Town & Country

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility does not have adequate staffing, resulting in residents’ needs not being met

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the memory care unit and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as staffing schedule. Regarding the allegation that facility does not have adequate staffing, resulting in residents’ needs not being met, the investigation revealed the following: Facility management indicates staffing challenges due to call offs, resignations and terminations. Facility is using agency to fill holes in the staffing schedule. Facility staffs 8 caregivers and a med tech for 1st and second shift and 4-6 caregivers/ med tech for NOC shift. Five out of five staff state facility is using agency to cover holes and is staffed when agency comes in. Five out of five staff statethe state’s words, verbatim · CDSS document, Nov 12, 2025 · control 22-AS-20251110084114

Allegation investigated: Staff are not meeting residents’ care needs due to lack of staff.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit to continue the investigation into the above allegation. LPA met with Director of Resident Services (DRS) Sara Modugno and stated the purpose of the visit. On August 20, 2025, the Department received a complaint, and the complaint investigation was initiated by LPA Cho on August 26, 2025 which was continued on today's date. During the course of the investigation, LPA interviewed seven Memory Care (MC) residents/MC staff, and obtained the following documentation: Resident Rosters, Personnel Report, Staff Contacts, (AM/PM/Noc) Shift Schedules/Time Cards for August 13, 15, 16, 2025, Face Sheets, Physician's Reports, and Service Plans. The investigation is as follows: It is alleged that the Staff are not meeting the residents' care needs due to lack of staff, affecting the residents' care in the Memory Care (MC) unit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 28, 2025 · control 22-AS-20250820170219

Allegation investigated: Facility staff are not properly addressing scabies Facility staff are not ensuring residents have clean bed linens Facility staff do not maintain passageways free from obstruction

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as medication orders. Regarding the allegations that facility staff are not properly addressing scabies, facility staff are not ensuring residents have clean bed linens and facility staff do not maintain passageways free from obstruction, the investigation revealed the following: On 09/03/2025, Resident 1 (R1) was sent out to St. Joseph Hospital for increased weakness after being diagnosed with Dermatitis. Facility was notified on 09/05/2025 that R1 was confirmed positive for Scabies via testing at the hospital. Two residents at the facility were visually confirmed to have Scabies and 17 residents have itchithe state’s words, verbatim · CDSS document, Sep 11, 2025 · control 22-AS-20250904143853

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff does not ensure that the facility is free of pests Staff are not meeting residents' hygiene needs

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as extermination records. Regarding the allegations that staff does not ensure that the facility is free of pests and staff are not meeting residents' hygiene needs, the investigation revealed the following: Facility provided documentation of pest extermination services provided by Skyline Pest Control on 06/03/2025, 07/01/2025, and 08/04/2025. Four out of four staff deny seeing pests inside the facility. LPA toured the memory care unit and did not observe any pests. Per physician correspondence, two residents are being treated for rashes with Elimite for Scabies and Clobetasol for fungal infections. There ithe state’s words, verbatim · CDSS document, Aug 13, 2025 · control 22-AS-20250811172747

Allegation investigated: Staff does not ensure cleaning chemicals are made inaccessible to residents in care Staff does not ensure medications are dispensed as prescribed

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA toured the memory care unit and interviewed staff as well as reviewed and obtained pertinent documentation such as medication administration records. Regarding the allegation that staff does not ensure cleaning chemicals are made inaccessible to residents in care and staff does not ensure medications are dispensed as prescribed, the investigation revealed the following: Memory care unit "Grace Gardens" has four kitchenettes in mini dining rooms for residents. LPA observed the door is unlocked in all four and all four had unsecured cleaning spray in an unsecured cupboard. One kitchenette had Windex and cleaning spray unsecured. LPA observed no staff in the kitchenettes but did observe a staff in the dining area. Grace Gardens servesthe state’s words, verbatim · CDSS document, Aug 13, 2025 · control 22-AS-20250805120829

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility failed to provide notice to resident when changing room location

