Oakwood Meadows Assisted Living

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.

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: Medication is being mishandled by staff. Staff is not communicating with other staff af shift change. Licensee retaliated against staff for speaking with state staff at the facility.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on October 23, 2025. LPA met with Director of Nursing (DON), Karen Padilla and stated the reason for the inspection. During the investigation, LPA interviewed the Administrator, the DON, the Human Resources Director, the Care and Admissions Director, multiple faciity staff, (2) residents and (2) hospice personnel. LPA reviewed documentation including Nurse Audits of Medication (July 2025), Physician's Orders, Staff Handbook with facility policies, staff Termination Letter, written staff statements, and other documentation. The results of the investigation are as follows: *cont on 9099C-1.. Substantiatedthe state’s words, verbatim · CDSS document, Feb 20, 2026 · control 59-AS-20251023111820

Allegation investigated: Staff hit resident.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on November 13, 2025. LPA met with Director of Nursing (DON), Karen Padilla. During the investigation, LPA interviewed the Administrator, the DON, and multiple faciity staff in Memory Care. LPA reviewed documentation relating to resident (R1), an incident report submitted for the incident occuring on September 1, 2025 and documentation from the faciltiy's internal investigation. The results of the investigation are as follows: Resident (R1) moved to the Memory Care Unit in the facility, on May 30, 2025, with a primary diagnosis of Senile Dementia and a history of lung cancer. The LIC602 (10/30/2025) notes that (R1) has “Behavioral Expressions”, including disorientation, lack of hazard awareness and impulse control, expressions of frustrations and hallucinations. **cont on 9099C-1.. Substantiatedthe state’s words, verbatim · CDSS document, Feb 18, 2026 · control 59-AS-20251113134057

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: Staff did not provide adequate meals to resident in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete a complaint investigation and deliver findings to a complaint received on July 11, 2025. LPA met with Director of Nursing (DON), Karen Padilla, and the Administrator, Danny Torgersen. During the investigation, LPA interviewed the administraotor, DON, multiple faciity staff, the lead culinary staff, resident (R1) and (2) of their family members, and several random residents while eating lunch in the dining room. LPA observed food being served to residents on the Assisted Living side during lunch on October 14, 2025 and reviewed meeting notes and observations made during and following a Care Conference held on January 17, 2025. Additional documentation was reviewed related to (R1) including, but not limited to, care plan and physician's report. The results of the investigation are as follows: **cont on 9099C-1... Substantiatedthe state’s words, verbatim · CDSS document, Oct 14, 2025 · control 59-AS-20250711115916

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: Staff mismanaged resident's medications. Staff did not seek medical attention for the resident in a timely manner.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete the investigation and deliver complaint findings. LPA met with Karen Padilla, Director of Nursing (DON), and Kayla Peria, Director of Care and Admissions, and stated the reason for the inspection. During the investigation, LPA interviewed the Administrator, DON, Director of Care and Admissions and a family member of resident (R1), who is the subject of the investigation. LPA reviewed pertinent documentation relating to (R1), including but not limited to: the physician's report, pre-placement appraisal, appraisal, the Medication Administration Record (MAR), and charting notes. (R1) moved to the community in October 2024 with a diagnosis of CVA (stroke), vision impairment, Diabetes Mellitus 2, and requiring assistance with feeding, dressing, showers and incontinence care. Resident previously had a kidney transplant, was fully aware, conscious and coherent and able to follow instructions. Resident was sent tothe state’s words, verbatim · CDSS document, Jul 22, 2025 · control 59-AS-20250513170952

Allegation investigated: Licensee is not preventing resident from being scalded by hot water while in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings to a complaint received on June 17, 2025, and met with Director of Nursing (DON), Karen Padilla. LPA later met with Administrator, Danny Torgersen, and stated the reason for today's inspection. During the course of the investigation, LPA interviewed the Maintenance Director, Director of Nursing, (3) care staff and (2) other residents who live in the same wing of the facility as (R1). LPA also observed multiple pages of documentation showing when hot water was tested throughout the building. The results of the investigation are as follows: The allegation states (R1) has been scalded in the shower for the last two months and has reported the problem but staff have not fixed it, and (R1's) skin is being burned by the scalding water. *cont on 9099C-1.. Unfoundedthe state’s words, verbatim · CDSS document, Jul 1, 2025 · control 59-AS-20250617165054

