The Montera

    5740 Lake Murray Blvd, La Mesa, CA 91942
    • Assisted Living
    • Memory Care

    Warm knowledgeable staff, mom happier

    I moved my mom here and have been very pleased - the staff are knowledgeable, warm and genuinely caring, and the memory-care team gives me real peace of mind. The property and renovated common areas are beautiful and clean, dining is excellent, activities and family supports are plentiful, and Mom is happier and more engaged; I highly recommend it.

    Loved one of resident
    Aug 2026

    Pricing

    Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Coordination with health care providers
    • Hospice waiver
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Memory care community services

    • Dementia waiver
    • Mild cognitive impairment
    • Specialized memory care programming

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (medical)
    • Transportation arrangement (non-medical)
    • Transportation to doctors appointments

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    4.35·(257)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      4.1
    • Staff

      4.3
    • Meals

      4.3
    • Amenities

      3.7
    • Value

      2.6

    Pros

    • Compassionate, resident-focused caregiving staff
    • Strong dining program with skilled chef and varied menus
    • Broad daily activity calendar including music, outings, and classes
    • Attractive, well-maintained grounds and outdoor spaces
    • Renovated common areas and contemporary social spaces
    • On-site amenities (theater, gym, barber, chapel, library)
    • Transportation and scheduled medical/shopping trips
    • Pet-friendly community
    • Laundry and all-inclusive meal service options
    • Restaurant-style and multiple dining venues
    • Responsive move-in and marketing support
    • Housekeeping and grounds maintenance praised
    • Secure memory-care environment
    • Value-oriented options in some unit types
    • Small-community, socially engaging atmosphere

    Cons

    • Inconsistent staffing and high caregiver turnover
    • Gaps in family communication and shift-change handoffs
    • Variable day-to-day care consistency across caregivers
    • Sanitation and pest-control concerns in some units
    • Medication-administration and med-tech role clarity issues
    • Uneven implementation of memory-care monitoring and protocols
    • Billing and pricing transparency inconsistencies
    • Patchy staff training and orientation practices
    • Physical accessibility limitations in some unit layouts
    • Uneven facility condition during phased renovations
    • Underutilization of certain amenities and exercise options
    • Infection-control events that disrupted programming and visitation

    Summary of reviews

    The Montera elicits a mixed but clear pattern: many families and residents praise the community for strong hospitality, good food, an active social calendar, and attractive grounds, while others identify operational weaknesses that can affect higher-dependency residents. Across reviews, positive themes center on warm, personable staff, an accomplished dining program, varied activities (live music, outings, creative and exercise classes), and extensive on-site amenities such as a theater, gym, chapel, transportation services, and multiple communal dining options. Renovated common areas, well-kept landscaping and garden features (including a koi pond), and a generally welcoming tour experience are frequently noted.

    Care quality and staffing present the largest area of divergence. Numerous accounts describe genuinely attentive, compassionate caregivers who know residents by name and facilitate social engagement; these staff members are often credited with residents' improved appetite, mood, and socialization. At the same time, a recurring operational theme is inconsistent staffing levels and turnover, which reviewers connect to variable caregiving continuity, uneven handoffs at shift change, and occasional delays in assistance for residents with higher needs. Related concerns include gaps in med-tech role clarity and medication-administration practices, which families advise verifying during any placement discussion.

    Dining and activities are generally strong points. The cuisine and buffet-style or restaurant-service dining receive frequent commendation for quality, portioning, and variety; special events and themed meals are highlighted. The activity program is broad, offering both passive and active options (music, arts, religious services, outings, and exercise classes). Some reviewers noted underutilized amenities or limited exercise options for more mobile residents; accessibility to certain programs can vary by building location within the campus layout.

    Facility condition and accessibility are mixed. Many common areas and select units have been recently remodeled and are described as contemporary and clean; maintenance and groundskeeping staff receive positive mentions. Conversely, other areas are described as dated or still undergoing renovation, and some unit types are small with limited in-room storage or appliance options. Physical-access limitations—such as storage and fixture heights and minimal grab-bar configurations—were noted for residents with mobility impairments, so assessing unit-specific accessibility is important.

