I toured this beautiful, new memory-care community and appreciated the bright rooms, cheerful courtyard, good food and a few truly caring staff (Christina and others went above and beyond). Sadly leadership and communication are unreliable: frequent staff turnover, understaffed shifts, unanswered calls/emails, billing surprises and unclear fees. I witnessed odor and cleanliness problems, delayed meds/CPAP help, residents neglected or left in distress, and slow/unhelpful maintenance. Activities and engagement were inconsistent-some residents thrive, many sit with little stimulation. The facility looks great and has compassionate employees, but safety, staffing and management failures mean I cannot recommend it.
The Vineyard at Fountaingrove Memory Care sits in the Fountaingrove neighborhood in Santa Rosa and focuses on serving seniors with memory loss, like Alzheimer's or dementia, in a safe, comfortable setting where routines help and where safety is a top concern, which is good because the facility features things like a sprinkler system, secure exits, and building-wide ADA accessibility so everyone can move around easily. The community provides several levels of care, including independent living, assisted living, memory care, skilled nursing, hospice, adult day services, and even home health and home care, so folks needing different levels of support can stay where they're comfortable. Residents can expect daily support with activities like bathing and dressing, medication reminders, personal laundry, and regular housekeeping, and that includes having a nurse on staff part-time plus access to a team of caregivers trained in dementia care and behavioral management who know how to keep people comfortable and cared for as needs change.
Every resident gets an individualized care plan, especially those with memory challenges, and there's the SPARK care program which is research-based and uses ideas from Montessori teaching to keep brains and hands busy with programs like arts and crafts, gardening, music classes, cooking, games, exercise, book clubs, movies, and even brain games and fitness activities, not to mention day trips around the area so residents can keep a sense of connection to the outside world. Meals are served three times a day in a social dining room-food comes from an executive chef and are made to fit special dietary needs, plus snacks are available at all times. Every neighborhood has a kitchen, dining space, washers/dryers, and individual air conditioning and heating, and the rooms are spacious with built-in storage and home-like touches like hardwood-style flooring and garden views to help everyone feel at ease. There's also WIFI, cable TV, a hot tub spa, a coffee shop, and a fitness center, along with a barber and salon onsite.
Outside, you'll find landscaped gardens and walking paths, while inside there are lounges, activity rooms, and private spaces for family gatherings or celebrations. Weekly outings to events or locations in town help engage residents, while programs include art therapy, music therapy with live performances or sing-alongs, and non-denominational worship. There's no allowance for pets, but residents often mention how caring and attentive the staff are, and management seems to make efforts to listen and address concerns as they come up. The Vineyard at Fountaingrove Memory Care accepts different payment options and helps with long-term care insurance and other practical needs, which can be helpful for families planning ahead. The facility holds a 3.7 rating from 19 reviews, with many folks noting the clean, odor-free environment and a real sense of community. Tours are available so interested families can see firsthand how daily life, meals, and activities happen there, and overall, this facility aims to support elders with cognitive conditions in ways that promote dignity, safety, and a sense of belonging.
Frontier Management is a leading senior living provider in the United States, operating over 120 communities across 19 states. Headquartered in Durham, Oregon, Frontier offers a range of senior living options, including independent living, assisted living, and memory care. Founded in 2000, Frontier has grown significantly and has been recognized for its excellence in senior care, earning multiple prestigious industry awards.
One of Frontier's hallmark programs is the Spark program, rooted in Montessori-style practices, which promotes purpose and engagement among residents. Initially designed for memory care, this program has been expanded to other types of care within Frontier's communities. The Spark program empowers residents to have an active role in their community, enhancing their daily lives through meaningful activities.
Frontier is also known for its dedication to resident health and well-being. Their communities offer comprehensive services tailored to individual needs, including customized healthcare plans through the Frontier Advantage Network, which aims to extend residents' stay by keeping them healthier for longer periods.
The company has undergone significant changes and growth in recent years, including a rebranding effort to refresh its image and enhance its services. Frontier's communities are spread across various states including Arizona, California, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Mississippi, Missouri, Montana, Nebraska, Nevada, Oregon, Tennessee, Texas, Utah, Washington, and Wisconsin.
Frontier Management's commitment to quality care, innovative programs, and extensive service options makes it a prominent name in senior living, continually striving to meet the evolving needs of its residents.
People often ask...
The Vineyard at Fountaingrove Memory Care offers competitive pricing, with rates starting at a cost of $7,855 per month.
