Pricing ranges from
    $3,849 – 5,003/month

    Savant of Riverside

    4609 Arlington Ave, Riverside, CA 92504
    • Independent Living
    • Assisted Living

    Friendly staff, excited to join

    I had a very positive tour and felt at ease right away. The building is clean and well-maintained, staff are friendly, professional and attentive, and the meals and activities are enjoyable. Communication and leadership felt engaged - I'm looking forward to joining the community and would recommend it.

    Current/former resident
    Jul 2026

    Pricing

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

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    Tour Type

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • 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

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    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

    3.49·(89)

    Overall rating

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

      3.1
    • Staff

      3.5
    • Meals

      2.9
    • Amenities

      3.5
    • Value

      3.8

    Pros

    • friendly, welcoming staff
    • clean, well-maintained interior
    • knowledgeable and informative tour staff
    • active activities program and resident council
    • on-site transportation and scheduled outings
    • memory-care transition support
    • accessible room layouts with ensuite bathrooms
    • competitive pricing and value
    • on-site bakery and pleasant dining spaces
    • attentive licensed nursing personnel
    • lake views and usable outdoor spaces
    • warm, family-like atmosphere

    Cons

    • inconsistent staffing levels and coverage gaps
    • gaps in medication management and pharmacy coordination
    • delays in emergency and pendant/alert response
    • variable caregiver training and conduct
    • variable meal quality and limited menu options
    • sanitation and odor concerns in some areas
    • inconsistent housekeeping and laundry processes
    • weak communication with families and billing inconsistencies
    • insufficient evening and weekend staffing
    • aging physical plant requiring upgrades
    • inadequate clinical oversight and RN/LVN handoff processes
    • service-charge transparency and unfulfilled service promises

    Summary of reviews

    Overview Savant of Riverside elicits strongly mixed impressions. Many reviewers highlight clear strengths: an inviting, family-like atmosphere, friendly and welcoming staff, clean corridors and common areas, and a robust activities calendar supported by an engaged resident council. Tour staff are frequently described as knowledgeable and helpful, and the community offers practical amenities such as on-site transportation, a bakery area, lake views, and accessible room layouts with ensuite bathrooms. Several accounts describe attentive licensed clinical personnel and meaningful memory-care transition support.

    Care quality and staffing Care-related feedback is polarized. Positive comments point to caring bedside attention from specific licensed staff and supportive short-term interactions; however, a recurring operational theme is inconsistent staffing and coverage gaps, particularly during evenings and weekends. Reviewers describe delays in emergency response and pendant/alert response times, which translates into concerns about responsiveness during off-hours. There are multiple indications of gaps in medication management and pharmacy coordination, as well as inconsistent clinical handoffs between RNs and LVNs. These patterns suggest variability in day-to-day clinical oversight rather than uniform performance across the facility.

    Staff conduct and communication Many reviewers praise individual caregivers for compassion and helpfulness, but others describe issues with staff conduct and inconsistent training. Communication with families and billing processes are also areas of concern: examples include delayed or unclear family notifications, unexpected charges or service promises that were not fulfilled, and perceived shortfalls in follow-up after tours or complaints. There are isolated, serious complaints about management and ownership that led to heightened family concern; some reviewers used strong language about administrative behavior and there are allegations that warrant direct inquiry during visits.

    Dining and housekeeping Dining impressions vary widely. Some residents and families report enjoyable meals and weight gain, while other accounts note reheated or overcooked entrées, limited menu choices (particularly for vegetarian diets), inconsistent meal temperature, and thin portioning or stale bread products. Housekeeping feedback is similarly mixed: many find the building clean and well-maintained, but there are also sanitation and odor concerns reported in specific areas, along with inconsistent laundry sorting and occasional upkeep issues. These items collectively point to variability in service execution rather than a single uniform standard.

    Facilities, activities, and safety features Physical facilities receive both praise and critique. Positive notes include pleasant common spaces, accessible elevators, safe bathroom configurations, and enjoyable outdoor areas with lake views. Conversely, some reviewers describe dated finishes in certain common areas, tight balcony configurations, and maintenance items that could benefit from targeted upgrades. Activities programming is a consistent strength: exercise classes, games, outings, and religious services are frequently cited as contributors to resident engagement and improved mood.

    Notable patterns and practical considerations The overall pattern is one of contrast: strong interpersonal strengths (friendly tours, engaged activity staff, and individual caregivers who go beyond basic duties) alongside operational weaknesses (staffing variability, medication and emergency-response gaps, inconsistent dining and housekeeping execution, and occasional management communication breakdowns). For prospective residents and families, recommended areas to evaluate during a visit include staffing ratios at different times of day, written medication and pharmacy procedures, sample meals, emergency-response protocols and pendant testing, laundry and housekeeping processes, and clarity on billed services and refund/compensation policies. If memory care is a consideration, ask specifically about transition supports, routine clinical oversight, and RN/LVN communication processes.

    Conclusion Savant of Riverside offers several notable strengths for families prioritizing community life, activities, and warm interpersonal interactions. At the same time, recurring operational concerns—especially around consistent staffing, medication management, emergency responsiveness, and dining/housekeeping consistency—suggest careful due diligence is warranted. Prospective families should tour at varied times (including evenings/weekends), request written policies and staffing data, sample meals, and seek direct answers about clinical oversight and incident follow-up before making a placement decision.

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    Location

    Map showing location of Savant of Riverside

    Savant of Riverside is located at 4609 Arlington Ave, Riverside, CA, 92504.

    About Savant of Riverside

    Savant of Riverside stands as a senior living community in Riverside, California, with a state license number 331881480 and a capacity for 236 residents, where folks can find private and companion housing, furnished or unfurnished, with choices that include memory care studios starting from $3,530 per month, shared and one-bedroom memory care and assisted living apartments, and all-inclusive rates from $2,700 a month. The place is newly renovated, so there's a modern feel with refreshed interiors, clean, bright communal areas, and cozy living spaces to suit different needs and preferences, and every room has cable TV, individual climate control, Wi-Fi, phone hookup, private baths with step-in showers, plus some even have private outdoor space and closets for storage. Residents can join in on scheduled group exercise classes in a fitness center, visit the music lounge with a piano, catch a show in the theater, play games in the games room, read in the library, or spend time outdoors in a courtyard or gardens, and there are special areas for gardening and walking too.

    There's a good mix of dining options, with a restaurant-style dining room serving three dietitian-approved meals a day, snacks, and beverages; staff can deliver meals to rooms, set up guest meals, offer multiple meal plans, and take care of meal delivery or takeout when needed, with diets like diabetic, low salt, vegetarian, kosher, and more handled by chefs and a dietitian. Activities staff put together things like creative arts and crafts, painting sessions, music, entertainment, seasonal events, fun games, and even outings around Riverside and local sights, while folks interested in personal care get help with everything from bathing, dressing, grooming, feeding, toileting, reminders for meds or meals, escorting to meals and events, and medical needs coordinated by on-call physicians, nursing staff, and scheduled transportation.

