Ivy Park of Roseville

Allegation investigated: Staff did not report incidents to resident's responsible party.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with James Dial during today’s inspection. LPA investigated allegation, “Staff did not report incidents to resident's responsible party.” LPA interviewed relevant party in which they stated R1 had a fall in the dining room in December 2025 and the incident was not reported to the responsible party. LPA interviewed Administrator in which he stated he recalled the incident however no documentation was taken and it appears staff did not notify the responsible party or CCL of the fall incident. Due to the information gathered LPA finds allegation to be SUBSTANTIATED. As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 59-AS-20260114162229

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 10, 2026

87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirements was not met by evidenced by: Incidents were not reported to responsible party and CCL, responsible parties, and physicians which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: Administrator agrees to review regulation 87211 and submit a plan to CCL on how they will ensure all incidents are reported to responsible parties and CCL within the required time frame.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct the annual continuation inspection. LPA met with Administrator James Dial during today's inspection. Currently there are 112 residents of which 6 residents are receiving hospice care. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 6 resident rooms, medication room, staff area, bathrooms, kitchen, common living spaces, outdoor spaces, and activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA measured the hot water to be 117 degrees Fahrenheit. There is a locked rooms for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. LPA reviewed 15 resident files and 15 staff files. LPA reviewed 5 resident medications comparing with current physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated training completed. LPA observed a copy of current liability insurance. No deficiencies observed during inspection. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jan 9, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met Administrator James Dial during today's inspection. LPA reviewed 15 resident files and 15 staff files. LPA reviewed medications of five residents comparing with Centrally Stored Medication Record and physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. At this time LPA will return on a later date to continue and complete annual inspection. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jan 7, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with administrator James Dial during today's inspection. LPA received 2 incident reports concerning medication errors. On 11/09/25 staff administered eye drops to R1 in error. Staff informed R1's PCP and responsible party. Resident had no adverse effects. On 11/22/25 it was found that R2 was receiving the wrong dosage of medication that was prescribed by R2's PCP. Responsible party and PCP were notified of the error. Resident had no adverse effects. Administrator stated that training was given to staff for both medication errors. There are deficiencies cited during today's inspection. Deficiencies cited on the 809-D. Exit interview conducted. Copy of report given and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 19, 2025

87465(a)(4) Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self administered medications as needed. This requirements was not met by evidenced by: Medication was given incorrectly to residents in care. Medication was also given to wrong resident. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: Administrator has completed training with staff regarding medication errors. Administrator agrees to send into LPA a copy of training given to staff and a statement of the actions that took place to resolve the errors that occurred. POC due by 12/19/25.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Business Office Director Danette Fadollone during today's inspection. The department received incident reports from facility and LPA arrived to gather further information in regards to the incident reports. LPA reviewed resident files and documentation. At this time no deficiencies issued as a result of the visit. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Nov 5, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cassandra Mikkelson conducted a case management visit regarding two separate incident reports received on August 6, 2025 and August 22, 2025 regarding medication errors. LPA also reviewed staff records and trainings and conducted interviews. LPA and Executive Director discussed the importance of accurate medication management and distribution to avoid medication errors in the future. As a result of this visit, a deficiency was cited on 9099-D page. Exit interview conducted with executive director. Appeal rights given.the state’s words, verbatim · CDSS document, Aug 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 11, 2025

87465(a)(4) Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility.The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirements was not met by evidenced by: Medication was given incorrectly to two residents in care. Medication was also given to wrong resident. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Training completed by facility for medication management and prevention of errors on 08/21/2025. Documents given to LPA to satisfy POC. POC cleared during visit.

