowledged receipt of report and licensee rights.
Kimberly GarciaAdministratorFacility administrator named in the report.

Inspection Report

Complaint Investigation
Census: 124 Capacity: 164 Deficiencies: 0 Date: 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.

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.
Findings
The Licensing Program Analyst conducted an unannounced case management visit, interviewed staff, reviewed facility records, and found no deficiencies during the inspection.

Employees mentioned
NameTitleContext
Amy DomingoLicensing Program AnalystConducted the unannounced case management visit.
Sabrina PriesmanExecutive DirectorMet with the Licensing Program Analyst during the visit.

Inspection Report

Complaint Investigation
Census: 126 Capacity: 164 Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
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.
Report Facts
Resident fall not reported: 1 Facility capacity: 164 Census: 126

Employees mentioned
NameTitleContext
Amy DomingoLicensing Program AnalystConducted the complaint investigation and delivered findings.
David ArmourAdministratorFacility administrator named in the report.
Sabrina PriesmanExecutive DirectorMet with Licensing Program Analyst during investigation and involved in exit interviews.
Simon JacobLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation.

Inspection Report

Complaint Investigation
Census: 126 Capacity: 164 Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
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.
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
NameTitleContext
Amy DomingoLicensing Program AnalystConducted the complaint investigation visit and authored the report
Simon JacobLicensing Program ManagerOversaw the complaint investigation
Sabrina PriesmanExecutive DirectorFacility representative who received the report and plan of correction
Kimberly GarciaAdministratorFacility administrator named in the report header

Inspection Report

Complaint Investigation
Census: 126 Capacity: 164 Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
Failure to ensure resident was free from abuse resulting in bruising, violating personal rights under CCR 87468.1(a)(3).
Report Facts
Residents in care: 126 Licensed capacity: 164 Deficiency type count: 1 Plan of Correction due date: Jun 28, 2024

Employees mentioned
NameTitleContext
Amy DomingoLicensing Program AnalystConducted the complaint investigation visit
Simon JacobLicensing Program ManagerNamed in report as Licensing Program Manager
Kimberly GarciaAdministratorFacility Administrator named in report
Sabrina PriesmanExecutive DirectorMet with Licensing Program Analyst during investigation

Inspection Report

Annual Inspection
Census: 92 Capacity: 164 Deficiencies: 0 Date: 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
NameTitleContext
Amy DomingoLicensing Program AnalystConducted the inspection and authored the report
Sabrina PriesmanExecutive DirectorFacility representative met during inspection and exit interview
Simon JacobLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Follow-Up
Census: 92 Capacity: 164 Deficiencies: 1 Date: 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.

Deficiencies (1)
Failure to ensure that Resident 1's medication was administered as ordered by the physician.
Report Facts
Residents in care: 92 Total licensed capacity: 164 Deficiency count: 1 Plan of Correction due date: Jun 29, 2024

Employees mentioned
NameTitleContext
Amy DomingoLicensing Program AnalystConducted the unannounced case management visit and cited the medication administration deficiency
Sabrina PriesmanExecutive DirectorMet with Licensing Program Analyst during the visit and participated in the exit interview
Simon JacobLicensing Program ManagerSupervisor overseeing the inspection

Inspection Report

Complaint Investigation
Census: 89 Capacity: 164 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Capacity: 164 Census: 89

Employees mentioned
NameTitleContext
Amy DomingoLicensing Program AnalystConducted the unannounced case management visit and inspection
Sheryl McCaskillOperation SpecialistMet with Licensing Program Analyst during the visit and participated in exit interview

Inspection Report

Complaint Investigation
Census: 138 Capacity: 164 Deficiencies: 1 Date: Feb 29, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of neglect resulting in serious injury from a resident on resident altercation, and a separate allegation of illegal eviction.

Complaint Details
The complaint investigation was substantiated for neglect resulting in serious injury from a resident altercation. The allegation of illegal eviction was unsubstantiated.
Findings
The investigation substantiated the neglect allegation where lack of supervision led to a resident assault causing serious injury. The facility failed to ensure adequate supervision for Resident 1, resulting in immediate safety risks. The illegal eviction allegation was unsubstantiated based on staff and outside source interviews and records.

Deficiencies (1)
The facility did not ensure the amount of supervision determined necessary by assessments for one Resident 1, which posed an immediate safety risk to residents in care.
Report Facts
Capacity: 164 Census: 138 Staff on duty: 4 Residents in memory care unit: 28 Personal Care Attendant frequency: 4

Employees mentioned
NameTitleContext
Debbie CorreiaLicensing Program AnalystConducted the complaint investigation and unannounced visit
Kimberly GarciaExecutive DirectorFacility representative interviewed during investigation
David ArmourAdministratorFacility administrator named in report header
Simon JacobLicensing Program ManagerOversaw licensing program and signed report

Inspection Report

Complaint Investigation
Census: 143 Capacity: 164 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Technical Violations issued: 2 Medication Technicians on duty: 2 Caregivers on duty: 4 Delayed-egress doors: 4

Employees mentioned
NameTitleContext
Kimberly GarciaExecutive DirectorMet with Licensing Program Analyst during the visit and participated in exit interview
Dang NguyenLicensing Program AnalystConducted the unannounced Case Management - Incident visit
Lizzette TellezLicensing Program ManagerNamed in report header and signature section

Inspection Report

Complaint Investigation
Census: 140 Capacity: 164 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Census: 140 Total Capacity: 164

Employees mentioned
NameTitleContext
Kimberly GarciaDirectorMet with Licensing Program Analyst during the investigation and participated in exit interview
Renita HallLicensing Program AnalystConducted the complaint investigation visit
Denise PowellLicensing Program ManagerNamed in report header and signature section

Inspection Report

Census: 132 Capacity: 164 Deficiencies: 0 Date: 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
NameTitleContext
Kimberly GarciaAdministratorMet with Licensing Program Analyst during the visit and involved in the exit interview.
Jeunesse HolmesResident Services DirectorMet with Licensing Program Analyst during the visit.
Riza Gloria AlvarezLicensing Program AnalystConducted the unannounced Case Management - Incident visit.