The Vineyard at Fountaingrove Memory Care offers assisted living and memory care.
There are 23 photos of The Vineyard at Fountaingrove Memory Care on Mirador.
The full address for this community is 200 Fountaingrove Pkwy, Santa Rosa, CA, 95403.
Yes, The Vineyard at Fountaingrove Memory Care offers 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.
State of California Inspection Reports
120
Inspections
50
Type A Citations
39
Type B Citations
6
Years of reports
20 Jun 2023
20 Jun 2023
Found all exits unobstructed, fire extinguishers last serviced 8/9/2022, smoke detectors hard-wired with carbon monoxide alarms, bathrooms with grab bars and non-slip flooring, and hot water temperatures between 112.2 and 114.9 degrees Fahrenheit. Reviewed five resident files and six staff files but could not complete, planned to return to finish reviewing medications kept in a designated room and dispensed using two locked carts.
22 Jun 2023
22 Jun 2023
Identified safety hazards: razors in a resident bathroom and cleaners stored in a cabinet accessible to residents; six staff first-aid certificates were not current. Five resident records were current, and the administrator’s certificate was valid through 2024.
§ 87309(a)
§ 87705(f)(1)
14 Mar 2023
14 Mar 2023
Identified that on 2/26/2023 at about 9:00 PM, a staff member allegedly hit a resident three times, as reported by another staff member.
23 May 2024
23 May 2024
Identified that a resident eloped and was found about a block away in a hotel lobby, then escorted back; a physician’s report indicated the resident cannot leave unassisted. Imposed civil penalties of $1,000 for a third repeat violation within 12 months, with prior violations on 2/20/2024 and 6/22/2023.
§ 87705(b)(2)
17 Jan 2023
17 Jan 2023
Identified three incidents: an allegation that one resident abused another, a resident eloped from the home without staff knowledge, and a separate incident where one resident struck another with no injuries; civil penalties were issued for repeat violations within 12 months.
§ 87705
30 Jan 2025
30 Jan 2025
Investigated allegation that a night shift staff member did not meet residents' care needs and left residents in soiled condition for long periods. Found limited information from interviews and management turnover prevented a determination of whether the allegation occurred.
07 Aug 2025
07 Aug 2025
Investigated allegations that a staff member hit a resident and spoke inappropriately to the resident; found insufficient evidence to prove or disprove the incidents. No deficiencies cited.
26 Feb 2021
26 Feb 2021
Investigated allegations that staff restrained residents, failed to report falls, and lacked proper training; found insufficient information to prove or disprove the allegations.
29 Dec 2022
29 Dec 2022
Identified two self-reported incidents: a 12/16/2022 event where a resident hit another during escort, and a 12/15/2022 unwitnessed fall with head injury leading to ER care and hospice. Found no deficiencies cited.
17 Apr 2024
17 Apr 2024
Identified concerns included financial solvency, fire clearance issues, insufficient care and supervision with medication errors, administrator duties and qualifications, licensing fees, and future compliance. No deficiencies were cited during the conference.
23 Jul 2021
23 Jul 2021
Found infection control measures in place, including entrance screening, staff wearing masks, available PPE, secured medications and cleaners, and daily monitoring of staff and residents; no deficiencies were cited.
27 Mar 2024
27 Mar 2024
Found that several interior fire doors were wedged open and not fixed by the due date, and civil penalties of $700 were issued, to continue at $100 per day until addressed.
20 Jan 2022
20 Jan 2022
Investigated found that staff did not respond to a resident’s call bells promptly, with numerous delays lasting over 15 and 30 minutes. Other allegations—lack of supervision causing falls, insufficient staffing, not answering the main telephone, and failure to provide managed incontinence care—lacked sufficient evidence.
§ 87411(a)
22 Jun 2023
22 Jun 2023
Identified multiple elopement and wandering incidents by residents with dementia, including unassisted exits and removal of safety devices, plus an incident where one resident entered another’s room and grabbed belongings, causing bruising. Imposed civil penalties totaling $1,000 for a third repeat violation within 12 months, with earlier violations noted in late 2022 and early 2023.
§ 87705(b)(2)
26 Dec 2024
26 Dec 2024
Found no elopement; a resident wandered and was found in another resident's closet taking clothing when an item fell from the top and covered them. Reported missing on 12/24 between 6:00 and 6:30 pm, they were later located by a caregiver and admitted to the hospital on 12/25, where they remained; documents were gathered and staff interviewed, and no deficiencies were cited.