Allegation investigated: Staff caused injuries to a resident during transfers

Licensed Program Analyst (LPA) Cassandra Mikkelson and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced and met with Executive Director Neal Torres to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: ***Report continued on 9099-C*** Substantiated Staff do not timely respond to a residents alerts Interviews conducted with Executive Director and Staff members S1 and S2 indicated that staff are responding to call button pushes in a timely manner. LPA reviewed call button time logs which indicated that Resident R1 would frequently push their call button and staff responded timely. Interview with R1 indicated that when R1 pushes their call button, the staff respond within reasonable time frames. In review of five (5) resident call button logs, the average response time after a resident pushes their call button was five (5) to ten (10) minutes. Staff do not meet a resident’s incontinence needs Interviews with Executive Director and Staff Members S1 and S2 indicated that Resident R1 has incontinence. Staff follow incontinence care plan and assist R1 with toileting at least every two (2) hours or as requested. Interview with R1 indicated that they need assistance to the toilet and can use their call button to request assistance. During multiple visits with R1, there was no incontinence odor from R1 or R1’s room. Staff do not properly maintain a residents room Interviews with Executive Director and Staff members S1 and S2 indicated that housekeeping and laundry services are provided to Resident R1 weekly as indicated in their admission agreement. LPA observed R1’s room during multiple visits, which was tidy and clean, free of any odor or clutter. Interview with R1 indicated that R1 receives help with housekeeping and laundry services and does not have any complaints. In review with R1’s individualized service plan, R1 is able to maintain independence with housekeeping and laundry other than weekly services. Observation of five (5) resident rooms indicated that staff were properly maintaining resident rooms and assisting with cleaning as needed. **Report continued on 9099-C** Staff threatened a resident while in care LPA conducted interview and learned that S1 made a comment to R1 asking R1 why they didn’t like S1. There are multiple accounts of how the comment was received and its intention. There is insufficient evidence that S1’s comment was intended to be threatening towards R1. Staff did not meet a resident’s hygiene need LPA observed shower skin sheets completed by facility when each resident receives a shower. LPA observed R1 receives showers 2-3 times weekly and it is documented in facility charting notes when R1 refuses to shower. Observations of R1’s person and room indicated that R1 had sufficient hygiene and was free of any odors. Interview with R1 indicated they are receiving showers at least two times a week and did not have any complaints regarding hygiene needs. During tours of the facility on different dates, LPA observed residents in care to be free from odor and have sufficient hygiene. Staff failed to timely seek medical attention for residents LPA reviewed records and conducted interviews. Interviews indicated that facility policy is that when it is determined a resident is in need of emergency medical attention, the facility initiates emergency services. The Department was unable to determine through interviews and documentation if the facility failed to seek timely medical attention for R1. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Staff did not provide appropriate laundry services for a resident Interviews with Executive Director and Staff members S1 and S2 indicated that housekeeping and laundry services are provided to Resident R1 weekly as indicated in their admission agreement. LPA observed R1’s room which was tidy and clean, free of any odor or clutter. Interview with R1 indicated that R1 receives help with housekeeping and laundry services and does not have any complaints. Records reviewed indicated that R1 has laundry service and housekeeping once a week per the admission agreement. In review with R1’s individualized service plan, R1 is able to maintain independence with housekeeping and laundry other than weekly services. Staff are not properly trained Interview with Executive Director (ED), Staff member S1 and S2 indicated that all staff are trained when first hired and continually receive trainings in order to keep skills up to date. ED, S1 and S2 all indicated that staff attend trainings done by facility or by outside agencies. S1 and S2 often oversee staff members in order to ensure that they are following proper techniques that were learned in trainings. LPA observed training records for staff which contained trainings completed by staff. Staff completed trainings on transferring residents in care in and out of vehicles and lifting and transferring of residents (training completed by Vitas Hospice). Staff did not ensure a resident attended scheduled appointments Interviews with the Executive Director (ED) and Staff members S1 and S2 indicated that Resident R1 attended scheduled appointments. ED, S1 and S2’s interviews all indicated that R1 sometimes does not want to attend the scheduled appointment or want to get dressed/groomed to leave the facility for their appointment. Facility staff attempt to encourage R1 to go to their appointments but cannot force R1 to attend. In review with R1’s individualized service plan, R1 is independent with healthcare appointments and transportation or is assisted by family. **Report continued on 9099-C** Staff did not properly report incidents with authorized representatives In review of charting notes from facility dated 8/16/2024- 3/5/2025, facility staff documented when they spoke to R1’s RP each time an incident or event happened either via phone or in person when they arrived. Interviews with Executive Director and Staff Members S1 and S2 indicated that R1’s Authorized representative was notified of any incident involving R1, including refused showers, refusal to leave their room for meals, etc. Interview with R1 indicated that they spoke with their authorized representative and the authorized representative knew about incidents or any changes for R1 based on facility staff informing them. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. Interviews conducted with Resident Care Coordinator and Health Services Director indicated that R1 did have an injury sustained during a transfer. R1 sustained a skin tear on the front lower leg. Records reviewed indicated there was an incident report written regarding injury sustained during transfer. Based on the information obtained for the allegation above, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted with Executive Director and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 8, 2025 · control 59-AS-20250303125332

