Ivy Park At Sabre Springs

Allegation investigated: Licensee did not assess residents according to their level of care. Licensee did not ensure resident records were complete and current.

The following determination of findings have been made by Licensing Program Analyst (LPA) Nacole Patterson regarding the above allegations. This report was mailed to the Licensee. On 03/11/2025 it was alleged that Licensee did not assess residents according to their level of care, and Licensee did not ensure resident records were complete and current. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, resident, outside sources, and records review. Staff interviews were consistent regarding the facility's assessment procedures for residents. Staff informed that the only resident with an assessment adjustment during the timeframe of complaint was Resident 1 (R1). The assessment procedures outlined by staff were consistent with R1's onboarding and assessment documents. Staff informed that while R1 was appropriately assessed to be placed in the Assisted Living section of the facility, R1 experienced a change of condition shortly after athe state’s words, verbatim · CDSS document, May 31, 2026 · control 08-AS-20250311114348

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 allow resident to receive phone calls.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes. On 11/12/2026 it was alleged that Licensee did not allow Resident 1 (R1) to receive a phone call. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Staff interviews revealed that initially, an instruction existed for staff not to inform a specific outside source that R1 lived at the facility due to safety concerns. Interviews further revealed that the facility later changed this instruction, informing staff that if the outside person called, they must inform R1 and allow them to accept or deny the phone call. Staff stated that during a recent All-Staff meeting, training was provided regarding residents' personal rights to receive or reject phone cathe state’s words, verbatim · CDSS document, Jan 28, 2026 · control 08-AS-20251112131132

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 treat resident(s) with dignity. Staff did not respond to residents' call buttons in a timely manner. Staff did not provide adequate supervision to residents(s).

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes. On 05/08/2025 it was alleged that staff did not treat resident(s) with dignity, staff did not respond to residents' call buttons in a timely manner, and staff did not provide adequate supervision to residents(s). The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations. Regarding the allegation, "Staff did not treat resident(s) with dignity", it was alleged that specific staff members were observed yelling at residents and handling them roughly. (Continued on LIC9099 p.2) Substantiatedthe state’s words, verbatim · CDSS document, Oct 1, 2025 · control 08-AS-20250508132716

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 treat resident with dignity and respect.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes. On 10/14/2024 it was alleged that Staff did not treat resident with dignity and respect. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, records review, and LPA observations. Staff interviews did not corroborate the allegation, as staff consistently informed not hearing of or witnessing another staff treating a resident without dignity. Staff informed that the resident in question, R1, had become more reclusive and resistant to care due to a change in condition. An outside medical professional familiar with R1's care at the facility informed not observing any dignity issues between staff and R1. (Continued on LIC9099 p.2) Unsubstantiatedthe state’s words, verbatim · CDSS document, May 22, 2025 · control 08-AS-20241014144500

Allegation investigated: Staff did not distribute residents' medications as prescribed. Staff did not ensure that residents' medications were stored in their original container.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes. On 12/16/2024 it was alleged that staff did not distribute residents' medication as prescribed, and staff did not ensure that residents' medications were stored in their original container. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Seven (7) staff were interviewed regarding medication administration, six (6) of whom were Med Techs or trained to pass medications. All staff provided consistent information regarding the process for passing medications. No staff had observed or were aware of medication errors that had occurred. (Continued on LIC9099 p.2) Unsubstantiatedthe state’s words, verbatim · CDSS document, May 22, 2025 · control 08-AS-20241216101746

Allegation investigated: Facility door(s) were in disrepair. Resident(s) were not afforded privacy while care was being provided.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes. On 12/16/2024 it was alleged that facility doors were in disrepair and residents were not afforded privacy while care was being provided. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. It was claimed that resident doors at the facility were being propped open and that doors did not close properly. Staff members interviewed consistently informed that no resident doors had been kept open by staff without the resident's consent or outside of their preference. Staff informed that two residents prefered their doors to remain open, and staff checked on them regularly. No staff had knowledge of any resident door being in disrepair. (Continued on LIC90the state’s words, verbatim · CDSS document, May 22, 2025 · control 08-AS-20241216162250

Allegation investigated: Resident fall due to neglect.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Rob Daynes. On 07/02/2024 it was alleged that staff neglect led to Resident 1 (R1)'s fall, resulting in R1 lying on the floor throughout the night. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Staff interviews did not corroborate the allegation, as staff consistently denied that Resident 1 (R1) suffered a fall that resulted in them being unattended for hours without staff help. Staff informed that R1 lived in the Assisted Living section of the building and was mostly independent, not requiring assistance with Activities of Daily Living (ADLs) or checks throughout the night. Staff interviews revealed that R1 began to experience a change in cognition duringthe state’s words, verbatim · CDSS document, Mar 27, 2025 · control 08-AS-20240702125951

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.