    The building keeps up housekeeping-laundry, linens, trash, pest control, plant care-alongside grounds maintenance, with parking on-site for guests and residents. People get 24/7 support from a trained care staff, and emergency alert systems help give peace of mind. Facilities are wheelchair accessible, and services cover ambulatory support and transfers. There's a beauty salon and barber shop on-site, entertainment spaces, on-site shops, common areas to gather, and shared mailboxes. Pets live on site, though it isn't clear whether residents can bring any pets of their own. Savant of Riverside has both assisted living and personalized memory care for those facing Alzheimer's or cognitive decline, and also offers respite care if families need short-term help. The focus around here seems to be on creating comfort, safety, vibrant daily life, and close attention to each person's interests through personal care plans. There's a sense that the community feels refreshed and lively, with amenities and details designed to help people connect and enjoy each day.

    People often ask...

    Savant of Riverside offers competitive pricing, with rates starting at a cost of $3,849 per month.

    Savant of Riverside offers independent living and assisted living.

    There are 18 photos of Savant of Riverside on Mirador.

    The full address for this community is 4609 Arlington Ave, Riverside, CA 92504.

    No, Savant of Riverside 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 number331881480
    StatusLicensed
    Facility typeResidential Care Elderly
    Capacity232 residents
    LicenseeRIVERSIDE RETIREMENT VILLA LLC
    EffectiveApril 15th, 2024
    View the official license record