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 15, 2025

87468.2 Additional Personal Rights of Residents... (a)...(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This poses a potential health and safety risk for residents in care. This requirement was not met as evidenced by: Resident R1 sustained an injury during transfer.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Facility conducted a staff training on proper transfer techniques at time of incident. POC cleared at time of visit.

Type of visit: Required - 1 Year

On 01/22/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced to conduct the annual inspection. LPA met with Business Office Director Danette Fadollone during today's inspection. Facility Executive Director (ED) later joined the visit. Currently there are 110 residents of which 6 residents are receiving hospice care. During visit LPA was informed that Chad Rogers is no longer the ED of the facility. Neal Torres is the ED now and has been since December 2024. ED stated that they did send in the paperwork to Community Care Licensing (CCL) to make the change. LPA requested for facility to resend the documents. LPA toured facility with Business Office Director to ensure the health and safety of residents in care. LPA toured ten (10) resident rooms, medication room, bathrooms, kitchen, and activity areas. LPA observed residents in common areas participating in activities and in the dining room having lunch. The residence was found to be clean, safe, sanitary and in good condition. LPA observed the facility to have the mandated posters posted. Fire extinguishers are maintained and ready for emergency use. Facility has required food supplies. There are appropriate staff present to meet the needs of residents. LPA reviewed ten (10) resident files and ten (10) staff files. Staff records reviewed indicated training completed. LPA reviewed two (2) resident medications comparing with current physician orders. LPA requested facility to send a copy of the current liability insurance. LPA completed the full care tool and no deficiencies was observed. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Jan 22, 2025

Allegation investigated: Facility is retaining a resident with a higher level of care needed.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver compliant findings. LPA met with Chad Rogers during today’s inspection. LPA investigated the allegation, “Facility is retaining a resident with a higher level of care needed.” LPA interviewed staff and reviewed facility and resident documentation. Relevant party indicated that R1 had a change of condition resulting in resident requiring a 2 to 3 person assist with care. LPA interviewed staff and found R1 does require a 2-person assist and has a healing stage 1 wound. Homehealth is coming out to the facility to manage wound care. Through interviews LPA found staff are still able to meet R1’s care needs even though she is requiring more extensive care. Continuation on 9099-C. Unfounded LPA finds that although R1 does require 2 persons assist and more extensive care, R1 does not have a prohibited health condition and facility is still able to meet residents needs. Training was provided to staff on lifting techniques for R1. Due to the information gathered LPA finds allegation to be UNFOUNDED. The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. Relevant party indicated that residents can wait long periods of time because they are instructed to respond to certain residents first. Due to the information gathered, LPA finds the allegation to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 59-AS-20240821121518

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Bethany Mirlohi and Graham Gunby arrived unannounced to conduct a case- management. LPA met with Administrator Chad Rogers during today's inspection. LPA arrived to discuss two separate incident reports received from the facility. LPA interviewed administrator concerning incident and reviewed documentation. It appears facility followed proper protocol and regulation on each incident that occurred. At this time, no deficiencies cited during today's inspection. Exit interview conducted.the state’s words, verbatim · CDSS document, Aug 13, 2024

