Ocean Hills Assisted Living & Memory Care

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: Staff did not administer medications as prescribed by a physician Staff falsified resident’s medication administration record

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Sheryl Johnston and Resident Care Director Dennis Prejusa. The Department’s investigation consisted of interviews with residents, staff and outside sources, records review, and a tour of the facility. It was alleged that staff falsified resident’s medication administration record and staff did not administer medications as prescribed by a physician, specifically for Resident 1 (R1). The Department was unable to interview R1 due to R1 passing away in October 2021. Review of R1’s medical assessment and reappraisal records from 2020 revealed that R1 did not have a diagnosis of cognitive impairment, was diagnosed with a major neurocognitive disease (MND), but was not confused or disoriented, was able to follow directions, and required assthe state’s words, verbatim · CDSS document, Apr 17, 2025 · control 08-AS-20210923101017

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 comply with terms and conditions of the admission agreement Residents are not being adequately assessed for the appropriate level of care Licensee is not updating appraisal to accurately reflect the residents service needs Insufficient staff to meet residents care needs

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Sheryl Johnston. During today's visit, LPA observed residents in care and reviewed and obtained copies of facility records. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the licensee did not comply with terms and conditions of the admission agreement, specific to meal quality, residents were not assessed for appropriate level of care, the licensee did not update appraisal to reflect residents’ service needs, and insufficient staff to meet resident care needs. Review of resident assessment records, needs and service plans, and physician’s reports from residents present at the facility in 2020 revealedthe state’s words, verbatim · CDSS document, Dec 13, 2024 · control 08-AS-20210601095347

Allegation investigated: Facility staff did not assist resident with toileting needs Facility staff mismanaged resident's medications Facility charged resident for services not rendered Facility staff used improper transfer technique resulting in bruising Facility staff left resident in soiled clothing for an extended period of time Facility is not providing a good quality of food Facility is not kept free of insects Facility is not kept clean

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Business Office Manager Kristin Mulligan. During today's visit, LPA observed residents in care and reviewed and collected copies of facility records. LPA was away from the facility for approximately 1 hour between 12:20pm and 1:20pm. The Department’s investigation consisted of interviews with staff and outside sources, records review, and a tour of the facility. It was alleged that staff did not assist resident with toileting needs, staff mismanaged resident’s medications, staff used improper transfer technique resulting in bruising, staff left resident in soiled clothing for an extended period of time, facility is not providing a good quality of food, facility is not kept free of insects, and facility is not kept clean. Continued onthe state’s words, verbatim · CDSS document, Apr 24, 2024 · control 08-AS-20200611092333

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: Lack of supervision resulting in sexual abuse

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director (ED) Sheryl Johnston and Director of Resident Care (DRC) Dennis Prejusa. During today’s visit, LPA observed residents in care and interviewed staff. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that lack of supervision resulted in sexual abuse involving Resident 1 (R1) and Resident 2 (R2). Review of R1’s medical assessments dated September 2023 revealed that R1 had a diagnosis of major cognitive impairment, was confused and disoriented, and was unable to follow directions, but R1 was able to communicate their needs. Continued on LIC9099-C page... Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 4, 2023 · control 08-AS-20231020151106

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: Resident was left unattended for extended period of time resulting in resident's hospitalization.

Licensing Program Analyst (LPA) Esther Miller conducted an unannounced visit to deliver findings for a complaint investigation. LPA was granted entry by Sheryl Johnston, Executive Director (ED), after identifying herself. LPA discussed the purpose of the visit and the basic element of the allegation mentioned above with ED. On September 14, 2020, it was alleged that Resident 1 (R1) was left unattended for an extended period of time resulting in resident’s hospitalization. During today's visit, LPA toured the facility, reviewed facility records, and interviewed facility staff. On September 7, 2020, facility records indicated that R1 was last seen by staff around 2:30PM. R1 was prescribed medication to be taken at 4:00PM and given by Staff 1 (S1). S1 admitted to facility that they [Continued on LIC9099-C, Page 1 of 2] Substantiatedthe state’s words, verbatim · CDSS document, Sep 6, 2023 · control 08-AS-20200914151143

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