    Inspection Reports

    253

    Reports

    78

    Type A Citations

    89

    Type B Citations

    185

    Complaints

    7

    Years

    15 May 2026Inspection
    Investigated a reported incident of staff hitting a resident; observed the medication area secured, exit signs posted, and no immediate health or safety concerns at the time, with the incident status still pending.
    15 Apr 2026Complaint
    Found that the medication and meals allegations were unfounded. No other concerns were identified.
    09 Apr 2026Inspection
    Found no deficiencies and observed that safety measures, records, and living areas were well maintained.
    30 Mar 2026Complaint
    Identified lack of supervision during the night shift contributed to a resident's death. Staff did not monitor oxygen use or provide required safety checks.
    • Type A87468.2(a)(4)
    • Type A87468(a)(4)
    • Type A87468.1
    30 Jan 2026Complaint
    Investigated the allegation that a staff member failed to keep a resident's bed in proper working condition; determined the resident did not reside at the reported address.
    17 Dec 2025Complaint
    Investigated allegations that staff did not keep premises in good repair and free from pests.
    11 Dec 2025Complaint
    Investigated a claim that staff stole money from a resident; interviews and records review found no credible evidence supporting the theft.
    10 Oct 2025Complaint
    Investigated bed bug allegation and reviewed interviews, records, and site observations. Found no evidence of an active infestation after treatment and ongoing pest-control measures.
    24 Sept 2025Complaint
    Investigated the allegation that a resident hit another resident due to staff neglect.
    21 Aug 2025Complaint
    Investigated the allegation that a resident's visitor was told to leave due to insurance. Interviews and policy review showed 24/7 visitation with no denial or room restrictions, and no evidence supported the claim.
    21 Aug 2025Inspection
    Conducted a case management visit to deliver amended findings on two complaints and discussed with the business office manager.
    20 Aug 2025Complaint
    Investigated allegations found residents waited hours for incontinence care and call-light responses. One resident received incontinence supplies that were the wrong size.
    • Type B87625(b)(3)
    • Type B87468.2(a)(4)(a)(4)
    • Type B87307(a)(3)(D)(a)(3)
    20 Aug 2025Complaint
    Identified pest-control issues with bed bugs and roaches and gaps in documenting treatments; also reviewed allegations of illegal eviction and dietary plan concerns.
    • Type B87303(a)
    20 Aug 2025Complaint
    Investigated an allegation that staff failed to arrange medical care for a resident's condition, which led to a severe infection and hospitalization.
    • Type B87465(a)(1)(a)
    20 Aug 2025Complaint
    Investigated three allegations about medical treatment access, meal timing, and room access; found no evidence to support them.
    18 Aug 2025Complaint
    Investigated an allegation that staff did not administer a resident's medications as prescribed and misused medications, with evidence showing a delay in refilling and providing the medication. A second allegation that staff changed a resident's pharmacy without consent was not supported by the evidence.
    • Type B87465(c)(2)
    • Type B87465(a)(1)
    15 Aug 2025Complaint
    Investigated allegation of lack of supervision/neglect causing a pressure injury; staff followed hospice and wound care guidelines and adherence was documented.
    12 Aug 2025Complaint
    Investigated a complaint that a resident's care needs, including foot care and a wheelchair repair request, were not adequately addressed. The investigation concluded there was insufficient evidence to prove the allegation.
    12 Aug 2025Inspection
    Investigated a complaint control number 18-AS-20240509101436. Interviews with staff and residents were conducted and no health and safety concerns were identified.
    10 Aug 2025Complaint
    Investigated two allegations that staff failed to supervise a resident and failed to assist with toileting; found insufficient evidence to support the allegations.
    10 Aug 2025Complaint
    Investigated two allegations about illegal drug use and residents smoking inside rooms. Interviews with staff and residents and review of records found no evidence of illegal drug use; while some residents admitted smoking indoors contrary to rules, staff issued warnings and eviction proceedings were in progress for one resident.
    01 Aug 2025Complaint
    Investigated a complaint about incontinence care and identified that four residents were not kept clean and dry.
    • Type A87625(b)(3)
    27 Jul 2025Complaint
    Investigated a complaint alleging neglect, lack of supervision, and failure to follow resident care plans, including feeding concerns, unresponsiveness to emergency calls, intoxication risks with medications, and in-room surveillance cameras. The investigation included interviews and record reviews.
    27 Jul 2025Complaint
    Investigated allegations that a resident faced an uncomfortable room temperature and that staff did not treat residents with respect; interviews and checks found no evidence to support them.
    26 Jul 2025Complaint
    Investigated an allegation that staff mismanaged a resident's medication and found insufficient evidence to support it.
    26 Jul 2025Complaint
    Investigated the allegations and found no evidence to support claims that medications were not administered as prescribed, residents were not kept in a safe environment, or the facility was not in good repair.
    26 Jul 2025Complaint
    Investigated an allegation that a resident was hit by another resident due to lack of supervision; the evidence did not support the allegation.
    26 Jul 2025Complaint
    Investigated a complaint alleging bed bugs and forced relocation; the findings noted bed bugs in several rooms, temporary room changes for residents, and ongoing pest control measures.
    21 Jul 2025Complaint
    Investigated a complaint alleging a resident developed a pressure injury due to neglect, staff did not seek timely medical attention, residents were left in soiled bedding, and call buttons were not answered promptly.
    18 Jul 2025Complaint
    Investigated the allegation that staff did not provide activities to residents. Interviews with staff and residents and an observation showed daily activities occurred.
    18 Jul 2025Complaint
    Investigated a complaint about resident care and found all allegations unsubstantiated.
    14 Jul 2025Complaint
    Investigated allegations that a resident’s room had bed bugs, that sleep was disturbed by construction, that residents were isolated, and that residents lacked electricity; interviews and records were reviewed.
    14 Jul 2025Complaint
    Investigated an eviction allegation and a personal belongings withholding allegation; found insufficient evidence to prove either.
    02 Jul 2025Inspection
    Delivered an amended licensing report following a case-management visit related to a complaint.
    16 Apr 2025Complaint
    Investigated the allegation that proper eviction protocols were not followed with a resident in care; records showed the eviction followed legal procedures.
    16 Apr 2025Inspection
    Observed no deficiencies cited. Premises were clean, well maintained, and safe with proper medication storage and functioning safety systems.
    08 Mar 2025Complaint
    Investigated allegation that staff did not readmit a resident after hospitalization.
    16 Jan 2025Complaint
    Found that the allegation that staff prevented a resident from returning due to a stage 4 pressure injury was unfounded.
    18 Nov 2024Complaint
    Investigated an allegation of Personal Rights; found the complaint unfounded after interviews and records review.
    23 Oct 2024Complaint
    Investigated the pest infestation allegation and found it unfounded.
    04 Oct 2024Complaint
    Investigated allegations found residents did not have a reasonable level of privacy during medical treatment and were not provided a diabetic diet.
    • Type B87468.2(a)(1)
    • Type B87555(a)
    04 Oct 2024Complaint
    Investigated an allegation that staff did not seek timely medical attention for a resident; findings showed insufficient information to prove the allegation.
    02 Oct 2024Complaint
    Investigated an allegation that a staff member yelled at and embarrassed a resident in the courtyard. Interviews did not establish that the staff member yelled or threatened to call the police.
    02 Oct 2024Complaint
    Identified unauthorized transactions on a resident's bank card between 06/30/2022 and 08/17/2022, including Uber Eats and Uber Pass, based on bank records and interviews.
    02 Oct 2024Complaint
    Found insufficient information to verify the allegations regarding staff handling funds, shower assistance, safeguarding personal belongings, meal service, and hydration.
    01 Oct 2024Complaint
    Investigated allegations about medication management, notification to representatives, meal quality, room cleanliness, and roommate assignments; findings did not provide conclusive evidence of violations.