Allegation investigated: Staff not treating resident with respect.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings to a complaint received on May 7, 2025, and met with Director of Nursing (DON), Karen Padilla, stating the reason for the inspection. LPA later met with the Administrator, Danny Torgersen, During the course of the investigation, LPA interviewed the Administrator, the DON, the Resident Habilitation Director, Ombudsman, (2) representatives from a placement agency and resident (R1), who is the subject of the investigation. LPA reviewed documentation relating to (R1), including but not limited to, resident appraisal, physician's report, Care Conference case notes, other case notes and email communications with the Administrator. The results of the investigation are as follows: Resident (R1) moved to the community on January 31, 2025 with the primary diagnoses of Psoriatic Arthritis, chronic low appetite and severe PTSD. (R1) was independent with Activities of Daily Living (ADL's), including methe state’s words, verbatim · CDSS document, Jun 18, 2025 · control 59-AS-20250507155152

Allegation investigated: Staff are not caring for resident's wounds. Staff are not assisting resident with topical medication. Staff are allowing resident to sit in soiled bedding.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings for a complaint received on March 25, 2025. LPA met with Director of Nursing, Karen Padilla, and stated the reason for the inspection. LPA later met with Kayla Peria, Care and Admissions Director. During the investigation, LPA interviewed the Administrator, Director of Nursing, Care and Admissions Director, a care staff and resident (R1). LPA reviewed pertinent documentatation for (R1) including but not limited to the physician's report, hospital discharge paperwork, Medication Administration Record (MAR) for February 2025 and March 2025. The results are as follows: Resident (R1) moved to the community in December 2023 with a diagnosis of COPD, Chronic Respiratory Failure, and used oxygen. Resident was their own responsible person and could schedule medical appointments. *cont on 9099C-1.. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 22, 2025 · control 59-AS-20250325082305

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: Licensee did not ensure that resident was administered their medications according to physician's instructions while in care. Licensee does not ensure that residents are provided with food that is of good quality while in care. Staff did not respond to resident's requests for assistance as necessary while resident was in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to the remaining (3) allegations for a complaint received on January 8, 2025. LPA met with Administrator, Danny Torgersen, and stated the reason for today's inspection. LPA met with Director of Nursing, Karen Padilla, later during the inspection. During the investigation, LPA interviewed multiple staff and several residents and reviewed documentation related to resident (R1), who is the subject of the investigation. Documentation included (R1's) physician's report, charting notes, physician's orders and the Medication Administration Record (MAR) for December 2024. The results of the investigation are as follows: (R1) moved in on/around June 28, 2024 and resided in the Assisted Living Unit. The physician's report (October 31, 2024) notes (R1) has multiple diagnoses, but does not have Mild Cognitive Impairment (MCI) or Dementia, is able to leave the facility unsupervised, and can determine and communithe state’s words, verbatim · CDSS document, Apr 11, 2025 · control 59-AS-20250108113928

Allegation investigated: Staff did not safeguard resident's possessions while in care. Staff did not ensure that resident's laundry needs were met while in care. Staff did not accord dignity to resident while in care.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to continue the complaint investigation and deliver partial findings to a complaint received on January 8, 2025. LPA met with Kayla Peria, Director of Care and Admissions, and stated the reason for the inspection. Director of Nursing, Karen Padilla, met with LPA at 12:15 pm. During the investigation, LPA interviewed multiple staff and several residents and reviewed pertinent documentation related to resident (R1) including physician's report, charting notes, incident report and other documentation. The results of the investigation are as follows: Resident (R1) moved to the community on June 28, 2024 and moved out December 30, 2024. (R1's) physician's report (October 31, 2024) notes they have multiple diagnoses, including Parkinson's Disease, does not have Mild Cognitive Impairment (MCI) or Dementia, is able to leave the facility unsupervised, and can determine and communicate their need for prescription/non-prescriptiothe state’s words, verbatim · CDSS document, Apr 10, 2025 · control 59-AS-20250108113928