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and resident as well as reviewed and obtained pertinent documentation such as facility notes. Regarding the allegation that facility failed to provide notice to resident when changing room location, the investigation revealed the following: Resident 1 (R1) was moved from Independent Living to Assisted Living on 12/23/2024 due to ongoing health issues. Resident indicates agreeing to the move and facility notes confirm the agreement. Resident confirmed needing additional assistance from staff and had been having the conversation with staff about moving due to mobility issues and hip pain. Resident was re-assessed on 12/18/2024 and provided an updated service plan on 12/23the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 22-AS-20250701140411

Allegation investigated: Staff did not assist resident with feeding, resulting in significant weight loss Staff did not seek medical attention for resident in a timely manner Staff did not administer resident's medications Staff did not safeguard resident's personal belongings

On July 2, 2025, Licensing Program Analyst (LPA) Sam Haddadin conducted an unannounced visit to this facility to deliver findings regarding the following allegations: staff did not assist the resident with feeding, resulting in significant weight loss; staff did not seek medical attention for the resident in a timely manner; staff did not administer the resident's medications; and staff did not safeguard the resident’s personal belongings. During the investigation, LPA reviewed Resident 1’s (R1) facility file, including medical records, the admission agreement, inventory sheet, E mail records, staff roster , censuses and progress notes. LPA also interviewed staff members who were present during R1’s 32-day stay, as well as residents who lived at the facility before, during, and after that time. Regarding the allegation that staff did not assist R1 with feeding and did not administer medications, progress notes show that on October 6, 2024, R1 initially refused food and medication. Howethe state’s words, verbatim · CDSS document, Jul 2, 2025 · control 22-AS-20241209152259

Allegation investigated: Facility call system is not operational Facility staff failed to provide adequate care and supervision to a resident in order to prevent the occurrence of falls. Facility is not providing adequate toileting care to a resident.

On June 16, 2025, Licensing Program Analyst (LPA) Samer Haddadin met with Executive Director (ED) Sara Modugno to deliver the findings regarding a complaint filed on March 26, 2024. The investigation involved a review of facility records, staff and resident interviews, and direct observation. II. Allegations Investigated The Department received a complaint on March 26, 2024, which contained several allegations. The complaint alleged that the facility's call system was not operational, that staff failed to provide adequate care and supervision to a resident to prevent falls, and that the facility was not providing adequate toileting care to a resident. III. Investigative Findings Regarding the allegation that the facility's call system is not operational, the LPA reviewed records for three separate resident calls made using a pendant button, which indicated the system was functional. Furthermore, on June 16, 2025, the LPA and the ED tested the system directly.{**CONTINUE9099C**} Unsubstthe state’s words, verbatim · CDSS document, Jun 16, 2025 · control 22-AS-20240326115522

Allegation investigated: Facility failed to provide care and supervision resulting in multiple falls

LPA Samer Haddadin conducted an unannounced complaint visit to present findings regarding the above-mentioned reported allegation. Upon arrival, LPA Haddadin was greeted by Executive Director (ED) Sara Modugno, who granted access to the facility. During the investigation, LPA Haddadin toured the facility, interviewed staff members, and reviewed all medical records pertaining to the alleged incident involving resident (R1). Allegation Investigated: “Facility failed to provide care and supervision resulting in multiple falls.” Investigation Findings: Regarding the allegation, R1 was first admitted to the facility on October 1, 2022. A Pre-placement Appraisal, performed by the facility on September 22, 2022, stated the following regarding R1’s overall condition: R1 has severe hearing loss, motor impairment, is a fall risk, requires a wheelchair, has cognitive impairment, and is occasionally confused. LPA Haddadin conducted a record review of R1’s Physician Report, which also states R1 isthe state’s words, verbatim · CDSS document, Jun 4, 2025 · control 22-AS-20221122103427

Allegation investigated: Staff did not ensure the facility was free of pests.