    Management, communication, and business practices are another area of divided experience. Several families praise attentive sales and move-in assistance and responsive leadership, while others describe inconsistent follow-through on promised services, unexpected rate increases or fee structures, and occasional billing or collection disputes. Infection-control events, particularly COVID-related outbreaks, strained programming and visitation and exposed weaknesses in timely family communication during crises.

    Notable patterns for prospective families: The Montera appears to offer a high-quality lifestyle for residents who are reasonably independent or who benefit from strong social programming and good dining. The community can be an excellent fit when care needs are moderate and social engagement is a priority. Families considering The Montera for residents with more advanced mobility, toileting, or complex clinical needs should probe staffing continuity, transfer and two-person transfer policies, toileting and incontinence-care procedures, medication-administration safeguards, recent pest-control and sanitation actions, and how renovations will affect daily life. A focused walk-through of the specific unit, a review of current staffing ratios and training programs, and written clarification of fees and promised services are advisable steps before committing.

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    Location

    Map showing location of The Montera

    The Montera is located at 5740 Lake Murray Blvd, La Mesa, CA, 91942.

    About The Montera

    The Montera sits in a quiet suburb of La Mesa, California, and serves as a senior living community run by MBK Senior Living, which offers a full range of care, from independent living to assisted living, memory care, skilled nursing, respite care, continuing care retirement, and even hospice care for those who need it, and it's been certified as "A Great Place to Work." Residents live in pet-friendly studios or one-bedroom apartments, with floor plans for different living needs, and the property features modern utilities, strong security with video surveillance, and a well-kept landscape inspired by the southwest, including gardens, a walking path, shade outdoors, and a peaceful Koi pond, along with a courtyard for relaxing strolls. All apartments, including private and shared memory care studios, come with amenities for comfort and convenience, and residents can get help with activities of daily living like bathing and dressing if they need it. The community's friendly staff, including fully staffed caregivers and med techs, are available 24/7, plus licensed nursing staff and separate housekeeping are on site, and short-term stays are possible for respite needs.

    Residents enjoy a vibrant environment with restaurant-style dining, a Bistro for light snacks, and food made with nutritious, quality ingredients through a diverse culinary program led by skilled chefs. Engaging activities fill the calendar every day, and these range from group games in the game room, artistic projects in the art studio, and daily exercise, including Tai Chi and ability-focused training, to religious services, wellness programs, grooming in the salon or barber shop, and social gatherings that help people connect. There's easy access to medical care, with mobile physician visits, and transportation in a community van or car for trips to local attractions, plus scheduled outings and on-site parking for families visiting. The staff offers personalized support, from total care to specialized memory care for Alzheimer's or dementia, with care programs tailored to different needs, and bedridden care when needed. For those looking for information and help with planning, The Montera provides helpful resources, tools, caregiving support, glossaries, and real resident stories. Prices for private rooms range from $4,105 to $6,700, and residents can choose among studio apartments, deluxe studios, one-bedrooms, or shared rooms, depending on their needs. The Montera works hard to give seniors a comfortable place where there's time to relax in the courtyard or by the Koi pond, and opportunities to join in a variety of activities every day in a warm, welcoming environment, where friendly team members support independence and connections with others.

    About MBK Senior Living

    The Montera is managed by MBK Senior Living.

    Founded in 1990 and headquartered in Irvine, California, MBK Senior Living operates 38 communities across six western states. As a subsidiary of Fortune 500 company Mitsui & Co., MBK offers independent living, assisted living, and memory care services. Their Japanese-inspired philosophy centers on three core values: Ageless Exploration, Better Together, and Reason for Being.

    People often ask...

    The Montera offers competitive pricing, with rates starting at a cost of $4,885 per month.

    The Montera offers assisted living and memory care.

    There are 51 photos of The Montera on Mirador.

    The full address for this community is 5740 Lake Murray Blvd, La Mesa, CA 91942.

    No, The Montera does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In California, the Department of Social Services' Community Care Licensing Division licenses residential care facilities for the elderly, conducting inspections and investigating complaints.