    29 Sept 2024Complaint
    Investigated allegations that a resident was harassed by another resident. Interviews indicated harassment occurred, and personal belongings were present at the facility.
    • Type B87468(a)(1)
    29 Sept 2024Complaint
    Investigated an allegation that staff did not safeguard a resident's personal belongings. Interviews indicated no major concerns about safeguarding belongings, with some items reportedly found in the laundry.
    29 Sept 2024Complaint
    Investigated the allegation that staff failed to stop a resident from harassing others; found insufficient evidence to support the allegation.
    29 Sept 2024Complaint
    Investigated an allegation that staff did not prevent a resident from leaving. Interviews indicated the resident could go out and return on their own, and records were unavailable, so the allegation couldn't be verified.
    29 Sept 2024Complaint
    Investigated a complaint alleging residents could not access belongings, a mattress with bed bugs, and medication management issues. Interviews and record reviews showed no evidence to support these concerns.
    28 Sept 2024Complaint
    Investigated the allegation that lack of supervision allowed verbal abuse by a resident toward others; staff and residents reported ongoing bullying by that resident.
    • Type B87468(a)(1)
    28 Sept 2024Complaint
    Investigated allegations that a resident was physically and verbally assaulted by other residents and that the resident was being illegally evicted. The investigation did not yield sufficient evidence to prove these allegations.
    28 Sept 2024Complaint
    Investigated residents' care, staffing, and delivery timing; could not confirm the allegations.
    28 Sept 2024Complaint
    Investigated allegations that staff threatened or attacked a resident and spoke inappropriately to a resident. Interviews with staff and residents indicated no clear evidence of those actions, and concerns about safeguarding personal property and medication access were also explored.
    28 Sept 2024Complaint
    Investigated a complaint alleging a resident-on-resident assault and threats of eviction. Found insufficient evidence to support these allegations.
    26 Sept 2024Complaint
    Investigated a complaint alleging staff did not meet a resident's medical needs. Insufficient information to determine if the alleged incidents occurred.
    25 Sept 2024Complaint
    Identified failures to address a resident's medical needs, including a red stoma with excoriated skin and a leg wound, and delays in obtaining treatment. Found that staff did not consistently respond to call bells, causing residents to wait for assistance.
    • Type B87468.2(a)(4)
    • Type B87411(a)
    23 Sept 2024Complaint
    Investigated allegations of neglect and improper care, including leaving a resident on the floor overnight, missed meals, delays in bathing, and leaving residents in dirty or wet briefs, plus failing to assist with medical appointments.
    • Type A87415(a)(5)
    • Type A87555(b)(1)
    • Type A87625(b)(3)
    • Type B87464(f)(4)
    • Type B87465(a)(2)
    23 Sept 2024Complaint
    Identified safety concerns: a non-ambulatory resident was on the second floor with limited access to a bathroom. The local fire jurisdiction indicated there was no fire clearance for non-ambulatory residents on the second floor.
    • Type A87203
    22 Sept 2024Complaint
    Investigated allegations that residents' medications were not refilled on time and not administered as prescribed. Interviews and MAR reviews noted delays due to pharmacy processing and staffing shortages.
    • Type A87465(a)(4)
    22 Sept 2024Complaint
    Investigated allegations that a resident's care plan was not followed, physical therapy was not provided, the resident was left in a wet bed, water was not provided, and meals were missed. Found no evidence to support these concerns.
    22 Sept 2024Complaint
    Investigated two care-related allegations, including staff not assisting a resident and leaving a resident in a soiled diaper for an extended period. Findings showed no evidence to support the allegations.
    22 Sept 2024Complaint
    Investigated a resident's complaints that staff retaliated, forced a roommate, yelled, and caused missed medical appointments. Interviews and records showed no corroboration.
    21 Sept 2024Complaint
    Investigated an allegation that staff failed to provide adequate care and supervision due to staffing shortages. Findings included reports of unresponsive call bells, a ten-minute call system test with no response, and several residents describing insufficient staffing during PM and night shifts.
    • Type A87411(a)
    21 Sept 2024Complaint
    Identified issues included delaying medical attention for a resident, not providing prescribed medications, and unclean conditions in a resident's room.
    • Type A87465(g)
    • Type A87465(a)(4)
    • Type A87303(a)
    21 Sept 2024Complaint
    Investigated allegation that staff did not administer residents' medications as prescribed; interviews and observations showed nine of ten residents reported missing medications and staff shortages contributed to the issue.
    • Type A87465(a)(4)
    21 Sept 2024Complaint
    Investigated an allegation that staff handled a resident roughly and did not meet the resident's needs. No evidence supported these claims.
    21 Sept 2024Complaint
    Investigated a complaint about a resident's access to their bedroom and about dignity in treatment; interviews and observations found no evidence to support these specific claims.
    20 Sept 2024Complaint
    Investigated a complaint that staff did not re-order medications for a resident, causing shortages before refills. The investigation also noted that residents were not assisted with self-administration of medications as needed.
    • Type A87465(a)(4)
    20 Sept 2024Complaint
    Investigated the allegation that residents were entrapped in an elevator and that the elevators were not adequately maintained. Interviews and records showed residents were entrapped around February 2024, two elevators were observed working on 02/08/2024, and maintenance occurred in December 2023.
    • Type B87303(a)
    18 Sept 2024Complaint
    Investigated allegation that residents were not allowed to choose medical providers. Found unfounded after evidence showed the prior contract was canceled and residents were notified they could remain with their current provider or switch.
    18 Sept 2024Complaint
    Investigated the allegation that staff did not notify a resident's representative about an incident; the investigation found the allegation unsubstantiated.
    16 Sept 2024Complaint
    Investigated a complaint alleging staff did not release resident records upon request; records for a resident were not provided to the authorized representative.
    • Type B87468.2(a)(19)
    17 Jul 2024Complaint
    Investigated an allegation that pests were not properly addressed. Found the allegation unfounded.
    12 Jun 2024Complaint
    Investigated a bed bug infestation that led to the removal of a resident's belongings and a resident sleeping on a recliner for about two weeks. It also looked at safeguarding personal property and providing a proper bed or mattress.
    • Type B87217(b)
    • Type B87468.1(a)(2)
    05 Jun 2024Complaint
    Investigated the allegation that residents were issued unlawful eviction notices and found the allegation unfounded.
    29 May 2024Complaint
    Investigated allegations that staff retaliated against a resident and refused to accept the resident's rent money.
    20 May 2024Complaint
    Investigated a complaint alleging unsanitary conditions, staff intimidation, and rent overcharges for SSI residents. It also noted high anxiety reported by residents due to staff pressure.
    15 May 2024Inspection
    Conducted an unannounced visit to review open complaints and discuss an amended document with the administrator.
    14 Mar 2024Complaint
    Investigated two specific allegations that staff were not present on 09/29/2023 and residents did not receive medications around that time; documentation and interviews did not provide enough information to determine violations.
    14 Mar 2024Inspection
    Identified deficiencies during a pre-licensing change of ownership review, including trash bins in resident bedrooms lacking tight-fitting lids, water temperatures below 105 degrees in multiple rooms, and no Admissions Agreement posted.
    14 Mar 2024Complaint
    Investigated a complaint that a 60-day written notice of rent increase was not provided to residents.
    06 Mar 2024Complaint
    Investigated a complaint about cleanliness in common areas; observed stained hallway carpet and dust, but interviews and observations indicated cleaning occurred and no ongoing issue was found.
    27 Feb 2024Inspection
    Confirmed that the applicant and administrator completed COMP II and understood licensing requirements and operations.
    12 Feb 2024Inspection
    Observed that an infection control plan and staff training were on file and emergency planning was complete, but a quarterly drill was not conducted as required.