Allegation investigated: Staff did not provide adequate supervision, resulting in a resident wandering away from the facility unsupervised. Staff did not ensure that facility front door alarm was working.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA met with Business Office Director Danette Fadollone during today’s visit. LPA spoke to Administrator over the phone. LPA investigation allegation, “Staff did not provide adequate supervision, resulting in a resident wandering away from the facility unsupervised.” LPA obtained resident records and conducted interviews with staff and relevant party. Relevant Party indicated on March 15th at approximately 2 PM, they arrived at the facility to pick up R1 for a doctor’s appointment. Relevant Party reported they found R1 wandering in the facility parking lot unsupervised. Relevant party reported that facility was unaware resident was wandering outside the facility until she reported the incident. Continuation on 9099-C. Substantiated LPA interviewed staff member who works near the front door. Staff stated R1 wears a wander guard, but staff did not hear an alarm go off and did not see R1 leave the facility. Staff stated she was alerted by relevant party that R1 was outside wandering. Record review indicated that R1 was placed on the wanderguard system due to R1 having an increase in confusion. Wanderguard consent form was sign by R1’s responsible party on 2/14/24 and wanderguard bracelet was placed on R1’s walker. Due to the information gathered LPA finds allegation to be SUBSTANTIATED. LPA investigated allegation, "Staff did not ensure that facility front door alarm was working."LPA obtained resident records and conducted interviews with staff and relevant party. Relevant Party indicated on March 15th at approximately 2 PM, they arrived at the facility to pick up R1 for a doctor’s appointment. Relevant Party reported they found R1 wandering in the facility parking lot unsupervised. Relevant party reported that facility was unaware resident was wandering outside the facility until she reported the incident. LPA interviewed staff member who works near the front door. Staff stated R1 wears a wander guard, but staff did not hear an alarm go off and did not see R1 leave the facility. Staff stated she was alerted by relevant party that R1 was outside wandering. LPA interviewed staff in which he stated he helped fix the wanderguard system. Staff stated that sensors were set on a low setting and due to R1 wearing their wanderguard bracelet on the walker, the sensors did not pick up the signal. Staff have updated the wanderguard system so sensors are on high and whenever a wanderguard gets within 6 feet, the alarm will signal. Administrator stated he is checking the wanderguard system weekly in precaution. Although the wanderguard system was in working order, the facility did not ensure the R1’s location of the wanderguard was placed properly to ensure wanderguard sensors would work properly. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED. Deficiencies cited on 9099-D. Appeal rights provided.the state’s words, verbatim · CDSS document, May 1, 2024 · control 59-AS-20240318090507

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312 · Plan of correction due date: May 22, 2024

§1569.312 Basic services requirements. (d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. Based on interviews and record review the licensee did not provide adequate supervision which resulted in resident wandering away from facility which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 1, 2024

Plan of correction: Administrator stated the facility will be conducting elopement drills monthly with care staff. Administrator to send into LPA a copy of documentation of the first elopement drill. Documentation to be sent into CCL by 5/22/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(j) · Plan of correction due date: May 22, 2024

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. Based on interviews and record review the licensee did not ensure wanderguard alarm system was working correctly which poses a potential health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 1, 2024

Plan of correction: Administrator to send LPA plan on how wanderguard will be checked to be in working order for all residents with the wanderguard system. Plan to be submitted into CCL by 5/22/24.

Allegation investigated: Staff do not ensure residents are monitored for early signs of illness while in care. Staff do not ensure infection control requirements are followed.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA met with Chad Rogers during today’s inspection. LPA investigated the allegation, “Staff do not ensure residents are monitored for early signs of illness while in care”. LPA interviewed reporting party in which they reported residents signs and symptoms to facility staff, and staff informed reporting party that resident had to purchase their own covid test. Reporting party stated they purchased a covid test, returned to the facility, and resident tested positive for Covid. Continuation on 9099-C. Substantiated LPA interviewed administrator in which he stated staff did inform reporting party that resident needed to purchase their own covid test. LPA reviewed facility infection control plan and policies. LPA observed the following, “Oakmont will perform testing for residents in the following situations: Within 48 hours after the development of COVID symptoms". Due to the information gathered LPA finds allegation to be SUBSTANTIATED. LPA investigated allegation, “Staff do not ensure infection control requirements are followed.” LPA interviewed reporting party in which she stated that once resident tested positive, resident was in isolation in their room. There was PPE set up outside the resident room, and staff were made aware that PPE was needed when entering the resident room. Reporting party stated a staff member entered the resident room with no PPE on and delivered resident their meal. LPA interviewed administrator in which he stated a staff member did enter resident room without proper PPE. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED. As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Copy of report provided to the facility.the state’s words, verbatim · CDSS document, Mar 6, 2024 · control 59-AS-20240102141144