    License number374604855
    StatusLicensed
    Facility typeResidential Care Elderly
    Capacity225 residents
    LicenseeS-H MONTERA OPCO LLC; MSL COMMUNITY MANAGEMENT LLC
    EffectiveDecember 22nd, 2025
    View the official license record

    Inspection Reports

    117

    Reports

    2

    Type A Citations

    34

    Type B Citations

    72

    Complaints

    6

    Years

    12 Jun 2026Complaint
    Investigated the complaint alleging improper bathing, charges for services not rendered, and leaving a resident in a soiled brief. Found no evidence to support the allegations.
    12 Jun 2026Inspection
    Investigated a self-neglect incident and reviewed related documentation; observed evidence of alcohol delivery to a resident, indicating ongoing health and safety risk factors, while no immediate risks to other residents were identified.
    12 Jun 2026Complaint
    Investigated the allegation of neglect resulting in serious injury and determined it to be unsubstantiated.
    29 Apr 2026Inspection
    Observed no deficiencies and overall compliance with licensing requirements.
    08 Apr 2026Complaint
    Investigated two specific allegations about hospice care plan adherence and safeguarding resident belongings. No evidence was found to prove either allegation.
    08 Apr 2026Complaint
    Investigated a complaint alleging staff mishandled a resident's medication and did not follow infection control requirements. The investigation concluded the allegations were unsubstantiated.
    08 Apr 2026Complaint
    Investigated allegations about toileting care, feeding, room cleanliness, and laundry; found no evidence to support the concerns.
    19 Feb 2026Complaint
    Investigated two allegations that staff changed the Family Council bulletin board without consent and did not respond to written concerns within 14 days. Found no evidence to prove the alleged violations.
    29 Jan 2026Inspection
    Found no deficiencies during the unannounced quarterly case management visit; conditions were clean, safe, and in good repair.
    28 Jan 2026Complaint
    Investigated a complaint that rate increase notices did not include the amount, reasons, or descriptions of additional costs.
    • Type B1569.655(a)
    21 Jan 2026Complaint
    Found that the seven-day written death report to the licensing agency was not completed for a resident death on 10/14/2025.
    • Type B87211(a)(1)(A)(a)(1)
    10 Dec 2025Complaint
    Investigated allegation that staff did not assist a resident during a shower, causing a fall, and did not seek timely medical care; evidence showed staff were near the shower, responded when called, and medical evaluation occurred after the incident. The findings indicated there was no evidence to support the allegations.
    25 Nov 2025Inspection
    Identified an incident in which a resident displayed aggressive behavior toward visiting family members. Updates to the resident's service plan were made on 11/24/2025, Lewy Body Dementia was noted per medical records, and staff were observed using de-escalation and monitoring triggers; no deficiencies were issued.
    25 Nov 2025Inspection
    Investigated a case involving a resident eloping; staff followed procedures and no deficiencies were cited.
    19 Nov 2025Complaint
    Investigated a complaint alleging staff retaliated against a resident and found no evidence to support the allegation.
    19 Nov 2025Complaint
    Investigated concerns about delayed response to resident calls and related injuries; found no evidence to prove the allegations.
    19 Nov 2025Complaint
    Investigated two allegations regarding admission agreement compliance and timely assistance; found no evidence to support violations.
    18 Nov 2025Complaint
    Investigated two allegations: failure to provide call button logs to the responsible party and insufficient staffing with retaliation. Both allegations were unfounded.
    16 Nov 2025Inspection
    Identified that a resident fell in the common room, was assessed, and transported to the hospital for treatment, returning the same day.
    13 Nov 2025Inspection
    Observed no deficiencies related to infection control during the COVID-19 outbreak response.
    23 Oct 2025Inspection
    Identified licensing deficiencies during a collateral visit.
    09 Oct 2025Complaint
    Investigated the allegation that staff did not properly dispense medications to residents; findings showed reattempts after refusals, documentation of refusals, and no evidence of improper dispensing.
    01 Oct 2025Complaint
    Investigated and found that a resident's prescribed medication renewal was not completed in time, causing a lapse in treatment.
    • Type B87465(a)(1)
    01 Oct 2025Complaint
    Investigated allegation that staff did not follow proper food handling techniques. Findings indicated the dining area was clean, food was cleared promptly, and staff monitored the area after meals.
    01 Oct 2025Inspection