Inspection Report

Complaint Investigation
Census: 137 Capacity: 164 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Capacity: 164 Census: 137

Employees mentioned
NameTitleContext
Amy DomingoLicensing Program AnalystConducted the complaint investigation visit and delivered findings
Kimberly GarciaExecutive DirectorMet with Licensing Program Analyst during investigation and exit interview
Simon JacobLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Capacity: 164 Deficiencies: 0 Date: 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
NameTitleContext
Kimberly GarciaExecutive DirectorMet with Licensing Program Analyst during the visit and involved in exit interview
Alyssa RamirezLicensing Program AnalystConducted the unannounced Case Management - Incident visit
Simon JacobLicensing Program ManagerNamed in report header

Inspection Report

Complaint Investigation
Census: 121 Capacity: 164 Deficiencies: 2 Date: 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.

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.
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.

Deficiencies (2)
Licensee’s staff (S1) did not accord dignity to 1 of 121 residents (R1), posing a potential personal rights risk.
Licensee staff (S1) did not ensure 1 of 121 residents (R1) was free from abuse, posing a potential personal rights risk.
Report Facts
Residents present: 121 Total licensed capacity: 164 Deficiency count: 2 Plan of Correction due date: Mar 30, 2023

Employees mentioned
NameTitleContext
Dang NguyenLicensing Program AnalystConducted the unannounced Case Management visit and investigation
Lizzette TellezLicensing Program ManagerSupervised the licensing evaluation
Mayra RodriguezBusiness Office DirectorMet with Licensing Program Analyst during visit and exit interview
Eva AmorimCompass Rose (Memory Care) DirectorMet with Licensing Program Analyst during visit

Inspection Report

Complaint Investigation
Census: 134 Capacity: 164 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Capacity: 164 Census: 134

Employees mentioned
NameTitleContext
David ArmourExecutive DirectorMet with during investigation and exit interview
Liliana SilveiraLicensing Program AnalystConducted complaint investigation
Denise PowellLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Annual Inspection
Census: 133 Capacity: 164 Deficiencies: 0 Date: 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
NameTitleContext
David ArmourDirectorMet with Licensing Program Analysts during the inspection and discussed the purpose of the visit.

Inspection Report

Complaint Investigation
Census: 138 Capacity: 164 Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
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.
Report Facts
Residents with active COVID-19 diagnoses: 28 Census: 138 Total Capacity: 164

Employees mentioned
NameTitleContext
David ArmourExecutive DirectorMet with during the visit and discussed mask-wearing deficiencies; involved in exit interview and plan of correction.
Jessica MalloryResident Services DirectorPresent during the County of San Diego Healthcare Associated Infection team assessment.

Inspection Report

Routine
Capacity: 164 Deficiencies: 0 Date: 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
NameTitleContext
Amy DomingoLicensing Program AnalystConducted the announced Case Management visit.
Elizar PerezNurse Contractor, RN, BSN, PHNAccompanied the Licensing Program Analyst during the visit.
David ArmourExecutive DirectorLicensee interviewed during the visit.

Inspection Report

Complaint Investigation
Census: 137 Capacity: 164 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Capacity: 164 Census: 137

Employees mentioned
NameTitleContext
Debbie CorreiaLicensing Program AnalystConducted the complaint investigation and facility tour
David ArmourExecutive DirectorFacility representative met during the investigation
Simon JacobLicensing Program ManagerNamed as Licensing Program Manager on the report

Inspection Report

Complaint Investigation
Census: 137 Capacity: 164 Deficiencies: 0 Date: 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.

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.
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.

Report Facts
Capacity: 164 Census: 137

Employees mentioned
NameTitleContext
David ArmourExecutive DirectorMet with during investigation and named in report
Debbie CorreiaLicensing Program AnalystConducted the complaint investigation
Simon JacobLicensing Program ManagerNamed in report as Licensing Program Manager

Inspection Report

Routine
Census: 124 Capacity: 164 Deficiencies: 0 Date: 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
NameTitleContext
David ArmourExecutive DirectorMet with during the visit and named in the report narrative.
Lean AlhambraResident Services DirectorMet with during the visit and named in the report narrative.
Dang NguyenLicensing Program AnalystConducted the announced Case Management visit.
Jennifer WestNurse ContractorAccompanied the Licensing Program Analyst during the visit.
Elizar PerezNurse ContractorAccompanied the Licensing Program Analyst during the visit.

Inspection Report

Annual Inspection
Census: 109 Capacity: 164 Deficiencies: 0 Date: 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
NameTitleContext
David ArmourExecutive DirectorMet 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 Date: 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.

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.
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.

Deficiencies (1)
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.
Report Facts
Capacity: 164 Census: 107 Plan of Correction Due Date: Jul 12, 2021

Employees mentioned
NameTitleContext
David ArmourExecutive DirectorMet with during investigation and named in findings related to supervision deficiencies
Debbie CorreiaLicensing Program AnalystConducted the complaint investigation

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March 25, 2026

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January 22, 2026

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January 7, 2026

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December 19, 2025

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December 19, 2025

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September 26, 2024

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June 14, 2021

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