    • Type B1569.(c)
    31 Jan 2024Inspection
    Observed a clean, well-maintained environment with functioning safety equipment and adequate staffing; no deficiencies were cited.
    24 Jan 2024Complaint
    Investigated a set of complaints about meals, restroom assistance, personal hygiene, and urine-soiled carpets in a care setting.
    • Type B87468.2(a)(4)
    • Type B87303(a)(a)
    24 Jan 2024Inspection
    Identified a deficiency when resident medical records were not available for review during a complaint investigation.
    • Type B87506(d)
    24 Jan 2024Complaint
    Investigated two medication-related allegations. Records were incomplete due to a transition between management teams, and interviews did not corroborate the claims.
    23 Jan 2024Complaint
    Identified concerns that staff did not meet residents' needs and did not provide adequate supervision. Found dirty bedrooms and rugs and inadequate food service.
    • Type B87468.2(a)(4)
    • Type B87411(a)
    • Type B87303(a)
    • Type B87555(b)(17)
    23 Jan 2024Complaint
    Investigated the allegation that the signal system was not operable and found that staff pagers were not functioning, causing delayed responses to residents' call buttons. A review of records and interviews showed several call requests lasting thirty minutes or more.
    • Type B87303(i)(1)
    23 Jan 2024Complaint
    Investigated a complaint that staff did not respond promptly to resident call buttons, with records showing multiple calls lasting at least 30 minutes.
    • Type B87468.2(a)(4)
    23 Jan 2024Complaint
    Investigated a complaint that staff did not administer medication as prescribed; due to the medication MAR not being available and the resident not being available for interview, no determination could be made.
    11 Jan 2024Inspection
    Identified that a resident's original records were not retained for at least three years after termination and were unavailable for review during a complaint investigation after a management change.
    • Type B87506(e)
    11 Jan 2024Complaint
    Investigated the allegation that a resident did not have a comfortable environment; interviews and records did not corroborate the claim.
    07 Dec 2023Inspection
    Identified that seven admission agreements failed to specify the funding source or whether the resident or their representative declined to disclose it.
    • Type B87507(g)(3)(F)
    09 Nov 2023Inspection
    Confirmed non-ambulatory residents were moved to the first floor after a fire clearance violation; no non-ambulatory residents were found on the second floor and no health or safety concerns were observed.
    09 Nov 2023Complaint
    Investigated the allegation that a resident's monthly rate was increased by $2,500. Found a letter informing the resident of the rate increase to $4,500 per month, effective 01/01/2024, and determined the allegation unfounded.
    19 Oct 2023Complaint
    Investigated an allegation that staff misplaced a resident’s phone and clothing. Interviews and records showed no clear evidence of missing belongings.
    13 Oct 2023Complaint
    Investigated a complaint alleging staff theft and inadequate care; reviewed records and interviewed residents, but found no evidence to support the allegations.
    10 Oct 2023Inspection
    Identified solvency concerns after an audit found income did not cover operating costs.
    06 Oct 2023Inspection
    Investigated complaints about residents on the second floor who require assistive devices to ambulate. Found there is no fire clearance permitting non-ambulatory residents on that floor.
    22 Sept 2023Complaint
    Investigated the allegation that a staff member accepted a power of attorney for a resident; records showed an employee was designated as POA for the resident with another resident acting as a witness.
    • Type B87217(d)(2)
    22 Sept 2023Inspection
    Identified a missing staff file for an employee, resulting in incomplete personnel records, and a citation was issued.
    08 Sept 2023Inspection
    Identified that an admission agreement was not completed for a resident and the rate charged was not identified.
    • Type B87101(a)
    08 Sept 2023Complaint
    Investigated a rodent issue and a claim that staff refused to assist a resident with showering; found insufficient information to prove either allegation.
    08 Sept 2023Complaint
    Investigated the allegation that a resident was overcharged. The admission agreement contained no documented rate for care and services, resulting in insufficient evidence to prove the charge.
    22 Aug 2023Complaint
    Investigated a complaint alleging staff did not provide residents with assistance and adequate food; seven residents reported receiving the care they need and enough food.
    17 Aug 2023Complaint
    Investigated an allegation that staff illegally evicted a resident after the resident was placed on a 51/50 hold, discharged, and later returned.
    10 Aug 2023Inspection
    Verified an unannounced case-management visit to address a prior complaint and reviewed related materials with management.
    09 Aug 2023Inspection
    Identified a deficiency involving a blank Admission Agreement on file for a resident admitted in October 2021, showing no admission agreement signed within seven days of admission.
    • Type B87507(c)
    09 Aug 2023Complaint
    Identified two deficiencies: a resident was left soiled without assistance with toileting, and a resident's bedroom was not kept clean.
    • Type B87468.2(a)(4)
    • Type B87303(a)
    29 Jul 2023Complaint
    Investigated an illegal eviction allegation where a resident discharged from higher care was refused reentry after clearance.
    • Type A87224(a)
    29 Jul 2023Complaint
    Investigated allegations of profanity by staff toward residents and of an uncomfortable temperature; temperature readings were within the required range, and some residents stated profanity was not heard.
    27 Jul 2023Inspection
    Observed management changes, new staffing, and a dining contract update with resident engagement.
    25 Jul 2023Complaint
    Investigated the allegations that residents were left in soiled diapers, were served raw chicken, and had belongings missing; evidence did not establish violations.
    24 Jul 2023Complaint
    Found that staff neglect led to a resident developing an unstageable pressure injury; records and interviews supported the finding.
    • Type A87468.2(a)(4)
    20 Jul 2023Complaint
    Investigated an allegation that residents were moved out without their consent; interviews and records indicated residents were relocated to another facility without notice or consent, and eviction notices were not on file.
    • Type A87468.2(a)(20)
    12 Jul 2023Complaint
    Investigated the allegation that staff did not seek timely medical attention for a resident in care; there wasn't enough information to prove the claim.
    10 Jul 2023Inspection
    Identified that a resident was hospitalized on 11/09/21 and there was no incident report on file for the hospitalization, posing a potential threat to residents' health and safety.
    • Type B87211(a)(1)(D)
    10 Jul 2023Complaint
    Investigated allegations that a resident experienced improper catheter care leading to hospitalization, was malnourished, dirty, with feces on the carpet, a room odor, and staff unable to communicate with the resident.
    10 Jul 2023Complaint
    Investigated two allegations and concluded there was insufficient evidence to prove either.
    26 Jun 2023Inspection
    Found that a previously cited deficiency was cleared during this visit, and a civil penalty was assessed for late response.
    • Type A87465(a)(4)
    • Type A87761(a)
    22 Jun 2023Complaint
    Identified the allegation that staff did not assist a resident with hygiene after incontinence.
    • Type B87468.2(a)(4)
    22 Jun 2023Complaint
    Investigated the allegation that a staff member sexually assaulted a resident; interviews and records did not provide evidence to corroborate or refute the claim.
    17 Jun 2023Complaint
    Investigated a complaint that staff did not administer medications per physician orders; seven prescribed medications were missing and unavailable for dispensing. The investigation included a medication audit and interviews with residents and staff.
    • Type A87465(a)(4)
    12 Jun 2023Complaint
    Investigated allegation that staff refused to accept a resident back into care after a temporary admission. The resident was not allowed to return unless under hospice supervision.
    • Type B87468.2(a)(20)
    12 Jun 2023Complaint
    Investigated allegation that staff handled a resident roughly. There wasn't enough information to prove it.
    07 Jun 2023Inspection
    Investigated an allegation that residents could not exit because the main entrance doors would not open. Observed staff opened doors from inside using a makeshift method, posing an immediate safety risk.
    25 May 2023Inspection
    Identified deficiencies related to administrator qualifications and integrity, and incomplete staff training documentation.