    Identified two incidents involving residents and staff, one on September 26 involving two residents and another on September 29 involving staff confining a resident to a wheelchair; no deficiencies were cited.
    18 Sept 2025Complaint
    Investigated allegation that lack of supervision allowed a resident to elope. Evidence showed staff were unaware of the resident's absence and supervision did not meet the resident's needs.
    • Type B87468.2(a)(4)
    15 Aug 2025Inspection
    Identified a deficiency due to a perimeter being locked without fire clearance.
    14 Aug 2025Inspection
    Identified locked perimeter gates without fire clearance, creating an immediate safety risk for residents.
    • Type A87705(f)(2)
    13 Aug 2025Inspection
    Confirmed no deficiencies were issued after a case management visit that discussed delayed egress and a locked perimeter.
    04 Aug 2025Inspection
    Conducted an unannounced case management visit, offered an amended report for a prior visit, and obtained signatures on licensing documents.
    04 Aug 2025Inspection
    Identified a deficiency alleging a resident sustained multiple falls because staff did not follow the resident's care plan.
    01 Aug 2025Inspection
    Observed no deficiencies during a pre-licensing visit.
    25 Jul 2025Complaint
    Found that a December 30, 2024 eviction letter contained false information about a resident's care needs; other complaints were not supported by evidence.
    • Type B8707
    25 Jul 2025Complaint
    Investigated allegations about disseminating information for resident council meetings, designating a staff liaison, ensuring resident dignity in staff interactions, and providing safe, healthy, and comfortable accommodations. Observed that meetings were posted on calendars and bulletin boards, a designated staff liaison existed, dignity was observed in interactions, and call lights were answered promptly with satisfactory wake-up coordination.
    25 Jul 2025Complaint
    Investigated allegations that staff did not provide adequate supervision and adequate food service, and found insufficient evidence to support the claims.
    22 Jul 2025Complaint
    Investigated concerns about medication management, wound care, and resident assessments following an unannounced visit. Reviewed records and interviewed staff, residents, and outside sources.
    18 Jul 2025Complaint
    Investigated a complaint that a resident with incompatible needs was retained and that staff did not provide timely incontinence care.
    • Type B87466
    18 Jul 2025Inspection
    Conducted an unannounced case management visit to present an amended report and inform the administrator about licensing rights. An exit interview followed.
    17 Jul 2025Complaint
    Investigated two allegations: failing to protect the resident from harm and failing to facilitate medical care; found insufficient evidence to prove either.
    17 Jul 2025Complaint
    Investigated the allegation that staff did not timely respond to residents' pendant calls. Findings showed there was not a preponderance of evidence to prove the allegation.
    16 Jul 2025Complaint
    Investigated allegations about a resident's falls and wandering; found the assistive device was not consistently used during falls, while evidence did not support wandering out-of-unit.
    • Type B87464(f)(1)
    • Type B87464(f)
    • Type B87101(c)(3)
    • Type B1569.2(c)
    16 Jul 2025Complaint
    Investigated an allegation that staff did not ensure residents' basic needs were met. Findings showed residents received meals and were assisted as needed in the dining room or at their bedsides, with appropriate monitoring and nutritional intake.
    16 Jul 2025Complaint
    Investigated a claim that a resident suffered neglect resulting in serious bodily injury and that staff did not administer medications as prescribed. The investigation found no evidence to prove the alleged neglect or medication administration violations.
    10 Jul 2025Complaint
    Investigated a complaint alleging staff neglect causing pressure injuries, restricted visitation privacy, and failure to follow a resident's special diet; found no preponderance of evidence to support the alleged violations.
    10 Jul 2025Complaint
    Investigated allegations that a resident did not receive adequate food service, laundry needs were not met, and staff intimidated a resident. Findings indicated no corroborating evidence.
    10 Jul 2025Complaint
    Investigated allegations that staff did not assist with attending scheduled medical appointments, did not adequately communicate with the resident’s representative, and did not assist with toileting in a timely manner. Found no evidence to support these concerns.
    10 Jul 2025Complaint
    Investigated allegation that staff failed to observe residents for changes in condition. There was not a preponderance of evidence to prove or disprove the claim.
    08 Jul 2025Complaint
    Investigated a complaint alleging a questionable death and that hospice coordination did not ensure resident safety; records showed ongoing communication with medical staff and hospice and adjustments to care.