Allegation investigated: Due to lack of supervision, resident was assaulted.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete the complaint investigation and deliver findings for a complaint received on January 23, 2025. LPA met with Kayla Peria, Director of Care and Admissions, and stated the reason for the inspection. Director of Nursing, Karen Padilla, met with LPA at 12:15 pm. During the investigation, LPA interviewed multiple staff and several residents. Documentation was also reviewed, including, incident reports submitted to the Department, and pertinent paperwork from resident (R1/R2/R3's) files. The results of the investigation are as follows: The alleagation states that resident (R1) was assaulted several times in the last (4) months, (R1) is independent, and the Administrator refuses to let (R1) leave the building. There were no specific details on when the alleged assaults occurred. *Cont on 9099C-1.. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 10, 2025 · control 59-AS-20250123091955

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: Resident was left on floor for an extended period of time. Staff did not report change of condition. Staff left residents in soiled diapers for an extended period of time. Resident is not receiving showers as scheduled.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings to a complaint received on 11/12/24. LPA met with Danny Torgersen, Administrator, and Karen Padilla, Director of Nursing, and stated the reason for the inspection. During the course of the investigation, LPA interviewed the Administrator, Director of Nursing, Business Office Director, (3) staff, resident (R1) and a family member of (R1). LPA also reviewed documentation relating to (R1), including their physician's reports, appraisal/care plans, narrative charting notes, (2) incident reports (LIC624), shower schedules for months September- November 2024 and the Alarm Reset Report for 11/10/24 from 1200 hours through 23:59 hours. The results of the investigation are as follows: (R1) moved to the community and has resided on the Assisted Living side since moving in on 12/27/23. (R1's) physician's report (dated 10/16/24) notes resident has a diagnosis of Dementia with agitation and is takithe state’s words, verbatim · CDSS document, Feb 11, 2025 · control 59-AS-20241112093306

Allegation investigated: Due to staff neglect, resident received multiple pressure injuries

On 2/4/25, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Daniel Torgerson. LPA conducted facility and home health records review and extensive interviews. LPA is unable to find and or meet the preponderance, per policy. R1 was admitted on 9/12/24 with history of CVA, heart failure and dysphagia. At admission, R1 also had redness on their heal and coccyx. Home Health was provided throughout R1's stay. 10/3/24, R1 had a new stroke which contributed to further decline. Throughout R1's stay, records and interviews found that R1's care plan was followed as directed by home health and resident appraisals. R1 was sent to the hospital on 12/2/24 for change of condition and passed away in the hospital on 12/4/24. report continued... Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 4, 2025 · control 59-AS-20241202113451

Allegation investigated: Facility withheld residents medications upon move out.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to commence and conclude a complaint investigation. LPA met with Danny Torgersen, Administrator, and Karen Padilla, Director of Nursing, and stated the reason for the inspection. During today's inspection, LPA interviewed the Administrator, Director of Nursing (DON) and (1) Med-Tech staff who conducted the discharge with prior resident (R1) on 12/30/24. Documentation related to (R1) was reviewed including the physician's report, charting notes, physician's orders, December Medication Administration Record (MAR), and medications released upon discharge. The results of the investigation are as follows: cont on 9099C-1.. Unfoundedthe state’s words, verbatim · CDSS document, Jan 3, 2025 · control 59-AS-20241231154627

Allegation investigated: Unlawful eviction.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to open and close a complaint investigation. LPA met with Daniel Torgersen, Co-Administrator, and Karen Padilla, Director of Nursing, and explained the purpose of the inspection. The results of the investigation are as follows: The Department received a copy of each 30-day eviction notice issued to (5) different residents on/around 10/1/24. The notices were provided to the Department timely and included all of the required information, per Regulation 87224. All notices were issued due to non-payment of rent. The Co-Administrator stated on 10/15/24 that (3) of the (5) residents have now made payment towards the unpaid rent balances, and the 30-day notices have been rescinded. There are (2) residents who are currently working with the Social Services Director to arrange for payment so those notices may be rescinded also. The Co-Administrator confirmed that the facility has always been issuing monthly rent invoices to resthe state’s words, verbatim · CDSS document, Oct 15, 2024 · control 59-AS-20241007121222

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.