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(9) · Plan of correction due date: Mar 25, 2024

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (9) The licensee shall ensure that infection control practices are maintained in the facility as specified in Section 87470, Infection Control Requirements. This requirement is not met as evidenced by: Based on record review and interviews the licensee did not follow facility plan which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: Administrator to complete training with all staff concerning infection control policies and regulations. Copy of training to be sent into CCL by 3/25/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(b)(2) · Plan of correction due date: Mar 25, 2024

87470 Infection Control Requirements. (b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply:(2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. This requirement is not met as evidenced by: Based on interviews the licensee did not follow infection control plan which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: Administrator to complete training with all staff concerning infection control policies and regulations. Copy of training to be sent into CCL by 3/25/24.

Allegation investigated: Facility is not abiding by the admissions agreement. Facility staff are not allowing residents to have visitors.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA met with Chad Rogers during today’s inspection. LPA investigated the allegation, “Facility is not abiding by the admissions agreement”. LPA obtained copies of admission agreement, resident invoices, and other pertinent documents. Reporting party stated resident was being charged for meals to be delivered to resident room which was against the admission agreement. Resident LIC602 states resident is ambulatory and does not require help while feeding themselves.. LPA reviewed resident invoices and observed resident was being charged for rent, care fees, guest meals, and tray service monthly. Continuation on 9099-C. Unfounded LPA reviewed resident admission agreement in which it states, “Ivy Park will provide room service to your apartment during a temporary illness, at no extra charge, not to exceed three days a year. During other times optional room service will be provided to you at your request for an extra charge”.In addition, admission agreement states, there will be an extra fee for guest meals. LPA interviewed administrator in which he stated there is a fee for food being delivered to resident room. Due to the information gathered LPA finds the allegation to be UNFOUNDED. LPA investigated the allegation, “Facility staff are not allowing residents to have visitors.” LPA obtained copies of resident’s documents and conducted interviews. LPA interviewed relevant parties in which they stated facility allows visitors for the resident during business hours but they are not allowing overnight visitors to stay with the resident. LPA interviewed administrator in which he stated that the facility will allow overnight visitors with the prior approval of the administrator, and it can only be for a short period of time. Administrator stated resident was allowing their granddaughter to stay the night without the approval of the facility or any type of notification. Administrator stated he sent a letter to the resident and their responsible party in October 2023 stating resident’s granddaughter was not permitted to stay the night in resident room without the permission of the facility. LPA reviewed the admission agreement in which it states, “Before any visitor stays in your apartment overnight you must notify the executive director in writing. All visitors must register at the front desk when entering the community.” Due to the information gathered, LPA finds allegation to be UNFOUNDED. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Feb 21, 2024 · control 59-AS-20231220093910