    08 Jul 2025Complaint
    Investigated a complaint that staff were not meeting residents' needs due to inadequate staffing and found no preponderance of evidence to prove the allegation.
    08 Jul 2025Complaint
    Investigated a complaint alleging wound care needs were not met, incontinence care was not provided, and visitation rights were restricted. The allegations were unsubstantiated.
    02 Jul 2025Inspection
    Conducted an unannounced collateral follow-up to a complaint investigation, reviewed client documentation, and concluded with an exit briefing.
    30 Jun 2025Complaint
    Investigated allegations of insufficient staffing, rooms not kept clean, and lack of assistance; evidence did not support the allegations.
    30 Jun 2025Complaint
    Investigated a complaint alleging neglect/lack of supervision when a bed fell on a resident's neck. Records and interviews showed no injuries and standard safety checks were followed.
    23 Jun 2025Complaint
    Investigated allegations that a resident developed an infection due to inadequate wound care and that changes in condition were not reported to the resident's responsible party; identified gaps in wound care and in communication.
    • Type B87465(a)(1)
    • Type B87466
    23 Jun 2025Complaint
    Investigated the allegation of a malodor from mold in/around a resident's unit; findings showed no mold and no malodor during visits and reviews.
    17 Jun 2025Complaint
    Investigated the allegation that staff were not properly trained to administer medication. Records showed staff completed annual medication training and demonstrated knowledge of proper medication administration.
    12 Jun 2025Complaint
    Investigated a complaint alleging sexual abuse, medication mismanagement, bedding deficiencies, and dietary request issues. Found no evidence to support the allegations.
    30 Apr 2025Complaint
    Investigated a complaint alleging lack of supervision resulting in a resident-to-resident altercation and reporting requirements. Evidence from interviews and records showed the December 2, 2024 incident involved a fall, no assault occurred, and it was documented; no regulatory violations were established.
    22 Apr 2025Complaint
    Investigated a complaint about medication administration. Interviews and MAR reviews showed proper medication delivery.
    08 Apr 2025Inspection
    Identified a resident-to-resident altercation reported April 1, 2025, and welfare checks and staff interviews followed.
    08 Apr 2025Inspection
    Identified a self-reported head injury to a resident and conducted welfare checks, staff interviews, and records review. No immediate health or safety risks were observed.
    26 Mar 2025Inspection
    Identified a death report involving a resident on hospice after a fall with a brain bleed. No immediate health or safety risks were observed.
    26 Mar 2025Inspection
    Investigated a self-reported resident-to-resident altercation; welfare check completed with no immediate health or safety risks observed.
    18 Mar 2025Complaint
    Investigated allegations that infection control wasn't followed and that residents with illness were not properly separated. Findings showed an infectious outbreak, no posted outbreak notices, and insufficient separation of ill residents.
    • Type B8470(2)(A)
    • Type B87468.1(a)(2)
    18 Mar 2025Complaint
    Investigated an allegation that infection control communications were not followed during a GI illness outbreak. The investigation found that notifications to the health department and others were not completed as required.
    • Type B87211(a)(2)
    18 Mar 2025Complaint
    Investigated the allegation that staff did not provide a resident reappraisal after a change in condition. Found deficiencies in documentation, communication, and signatures related to assessments and changes in condition.
    • Type B87463(f)
    18 Mar 2025Complaint
    Investigated three allegations about how staff interacted with a resident, including disrespect, retaliation for a complaint, and speaking in an inappropriate manner.
    07 Mar 2025Inspection
    Identified a resident briefly AWOL; staff located the resident and welfare checks confirmed the resident was unharmed.
    07 Mar 2025Inspection
    Identified a resident-to-resident altercation involving two residents; one had a swollen wrist and was transported to the hospital, then returned with no injuries. Welfare check confirmed both were unharmed, and all responsible parties and medical staff were notified; no deficiencies were observed.
    05 Feb 2025Inspection
    Identified an incident in which a resident outside the property fell from a motorized wheelchair and was helped back inside; the resident was evaluated at the hospital and returned the same day. No ongoing health or safety risks were observed and no deficiencies were cited.
    30 Jan 2025Inspection
    Observed most areas in compliance with regulations; a technical violation was issued.
    21 Jan 2025Complaint