    • Type B87405(d)(5)
    17 May 2023Complaint
    Observed multiple residents smoking indoors where oxygen is in use, with cigarette smell in hallways and bedrooms.
    • Type A87618(b)(3)(C)
    17 May 2023Complaint
    Investigated an allegation that staff left a resident in a wheelchair for an extended period due to not assisting with transfers. Records and interviews could not determine when the resident was left nor for how long.
    10 May 2023Inspection
    Identified missing documentation of health changes and falls for a resident, and failure to report a hospitalization in March 2022. Noted an incomplete admission agreement.
    • Type B87466
    • Type B87211(a)(1)(D)
    • Type B87507(a)
    10 May 2023Complaint
    Investigated a complaint that a resident's bedroom heater was not working and that a resident did not receive meals.
    • Type B87303(b)
    10 May 2023Complaint
    Investigated an allegation that staff failed to provide a resident with appropriate supervision; found insufficient information to support the claim.
    25 Apr 2023Inspection
    Identified deficiencies related to medication administration and resident records, including injections given by an unskilled staff member and missing admission agreements and written care plans, plus lack of training documentation for catheter care.
    • Type A87465(c)(2)
    • Type A87629(a)
    • Type B87623(b)(2)(B)
    • Type B87507(c)
    • Type B87467(a)
    25 Apr 2023Complaint
    Observed cigarette butts and loose tobacco in a resident’s bedroom, indicating smoking occurred in a non-designated area.
    • Type B87468.1(a)(2)
    21 Apr 2023Complaint
    Investigated an allegation that staff failed to ensure a resident received a subcutaneous injection; due to insufficient information, could not prove the allegation.
    23 Mar 2023Complaint
    Investigated allegations that staff failed to assist a resident with health conditions leading to hospitalization, failed to assist with medical appointments, and failed to answer incoming calls. Findings showed the resident's health condition was managed during care, with hospitalization on March 18, 2023, and there was insufficient information to substantiate the other two concerns.
    06 Mar 2023Inspection
    Identified that a written report about a resident's death wasn't submitted to the licensing agency within seven days.
    27 Feb 2023Inspection
    Identified safety concerns from multiple resident falls in 2022 and unauthorized occupancy by homeless individuals in two bedrooms, along with incomplete incident reporting.
    • Type B87211(a)(1)
    27 Feb 2023Complaint
    Investigated an allegation that a resident was hit in the head by an unknown person, with hospital records showing a hospitalization and multiple falls.
    24 Feb 2023Complaint
    Investigated an allegation that a resident did not receive prescribed eye drops after eye surgery; found no record of administration and staff acknowledged they had not given the drops.
    • Type A87465(a)(4)
    10 Feb 2023Complaint
    Identified that staff did not respond promptly to a call light and the front desk alert system was not monitored.
    • Type ACCR87303(i)(1)(B)
    08 Feb 2023Complaint
    Observed an insect infestation and maintenance problems, including a damaged exterior overhang, missing electrical faceplates in a resident room, and a tilting sink.
    • Type B87303(a)
    31 Jan 2023Complaint
    Investigated an allegation that a staff member dispensed a medication to one resident that belonged to another resident. Records showed the incident occurred on March 15, 2021, and the staff member could not be interviewed.
    • Type B87411(a)
    31 Jan 2023Complaint
    Investigated a complaint alleging a resident was not provided a shower because hot water was not available. Observed hot water temperatures in three resident bedrooms were outside regulatory limits and staff gave conflicting accounts; the resident did not provide a statement due to death, resulting in insufficient information.
    26 Jan 2023Inspection
    Identified that a non-ambulatory resident remained on the second floor in room 203, posing an immediate risk to health and safety. Found twelve staff members not listed on the employee roster.
    • Type A87203
    • Type B87355(e)(2)
    20 Jan 2023Inspection
    Identified gaps in infection control practices and PPE management, including lack of N95 fit testing, staff not wearing masks during the visit, insufficient PPE supply, missing hand hygiene supplies, and no infection control plan submitted.
    17 Jan 2023Inspection
    Identified failure to perform a pre-admission appraisal before admitting a resident and failure to report suspected abuse to the local ombudsman, licensing agency, and local law enforcement within 24 hours.
    • Type B87455(c)
    17 Jan 2023Inspection
    Investigated a complaint about the second-floor placement of a non-ambulatory resident. Observed a resident on the second floor with an assistive device.
    17 Jan 2023Complaint
    Investigated a report that a resident was hit and cursed at by another resident; evidence insufficient to prove the allegation.
    10 Jan 2023Inspection
    Investigated an allegation that a resident did not receive prescribed medication on January 7 and 8, 2023; interviews and records showed the medication package was empty and no doses were documented.
    • Type A87468.2(c)
    10 Jan 2023Complaint
    Investigated the allegation that staff were not present at times and the allegation that trash was not removed from resident rooms; interviews yielded mixed responses and information did not establish the issues.
    10 Jan 2023Complaint
    Investigated the allegation that a resident’s toilet was in disrepair. The toilet seat was in disrepair and replaced in the same month, the resident could use the toilet but the seat was not secure, and it was unclear how long the issue lasted.
    21 Dec 2022Complaint
    Investigated the allegation that a resident developed a maggot-infested wound while in care. Found insufficient information to confirm maggots were present in the wound or how they developed.
    16 Dec 2022Complaint
    Identified insufficient staff to meet residents' needs, with residents waiting over two hours for assistance and night-shift staff sometimes not responding.
    • Type A87411(a)
    15 Dec 2022Complaint
    Investigated an allegation that staff did not assist a resident with meals or toileting during admission; interviews were inconsistent and the resident had died.
    14 Dec 2022Inspection
    Found that a resident requiring an indwelling catheter did not receive care from an appropriately skilled professional, and that an alert necklace/pendant fee was not clearly specified in the admission agreement.
    • Type A87468.2(a)(1)
    • Type B87405.1(g)(3)(C)
    14 Dec 2022Complaint
    Investigated allegations that the facility did not follow its program plan and overcharged a resident.
    14 Dec 2022Complaint
    Investigated the allegation that the licensee does not have sufficient resources to meet operating costs. Observations and interviews indicated utilities were available and a third-party vendor reported unpaid bills, but information was not sufficient to determine the allegation.
    04 Nov 2022Inspection
    Observed that the main entrance/exit doors did not open properly, reportedly since October 17, 2022. Staff were stationed at the front lobby to ensure entry during all hours.
    21 Oct 2022Inspection
    Identified concerns about residents' personal rights due to video evidence showing a resident being pushed by staff and a camera being confiscated; there was also an altercation captured on video.
    • Type A87211
    • Type B87211
    06 Oct 2022Complaint
    Found there wasn't enough evidence to prove the alleged issues with staffing, medication timing, and food service.
    23 Sept 2022Inspection
    Identified that the air conditioning unit serving two bedrooms was not fully repaired by the due date.
    19 Sept 2022Complaint
    Investigated allegation that personnel were not competent to meet residents' needs following an assault incident.
    • Type B87411(a)
    09 Sept 2022Complaint
    Identified that lobby doors were locked in the evening and only one staff member was available, which could delay entry for emergency responders. This posed a health and safety risk to residents.
    • Type A87411(a)
    09 Sept 2022Complaint
    Identified that the air conditioning unit in residents' bedrooms was not operable for at least four weeks, causing uncomfortably high temperatures.
    • Type B87303(b)
    01 Sept 2022Inspection
    Identified insufficient staffing and inadequate monitoring of the call system, risking resident safety.
    • Type A87468.2(a)
    31 Aug 2022Inspection
    Investigated the allegation that only one staff member was on duty and residents were not checked for several hours, with a resident needing turning and diaper change and the call system not monitored.
    15 Aug 2022Complaint
    Investigated a complaint that a resident was not fed around August 8, 2022 after staff and hospice directed not to feed; the resident reportedly did not eat a meal that day.