Allegation investigated: Staff did not prevent facility from being hazardous leading to resident suffering a fall while in care. Staff attempted to administer a medication that fell on the floor to a resident in care. Staff did not keep facility free of mold. Staff did not respond to resident's request for a meal replacement.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings. LPA met with Chad Rogers during today’s inspection. LPA investigated allegation, “Staff did not prevent facility from being hazardous leading to resident suffering a fall while in care”. LPA conducted interviews, file reviews, and toured resident room. LPA interviewed resident in which they stated that upon move in they observed a large warp in the flooring in their bathroom. They informed the facility about this, but while waiting for the floor to be fixed they had a fall and hurt their hand. Resident stated they did not seek medical attention or inform the facility nurse. Resident stated their physical therapist(PT) from an outside agency was aware of the injury. Continuation on 9099-C. Unsubstantiated Resident was unable to provide LPA the contact information for PT and LPA was unable to interview. LPA interviewed a staff member from the maintenance team in which they stated there was a very small bubble in the flooring of the bathroom. Staff stated they don’t believe it was a tripping hazard but they did replace the whole bathroom floor. LPA observed a receipt from an outside agency for 10/4/23, in which company replaced the entire bathroom floor. LPA reviewed the work orders from maintenance, in which it shows the staff became aware of the flooring issue on 09/21/23. LPA interviewed the Health Services Director in which she stated she was unaware of any fall or trip hazard in resident room. LPA finds the allegation to be UNSUBSTANTIATED. LPA investigated allegation, “Staff attempted to administer a medication that fell on the floor to a resident in care.” LPA interviewed resident in which they stated a medication technician (med tech) was dispensing their medications in the dining room. Med tech dropped resident pill on the ground and then proceeded to wipe off the pill and offer resident their medication. Resident was unable to provide LPA the name of the med tech. LPA interviewed health services director and she stated staff informed her that one time med tech handed resident their medications and resident dropped it on the floor and then resident picked it up off the ground and resident took it. Due to conflicting information LPA finds the allegation to be UNSUBSTANTIATED. LPA investigated allegation, “Staff did not keep facility free of mold.” LPA interviewed resident in which they stated that there was mold in their shower. Resident informed the maintenance team and they confirmed the mold and removed it. LPA interviewed maintenance staff in which he stated he did observe mold in resident room, but he did observe dirt in the shower divider. Staff stated they cleaned the area and replaced the shower divider. LPA toured the facility and did not observe mold in the facility. Due to the conflicting information, LPA finds allegation to be UNSUBSTANTIATED. Continuation on 9099-C. LPA investigated allegation, “Staff did not respond to resident's request for a meal replacement.” LPA interviewed resident in which they stated there were many issues with the kitchen. Resident stated many times the kitchen staff did not serve them the food they ordered. Resident stated they are allergic to melon and strawberries and the fruit was served to them on multiple occasions for breakfast. The kitchen staff refused them a meal replacement and just grabbed the melon from their plate instead. LPA interviewed kitchen staff and they stated there were a couple of times during the morning shift that resident was served melon with their breakfast food. The resident informed the kitchen staff and staff immediately replaced their food with no melon on their plate. Kitchen staff did not recall a time where staff grabbed the melon off the plate and refused a meal replacement. Due to the conflicting information LPA finds allegation to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview conducted. If the issue required a 3rd party, it did take longer than normal. LPA reviewed the work orders, and observed 18 completed work order tasks. All work orders were completed within a few days or within the week. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated allegation, “Facility is in disrepair.” LPA conducted a file review, interviews, and toured the facility. LPA interviewed the resident in which they stated there were many issues with the maintenance of the facility which included the doors not locking properly, the garbage area, elevator, and their room having multiple issues during their stay. LPA toured the facility which included resident room, common living spaces, kitchen, elevators, and dining room. LPA observed the facility to be in good repair. LPA reviewed the work orders and found resident had 18 work orders while residing within the facility. All work orders were resolved. LPA observed that there were several maintenance issues that came up, however all issues were resolved in a timely manner. Due to the information gathered LPA finds the allegation to be UNFOUNDED. The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. LPA interviewed kitchen staff in which they stated there were a couple of times during the morning shift that resident was served melon with their breakfast food. The resident informed the kitchen staff and staff immediately replaced her food with no melon on their plate. Kitchen staff stated resident’s allergy to melon was not listed in the dietary restriction binder in the kitchen that lists diets and allegories. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED. As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 10, 2024 · control 59-AS-20231108090803

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Jan 31, 2024

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Based on interviews and record review the licensee did not ensure resident was served safe food which poses a potential health, and safety risk to resident's in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: Administrator agrees to place a dietary restriction board in a common place in the kitchen for staff to review. Administrator to send LPA a picture of the board onced placed in the kitchen. POC due by 1/31/24.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct the annual inspection. LPA met with Administrator Chad Rogers during today's inspection. Currently there are 112 residents of which 7 residents are receiving hospice care. LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 7 resident rooms, medication room, staff area, bathrooms, kitchen, common living spaces, outdoor spaces, and activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA measured the hot water to be 119 degrees Fahrenheit. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. LPA reviewed 10 resident files and 10 staff files. LPA reviewed 3 resident medications comparing with current physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated training completed. LPA observed a copy of current liability insurance. No deficiencies observed during inspection. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jan 10, 2024