    Identified that a resident received a 30-day eviction notice after a change in condition and disagreement over care. Records showed missing assessments and no care conference addressing the change.
    • Type B87224(a)(4)(a)
    14 Jan 2025Complaint
    Identified that medications were not consistently administered according to physician orders and that information about family council meetings and a designated staff liaison was not provided.
    • Type B87465(c)(2)
    • Type B1569.158(g)(1)
    • Type B15969.158(h)(2)(i)
    14 Jan 2025Inspection
    Investigated a complaint that a mandated reporter knew about an incident requiring reporting to the local ombudsman, the Department, and local law enforcement. A technical violation was identified.
    19 Dec 2024Inspection
    Observed COMP II participation via a virtual interview; documented a capacity of 225 and a census of 188.
    27 Nov 2024Inspection
    Identified a resident's report that a staff member did not lock the wheelchair before transfer, which led to a fall. Welfare checks were performed and interviews with staff were conducted.
    27 Nov 2024Inspection
    Observed an unannounced case management visit following a self-reported incident. Found that fall protocol was followed, service plans were updated, and no deficiencies were observed.
    27 Nov 2024Inspection
    Identified no deficiencies after an unannounced case management visit, including welfare checks and staff interviews.
    22 Nov 2024Complaint
    Investigated the allegation that staff were not qualified and that the Memory Care Director position was vacant for about two months; interviews showed coverage by qualified personnel and no evidence of violations.
    21 Nov 2024Complaint
    Investigated a medication management complaint and a family council concern. Found gaps in admission medication information and inconsistent pharmacy naming, while staff showed support for family council meetings.
    • Type B1569.2(c)
    21 Nov 2024Complaint
    Investigated allegations that staff handled a resident in an inappropriate manner and spoke to a resident in an inappropriate manner; interviews indicated a staff member touched the resident without consent and made disparaging remarks.
    • Type B87468.1(a)(1)
    • Type B87468.1(a)(3)
    06 Nov 2024Complaint
    Investigated a complaint alleging a resident sustained a pressure injury due to staff neglect and that the resident's room was not clean.
    04 Nov 2024Inspection
    Investigated a complaint during an unannounced collateral visit and interviewed staff and outside sources. An exit interview was conducted.
    26 Sept 2024Inspection
    Identified that a case management visit followed a resident being sent to the emergency room for uncontrollable back pain. Welfare checks were performed and no immediate health or safety risks or deficiencies were observed.
    24 May 2024Inspection
    Observed that a self-reported incident of possible financial abuse involving a resident was addressed; welfare checks were conducted, residents and staff were interviewed, and no deficiencies were observed or cited.
    15 May 2024Inspection
    Investigated allegations of staff financial abuse against multiple residents and found no evidence of such abuse.
    15 May 2024Complaint
    Investigated allegation that staff financially abused a resident. Evidence showed no proof of financial abuse by staff.
    08 Jan 2024Inspection
    Identified delayed egress in Building B and a hospice waiver for twenty residents; observed adequate staffing, cleanliness, and safety measures, with a technical violation issued.
    27 Dec 2023Complaint
    Investigated whether staff did not assist a resident with wearing leg wrap devices as instructed. Records showed staff contacted the physician for clarification and later supported the resident per the doctor's directions.
    08 Nov 2023Complaint
    Investigated allegations that a resident's room was unsanitary, that the resident was left in soiled undergarments, and that staff did not seek medical attention; the findings determined the allegations to be unsubstantiated.
    23 Oct 2023Complaint
    Investigated allegations that staff did not follow a resident's care plan and that inadequate supervision led to falls; and that a resident was handled roughly, pendants were not responded to, and the responsible party was not consistently informed.
    • Type B87464(c)
    • Type B87464(f)(c)
    26 Sept 2023Inspection
    Identified a medication administration error in which a staff member gave a resident medications not prescribed to them; no injury occurred.
    • Type B87465(a)(4)
    25 Sept 2023Complaint
    Investigated the allegation that staff did not provide personal hygiene assistance to a resident. Interviews and records showed no evidence supporting the claim.
    18 Sept 2023Inspection
    Investigated a self-reported incident of a resident ingesting an essential oil during an activity; no deficiencies were observed.
    19 Jun 2023Complaint