On today's date, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility. The purpose of the visit was to deliver findings regarding allegations. LPA Haddadin was greeted by staff and granted entry after stating the visit's purpose. During the investigation, LPA Haddadin toured the facility, interviewed staff members and residents, and reviewed facility records. Investigation Findings Regarding the allegation that "staff did not ensure the facility was free of pests," LPA Haddadin, accompanied by the Administrator (AD), inspected both buildings of the facility. This inspection included the kitchen area, common areas, and six bedrooms in each building. No evidence of pests was found during the inspection. (CONTINUE ***9099C) Unsubstantiatedthe state’s words, verbatim · CDSS document, May 22, 2025 · control 22-AS-20250218143417

Allegation investigated: Staff are not meeting residents needs Staff do not have access to supplies for residents

Licensing Program Analyst (LPA) Jenifer Tirre met with Executive Director Sara Modugno for the purpose of delivering findings for the above allegations. The complaint consisted of observations and interviews. On March 12, 2025 the department received allegations that staff are not meeting residents needs and staff do not have access to supplies for residents. The investigation was completed by the Department and revealed the following: Regarding allegation “Staff are not meeting resident’s needs”, during visit LPA toured facility and observed staff assisting residents with meals, medications, changing of linens inside bedrooms and assisting residents with toileting needs. LPA also observed several staff members answering resident questions. During investigation LPA Tirre conducted interviews with residents and staff. Based on investigation interviews the following was revealed: six of seven residents stated that facility staff meet their care needs. Six Residents interviewed stated thathe state’s words, verbatim · CDSS document, Mar 19, 2025 · control 22-AS-20250312162740

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility did not ensure that it was free of pests

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint visit. LPA Mendivil was greeted and granted entry by Sammantha Meza, Liason and Crisitina Garcia, LVN explained the reason for the visit. Head Chef Pedro Miranda arrived shortly after. The Department received a complaint on 12/19/2024 and the initial investigation conducted on 12/26/2024. LPA Mendivil toured the facility and interviewed staff and residents. Regarding the allegation facility did not ensure that it was free of pests, the invesitgation revealed the following: It was alleged that in the Independent Living dining room there were pests present. LPA Mendivil toured the facility on 12/17/2024 for an annual visit and did not observe pests or rodents. LPA Mendivil toured Independent Living dinning room again on 12/26/2024 with Head Chef Pedro Miranda and Sous Chef Anthony Montes. LPA Mendivil observed staff cleaning the kitchen between meal services. LPA Mendivil observethe state’s words, verbatim · CDSS document, Dec 26, 2024 · control 22-AS-20241219150833

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Due to lack of staff, residents are not changed timely. Staff do not respond to call bell in a timely manner.

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection visit to deliver findings for complaint investigation into the above allegations. LPA explained the reason for the visit with Assisted Living Coordinator Nikka Solomon. During the course of the investigation LPA toured facility, reviewed records, conducted interviews with staff & residents, and requested pertinent documentation such as Resident Roster’s, staff roster’s, Physician’s reports, course completion records, resident care plans, and device activity reports. During investigation LPA reviewed facility records such as Employee Handbook, staffing rosters, in service meeting notes and Device activity reports. Facility rosters revealed that facility Assisted Living has 19 staff on file per 53 residents and Memory Care Grace Gardens has 17 staff per 57 residents. Course completion records reviewed for staff revealed that all staff must complete "Abuse, neglect, and exploitation in the elder care settingthe state’s words, verbatim · CDSS document, Aug 23, 2024 · control 22-AS-20240813123809

Allegation investigated: Due to lack of staff, colostomy care was provided by unqualified staff Due to lack of staff, residents did not receive their medications on time

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection visit to deliver findings for complaint investigation into the above allegations. LPA explained the reason for the visit with Assisted Living Coordinator Nikka Solomon. During the course of the investigation LPA toured facility, reviewed records, conducted interviews with staff & residents, and requested pertinent documentation such as Resident records, Resident rosters, staff rosters, Medication Administration Records, and Course Completion History. During investigation LPA conducted interviews with staff. Staff interviews revealed that one resident in facility required colostomy care. Staff interviews with six of twelve staff confirm that staff that assist with colostomy care residents require assisted hands on training for three weeks before assisting care independently. Staff interviews confirmed that not all staff receive this training only Medical Technicians, Nurses and Lead Caregivers. CONTINUED Othe state’s words, verbatim · CDSS document, Aug 23, 2024 · control 22-AS-20240813150102