    • Type A87468.2(a)(5)
    04 Aug 2022Complaint
    Identified that staff swore and yelled at residents, affecting their dignity, and observed trash, food packaging, spills, and soiled pads in the medication room and in rooms 123 and 127.
    • Type B87468.1(a)(1)
    • Type B87303(a)
    06 May 2022Complaint
    Investigated allegations that a resident did not receive meals and that a wheelchair-bound resident was left in bed all day due to staffing shortages.
    • Type B87411(a)
    06 May 2022Inspection
    Observed a resident yelling for help and noted staff would check on the resident’s needs; no health or safety concerns were observed at the time.
    04 May 2022Inspection
    Identified that a staff member was not trained in the required topics for self-administering medications and had been administering medications since February 2022, creating an immediate health and safety risk.
    • Type A1569.69(a)(4)(A)
    • Type A1569.69(a)(4)(B)
    • Type A1569.69(a)(4)(C)
    • Type A1569.69(a)(4)(D)
    • Type A1569.69(a)(4)(E)
    • Type A1569.69(a)(4)(F)
    • Type A1569.69(a)(4)(G)
    • Type A1569.69(a)(4)(H)
    • Type A1569.69(a)(4)(I)
    04 May 2022Complaint
    Investigated the allegation that staff sold resident medication; interviews did not corroborate the claim.
    28 Apr 2022Complaint
    Investigated allegation that a resident's narcotic medication went missing; administrator said a medication ran out before the new cycle and none were available to dispense.
    • Type A87465(c)(2)
    28 Apr 2022Complaint
    Investigated the allegation that staff did not properly assist a resident with oxygen administration. Found the allegation unsubstantiated.
    22 Apr 2022Complaint
    Found that calls from the signal system were not answered promptly, delaying resident assistance.
    • Type B87411(a)
    22 Apr 2022Complaint
    Identified that a resident's medications were not administered as prescribed, with several doses missing and some meds dispensed more than once a day for about a week. The issue posed an immediate threat to health.
    • Type A87465(c)(2)
    20 Apr 2022Complaint
    Investigated a complaint alleging meals and staffing issues at a senior care site. Nine residents interviewed; most reported adequate meals and staffing; findings indicate the allegations were unsubstantiated.
    19 Apr 2022Complaint
    Identified insufficient night staffing and inability to provide EMS with resident information during an emergency.
    • Type A87411(a)
    • Type A87415(a)
    19 Apr 2022Inspection
    Identified that a non-ambulatory resident who uses a wheelchair remained on the second floor, posing a safety risk.
    • Type A87203
    15 Apr 2022Complaint
    Investigated allegations that staff yelled at a resident, handled a resident roughly, and overcharged a resident; interviews did not provide enough evidence to support these claims.
    26 Mar 2022Inspection
    Identified a cleanliness violation after observing an extremely dirty carpet in room 143 and a dirty bathroom floor, fixtures, and bath mat, posing health and safety risks to residents.
    • Type A87303(a)
    26 Mar 2022Complaint
    Identified that staff did not respond promptly to call bells, left a resident in soiled clothing for several hours, and did not provide meals or dispense medications as prescribed.
    • Type A87468.2(a)(4)
    • Type A87465(h)(2)
    • Type A87555(a)
    21 Mar 2022Inspection
    Identified discrepancies about fire clearance and capacity limits; relocation of non-ambulatory residents and a city permit application were in progress.
    18 Mar 2022Inspection
    Identified that a resident with diabetes had glucose testing performed by an unskilled staff member, and there were no planned activities available for residents.
    • Type A87468.2(a)(8)
    • Type B87500(a)
    15 Mar 2022Inspection
    Identified no immediate health and safety concerns during an unannounced visit related to two complaints.
    11 Mar 2022Complaint
    Observed hot water in resident faucets did not consistently meet the required 105-120 degrees Fahrenheit range. Measurements in three rooms were outside these limits.
    • Type B87303(e)(2)
    10 Mar 2022Inspection
    Observed staff yelling at residents during changing and bathing, affecting their dignity and willingness to participate in care; a third-party interview described staff as rude.
    • Type B87468.1(a)(1)
    • Type B87468.2(a)
    01 Mar 2022Complaint
    Investigated a complaint about delayed staff response to residents' call buttons and a resident left on the toilet for an extended period; interviews and logs showed multiple calls not answered promptly and delays in restroom assistance.
    • Type B87411(a)
    25 Feb 2022Complaint
    Investigated allegations regarding medication administration, notifying responsible party about health changes, intimidation, and staff yelling; findings did not establish those claims.
    25 Feb 2022Inspection
    Found no deficiencies cited during an unannounced case-management visit.
    25 Feb 2022Inspection
    Investigated a complaint about hot water temperature on the second floor. Measurements found temperatures outside the 105-120 range, and plumbing work was ongoing; no citations were issued.
    24 Feb 2022Complaint
    Investigated a complaint that bed bug infestation wasn't controlled; bed bugs were found in several bedrooms and a resident reported bites.
    • Type B87307(d)(2)
    15 Feb 2022Complaint
    Investigated two allegations: one about staff causing injury to a resident and another about removing a resident's bedroom door.
    • Type B87468.2(a)(1)
    07 Feb 2022Inspection
    Observed insufficient staffing, with only one caregiver and one medication technician on duty, unlicensed staff administering injections, a resident not receiving prescribed insulin for two days, and missing written care records for two residents, along with hospice waiver concerns.
    01 Feb 2022Inspection
    Investigated staffing concerns; there was only one caregiver during the AM shift, causing delays in assisting residents and call bells going unanswered for at least 30 minutes.
    04 Jan 2022Inspection
    Identified deficiencies related to health and safety, including that weekly COVID-19 screening for staff was not conducted. Also found an unlisted staff member without fingerprint clearance and two staff members who had not completed the required annual training.
    • Type B87468.1(a)(2)
    • Type B87412(a)(13)(B)
    • Type B87411(c)
    23 Dec 2021Complaint
    Investigated the allegations about medication administration, shower access, and transportation charges; found insufficient evidence to prove the allegations.
    21 Dec 2021Complaint
    Investigated four complaints: staff did not respond to call buttons in a timely manner, the facility was malodorous, staff yelled at residents, and residents' bathing needs were not being met.
    • Type A87411(a)
    • Type B87303(a)(1)
    17 Dec 2021Inspection
    Observed missing regular nutritionist/dietitian/home economist consultation, no full-time staff dedicated to activities, and an individual working without an active background clearance.
    • Type B87468.2(a)(8)
    • Type B87465.1(a)
    • Type B1569.17(b)
    16 Dec 2021Inspection
    Observed an unannounced visit to obtain a signature for a complaint; met with the administrative contact and completed an exit interview.
    13 Dec 2021Complaint
    Observed bedbugs in multiple bedrooms, with residents affected.
    • Type B87307(d)(2)
    13 Dec 2021Complaint
    Identified insufficient staffing to meet resident needs and insufficient medication training for staff. Observed two resident bedrooms with non-working electrical outlets, though additional outlets were available in the same rooms.
    • Type A87411(a)
    • Type A1569.69(a)(1)
    18 Nov 2021Complaint
    Investigated allegations that insulin was not administered on time and that residents' hygiene was not maintained. Found insufficient evidence to prove the violations based on available records and interviews.
    10 Nov 2021Inspection
    Identified an allegation that a staff member was rough with residents. Interviews were conducted and no immediate health and safety concerns were reported.
    05 Nov 2021Inspection
    Observed insufficient staffing causing delays in assisting residents, with one resident waiting over 30 minutes and becoming soiled. Also, a required written report about a hospitalization was not submitted.
    • Type A87411(a)
    • Type B87211(a)(1)(D)
    05 Nov 2021Complaint
    Investigated the allegation that staffing was inadequate to meet resident needs; the finding deemed the allegation unsubstantiated.
    04 Nov 2021Inspection
    Identified missing administrative organization on file, inappropriate glucose testing by staff for residents with diabetes, and missing waivers for health-related conditions.
    • Type B87209
    29 Sept 2021Complaint
    Found insufficient staffing to meet residents' needs, including showers; the meals and dining room air conditioning allegations were unfounded.
    • Type B87303