    Investigated complaints about resident care and cleanliness. Found that staff did not meet residents' needs and areas were not kept clean.
    • Type B87625(b)(3)
    • Type B87303(a)
    02 Jun 2023Inspection
    Identified medication administration errors affecting two residents: one received medications not prescribed for them, and the other received medications at the wrong time of day. Both residents did not experience adverse effects.
    • Type B87465(a)(4)
    15 May 2023Inspection
    Observed a lapse that allowed a memory care resident to briefly leave the secured area when a family member disarmed an egress door. Staff did not consistently recognize the resident's memory care needs.
    • Type B87411(a)
    10 May 2023Complaint
    Investigated the allegation of insufficient staff and residents' hygiene; interviews, records, and observations indicated caregivers followed standard protocols and outside staffing was used during peak times, with no corroborating evidence found.
    22 Feb 2023Inspection
    Investigated an incident involving a resident with rib pain; welfare checks were performed and no immediate health and safety concerns were observed, and no deficiencies were cited.
    15 Feb 2023Complaint
    Investigated the allegation that staff did not contact a physician after a change in condition and the allegation that staff did not meet hygiene needs; records and interviews did not support these allegations.
    28 Dec 2022Complaint
    Investigated allegations that residents' needs were not met and that hot water temperature was not maintained; reviewed pendant responses, staff checks, and boiler replacement details.
    27 Sept 2022Complaint
    Investigated allegations that uncleared staff provided care to residents, that staff did not meet residents' needs in a timely manner, and that bed bugs were present. Records and interviews showed no uncleared staff and documented monthly pest-control treatments in 2020.
    23 Sept 2022Complaint
    Investigated allegations of insufficient staff to meet residents' needs, falsifying documentation, and inadequate supplies. Found no corroborating evidence to support these allegations.
    23 Sept 2022Complaint
    Investigated allegation that staff did not keep premises free of hazards; found no corroborating evidence and no hazard observed during a tour.
    08 Apr 2022Inspection
    Concluded no deficiencies were observed during an unannounced case management visit following a resident's death.
    08 Apr 2022Inspection
    Identified that a resident alleged rough arm grabbing during bathroom assistance by a contracted caregiver; interviews and checks showed no injuries and no health or safety concerns at the time.
    04 Mar 2022Complaint
    Found that during a power outage, emergency lighting and battery-powered lighting were not readily available to residents and staff, leaving some areas dark.
    • Type A1569.695(a)(7)(F)
    • Type B87303(h)
    04 Mar 2022Complaint
    Investigated the allegation that staff were not trained for emergencies, specifically on stairwell evacuation chairs. Evidence showed training occurred and staff participated in related drills.
    04 Mar 2022Complaint
    Investigated the allegation that emergency evacuation chairs were not in stairwells. Chairs were present and usable, though not recently installed, and the allegation was unfounded.
    18 Nov 2021Inspection
    Observed no deficiencies during an unannounced, required one-year visit. Reviewed infection control and COVID-19 mitigation measures.
    25 Aug 2021Complaint
    Investigated the allegation that a copy of the signed and dated admissions agreement was not provided to a resident's representative. A deficiency was cited.
    • Type B87507(e)
    25 Aug 2021Complaint
    Investigated an allegation that COVID-19 health guidance was not followed, including masking and routine testing.
    28 Jun 2021Complaint
    Investigated an allegation that dining areas exceeded 50% capacity. Found no violation of public health guidelines and noted adherence to mitigation measures.
    • Type B113789(a)
    • Type B113789(c)(10)
    30 Jul 2020Complaint
    Reviewed allegation of staff not properly trained to meet resident needs. Found staff receive initial on-boarding training, shadowing, monthly ongoing training, and one-on-one training to address issues. Allegation unsubstantiated.
    27 Jul 2020Inspection
    Reviewed a death report for a resident who passed away due to Cardiopulmonary Arrest with existing health conditions, including Dementia and Cerebral Atherosclerosis, while on Hospice.
    25 Feb 2020Complaint
    Determined that a resident was not being held against their will; miscommunication with the reporting party clarified, and resident aware of the freedom to leave with assistance. No evidence found of any restraints on residents.
    24 Jan 2020Inspection
    Conducted a follow-up visit regarding a reported fall incident, determining no deficiencies at the time of inspection.

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