Allegation investigated: Staff may be financially abusing residents Staff violated residents' personal rights

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection visit to deliver findings for complaint investigation into the above allegations. LPA explained the reason for the visit with Assisted Living Coordinator Nikka Solomon. During the course of the investigation LPA toured facility, reviewed records, conducted interviews, made visual observations and requested pertinent documentation such as Resident Roster’s, staff roster’s, Physician’s reports, employee handbook, resident care plans, food service invoices and Resident Council meeting notes. During investigation LPA reviewed facility records and records reviewed revealed that three residents (R1, R2 & R3) recently moved from facilities Assisted Living corridors to Memory Care Unit Grace Gardens. Reviewed Resident Physician’s reports and Care plans confirmed residents R1, R2, & R3 had a proper diagnoses for Memory care placement. CONTINUED ON 9099C Unfoundedthe state’s words, verbatim · CDSS document, Aug 23, 2024 · control 22-AS-20240805144055

Allegation investigated: Staff handles resident in a rough manner.

On this Day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Director of Residential Services Stephanie Jukic and explained the reason for the visit. The department received a complaint on 10/16/2023 and LPA Mendivil conducted an initial 10-day visit on 10/25/2023. During the course of the visit LPA interviewed staff and residents. LPA Mendivil obtained copies of pertinent documents such as physician reports and staff schedules. Regarding the allegation Staff handles resident in a rough manner, the investigation revealed the following: Based on interviews with 2 out of 2 staff all indicate they do not handle residents in a rough manner. Interviews with a witness report that they do not have concerns about staff being rough with residents. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 21, 2023 · control 22-AS-20231016164232

Allegation investigated: Due to lack of supervision, a resident eloped from the facility

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Stephanie Jukic and explained the reason for the visit. The department received a complaint on 10/27/2023 and initial 10 day visit was conducted on 11/02/2023. During the visit LPA interviewed staff and a resident, LPA obtained copies of physician reports and incident reports for Resident 1 (R1). Based on report R1 exited the second story of the Memory Care community via a door on the south side. R1 was able to make it down the street and found by a local business manager and returned to the facility. R1 was then assessed and uninjured. R1's family was notified of the incident and R1 was placed on 1:1 care for a month. Substantiatedthe state’s words, verbatim · CDSS document, Nov 2, 2023 · control 22-AS-20231027121729

Allegation investigated: Staff are not providing adequate food service to residents in care.

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced to continue the investigation and to deliver the findings into the above allegation. LPA explained the reason for the visit and reviewed the allegation with Chief Executive Officer/President Rob Goerzen. On July 27, 2023, the complaint investigation was commenced by LPA Andrea Mendivil which involved staff interviews, a kitchen tour, and obtaining copies of facility records. On August 24, 2023, LPA Jessica Cho continued resident/staff interviews and obtained copies of pertinent facility/resident records. Supplemental records along with the staff interviews were obtained by LPA Cho including a tour of the kitchen/dining room on August 31, 2023. On today’s date, LPA interviewed one staff and observed the lunch service. The following was revealed during the course of the investigation: It is alleged that the staff are not providing adequate food service to the residents in care. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 27, 2023 · control 22-AS-20230719155923

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff does not provide residents with dignity and respect.

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose to deliver the findings into the above allegation. LPA met with Director of Residential Services Stephanie Jukic and Director of Health & Wellness Nikka Solomon and explained the reason for the visit. On August 10, 2023, the complaint investigation visit was initiated. During the course of the initial visit, LPA interviewed residents and staff and obtained copies of pertinent facility and resident records which revealed the following: It is alleged that the staff does not provide residents with dignity and respect. It was determined based on the interviews conducted that seven out of the seven individuals could not corroborate with the allegation. Additionally, one out of the seven individuals interviewed has personally experienced being treated disrespectfully and without dignity; however, was unable to specify the details of the mistreatment and the name of the individual in question. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 24, 2023 · control 22-AS-20230803132853