    28 Sept 2021Complaint
    Investigated allegations that staff were verbally abusive, stole resident belongings, and threatened eviction, along with failing to respond to resident alerts. Findings indicated staffing shortages contributed to delays in responding to alerts, while the remaining allegations did not have sufficient evidence.
    • Type A87411(a)
    28 Sept 2021Complaint
    Investigated a complaint alleging a resident did not receive medications; records showed no physician orders for September and October 2020, resulting in two months with no medications dispensed.
    • Type A87465(a)(5)
    25 Sept 2021Complaint
    Investigated a complaint alleging staff did not respond to call buttons and concerns about food service; evidence showed multiple calls for assistance went unanswered for over 30 minutes, indicating delays in addressing residents' immediate needs.
    • Type A87411(a)
    25 Sept 2021Complaint
    Investigated the allegation that a resident eloped without staff knowledge.
    17 Sept 2021Complaint
    Investigated two allegations; the linen and room odor concerns lacked sufficient evidence, while evidence supported concerns that a resident was left in soiled clothing and had multiple falls.
    • Type A87464(f)(4)
    • Type A87608
    • Type A87468.2(a)(4)
    30 Aug 2021Complaint
    Interviews with staff and residents revealed that medication administration was conducted properly, with residents receiving correct medications on time and in the correct dosage. There was not enough evidence to prove or disprove the allegation regarding medication administration.
    24 Aug 2021Inspection
    Identified a relocation of a resident due to bug concerns and an extermination visit scheduled for 08/30/2021; no deficiencies were cited.
    13 Aug 2021Inspection
    Identified severely stained and dirty carpets in several bedrooms, plus safety/privacy concerns from a needed handrail in the shower of room 143 and broken/missing blinds in room 139.
    04 Aug 2021Complaint
    Identified that meals served were not nutritionally balanced and did not meet dietary requirements. A lunch included a corn dog, french fries, and tapioca pudding.
    • Type A87464(f)(3)
    04 Aug 2021Complaint
    Investigated two allegations that staff did not adequately feed a resident and did not address medical needs in a timely manner. Found no corroborating evidence to support these allegations.
    13 Jul 2021Complaint
    Investigated two allegations about ombudsman contact posting and first aid kit; both unfounded.
    02 Jul 2021Complaint
    Identified that a refund for April 2021, after the resident died on 04/18/2021, was not issued.
    • Type B87507(5)(A)(c)
    24 Jun 2021Complaint
    Investigated an allegation that staff restricted a resident's access to personal belongings and a cell phone, failed to meet the resident's needs, and did not communicate with the responsible party. Interviews indicated the resident had access to personal belongings and the cell phone, needs were being met, and staff communicated with the responsible party; found no evidence to support the allegations.
    08 Jun 2021Complaint
    Found that staff did not have residents' medical information readily available for responding emergency personnel, did not follow residents' care plans, did not administer prescribed medications, and left residents unsupervised.
    • Type A87411(a)
    • Type A87465(a)(5)
    • Type A1569.618(b)(3)
    03 Jun 2021Complaint
    Identified that a resident's file was incomplete at arrival, lacking level-of-care documentation.
    • Type B87506(a)
    27 Apr 2021Complaint
    Investigated the allegation that medications were not properly stored; medications were delivered to a resident's bedroom and later returned to staff, creating a potential safety risk.
    • Type B87465(h)(2)
    06 Apr 2021Complaint
    Identified insulin syringes drawn from insulin bottles and injected by medication technicians, and night-shift staffing was insufficient to meet residents' needs; temperature control and kitchen cleanliness were not found to be problematic.
    • Type A87628(a)
    • Type A87411(a)
    06 Apr 2021Complaint
    Found that two residents developed pressure injuries while receiving care, and staffing shortages contributed to delayed incontinent care at night.
    • Type A87625(b)(7)
    30 Mar 2021Complaint
    Investigated the allegation that a resident's medication was not dispensed as prescribed; a review found extra pills in two medication packages, posing an immediate risk.
    • Type A87465(c)
    30 Mar 2021Inspection
    Investigated concerns by conducting an unannounced visit to amend a prior complaint report.
    26 Mar 2021Complaint
    Identified that staff did not respond promptly to a resident's call light after they requested assistance.
    • Type A87411(a)
    23 Mar 2021Complaint
    Investigated a complaint that staff did not properly administer a resident's medication. Six medications refilled on 01/18/2021 were still in possession and dispensed to the resident after the refill date.
    • Type A87411(a)
    23 Mar 2021Inspection
    Identified a record-keeping violation where a resident's MAR was incomplete and unavailable for review, posing a potential health and safety risk.
    • Type B87211
    08 Mar 2021Inspection
    Investigated a complaint-related concern during an unannounced visit, interviewed residents, and found no health or safety concerns at the time.
    02 Mar 2021Inspection
    Identified that the front door was locked and required staff assistance to exit, and there was no approved fire clearance for locked doors.
    26 Feb 2021Complaint
    Investigated a complaint alleging uncomfortable room temperatures, delays in toileting assistance, and inadequate meals. Interviews reported comfortable room temperatures, timely toileting responses, and adequate meals.
    25 Feb 2021Complaint
    Investigated an allegation that staff verbally abused a resident; evidence did not establish that the allegation occurred.
    23 Feb 2021Complaint
    Investigated a complaint that dishes were not properly cleaned. Found that the dishwasher purifier tank failed, causing old food to remain on dishes during service.
    • Type B87555(b)(29)
    23 Feb 2021Complaint
    Investigated complaints about residents' medications not always being given on time, insufficient staffing to meet needs, and delays in responding to call buttons.
    • Type B87411(a)
    • Type B87465(c)(2)
    28 Jan 2021Inspection
    Investigated a denial of family visitation for a resident on hospice during COVID-19. It concerned residents' rights to have visitors during medically necessary or urgent matters.
    • Type B87468.1(a)(11)
    26 Jan 2021Complaint
    Investigated an allegation that a resident did not have access to oxygen, and evidence showed the resident was without oxygen for an extended period after a power outage.
    • Type A87611(1)(e)
    • Type A87465(a)
    • Type A87464(d)
    26 Jan 2021Complaint
    Found that staff answered the phones, allowed visits under public health guidelines, provided hygiene services, and administered medications as prescribed; no evidence of verbal abuse, and isolation of residents was used only for containment during COVID-19.
    19 Dec 2020Complaint
    Investigated the allegation that staff did not clean a resident's room; findings showed the room was cleaned as scheduled and documented. Found that there was not a preponderance of evidence to prove the violation occurred.
    22 Jul 2020Inspection
    Confirmed allegation of residents unable to leave rooms, socialize, or engage in activities during COVID-19 pandemic. Residents following CDC and county guidelines for safety.
    11 Mar 2020Complaint
    Investigated an allegation of staff harassment against a resident, finding it unfounded as no evidence supported claims of rumor spreading or unjust eviction notices. Conducted interviews and reviewed documents, confirming valid reasons for eviction notices given to the resident.
    • Type B87468.1(a)(11)
    05 Feb 2020Complaint
    Investigated allegations of rough handling and inappropriate language toward residents as well as cleanliness; determined that there was insufficient evidence to confirm these claims.
    • Type A87628(a)
    • Type A87411(a)
    29 Jan 2020Complaint
    Investigated allegations of staff yelling at a resident and not treating the resident with respect; both were unsubstantiated due to lack of evidence supporting the claims.
    24 Jan 2020Complaint
    Determined that the complaint was unfounded, as the allegation was false, could not have happened, and the license was closed at the time of the complaint.
    11 Dec 2019Complaint
    Confirmed that a resident eviction notice did not meet all required elements according to regulations.
    • Type B1569.682(a)(2)
    07 Nov 2019Inspection
    Reviewed recent Incident Reports related to a medical emergency involving a resident who passed out and vomited, prompting transport to a hospital, following up on the situation and subsequent return to the facility.

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