21 Mar 2025
21 Mar 2025
Identified ongoing financial solvency concerns and multiple compliance issues, including management changes without prior approval, fire clearance and firewatch problems, insufficient care and supervision with medication errors, and gaps in documentation and reporting. Discussed ongoing complaints and ownership change under review.
19 May 2023
19 May 2023
Found that a staff member mismanaged a resident's Warfarin by entering the order incorrectly into the electronic MAR, resulting in a missed dose on 5/15/23.
§ 87465(a)(5)
21 Mar 2025
21 Mar 2025
Found that the fire alarm system had not functioned for about a year, with no repair actions taken despite outreach from the fire department and a vendor, and fire watch logs were incomplete and inconsistent. Imposed a $500 immediate civil penalty for the fire clearance violation.
§ 87202(a)
17 May 2022
17 May 2022
Investigated and found that the allegation that residents and others stole property from the resident could not be proven. Found that the resident has dementia and tends to make inaccurate theft allegations; although some residents may have entered the resident's room uninvited, no evidence of wrongdoing was identified.
29 Jul 2025
29 Jul 2025
Found that the licensee did not issue the resident’s authorized representative a timely refund; the January refund was not issued within the required 15 days after the removal of the resident’s belongings.
§ 1569.652(c)
07 Aug 2025
07 Aug 2025
Identified that staff witnessed alleged abuse of a resident and failed to notify within the mandated time frame.
§ 9058
§ 15630(b)(1)
02 Mar 2021
02 Mar 2021
Found insufficient information to prove or disprove the allegation that the level of care provided was inadequate, that neglect occurred resulting in pressure injuries, and that staff failed to notify the authorized representative about a change in condition.
07 Aug 2025
07 Aug 2025
Identified that the current license number appeared in several locations on advertising materials and that required residents’ rights postings were present. Found no evidence to support the allegation that license numbers were missing from advertising or that required postings were absent.
21 Mar 2025
21 Mar 2025
Found that in December 2024 there was insufficient staffing to meet residents' needs, leaving no regular activities or music and causing long waits for assistance; the roster showed 30 people in care, with 4 needing two-person assistance, 26 needing one-person assistance, and 3 on hospice.
Indicated by January 2025 interviews that activities were not regular and there was no dedicated activities staff for months.
§ 87411(a)
31 Dec 2020
31 Dec 2020
Determined that podiatric services were curtailed due to Covid-19 precautions beyond the program's control, and that some residents refused bathing and nail care, with residents’ rights protecting refusals. Found care plans and program policies complete, and although photos showed wet diapers and feet needing care, there was not a preponderance of evidence to prove the allegation either occurred or did not occur.
03 Apr 2025
03 Apr 2025
Found no citations issued after an unannounced visit; new management arrived in February 2025, with 22 residents on the east side and the west side undergoing renovation, plus adequate food, staff, and working alarms and safe exits. The fire panel remained under repair per the fire department, with the fire watch log updated and kept in place.
§ 9058
14 Oct 2020
14 Oct 2020
Found insufficient information to prove or disprove the allegation that residents' incontinent needs were not met in a timely manner and the allegation that residents' medications were not provided as prescribed; the allegations were unsubstantiated.
23 Sept 2021
23 Sept 2021
Found that staff did not safeguard residents' personal belongings and that entrance automatic door openers were not functioning properly.
§ 87468.1(a)(12)
§ 87303(a)
09 Dec 2024
09 Dec 2024
Found that the claim of overcharging and not communicating promptly with the responsible party about move-out could not be proven by a preponderance of evidence. Written notice of termination prior to move-out was not confirmed as received, and personal items were removed after no response.
30 Jan 2025
30 Jan 2025
Found significant kitchen sanitation problems, including uncovered leftovers, leftovers reheated over several days, and an ant infestation, with cleaning practices not meeting standards. Found nighttime staffing shortages that led to delayed responses to resident calls and inconsistent incontinence care.
§ 87555(b)(9)
§ 87411(a)
22 Feb 2021
22 Feb 2021
Investigated allegations that staff did not notify residents' authorized representatives, improperly confined a resident, neglected residents' care needs, provided insufficient supervision resulting in a fall, and caused pressure injuries. Found insufficient evidence to prove or disprove these claims.
09 Jan 2025
09 Jan 2025
Identified medication mishandling, including a med tech failing to assist with a blood glucose check leading to a missed insulin dose, and a period when a prescribed medication was out of stock; First Aid/CPR training was found lacking for several staff. Noted that allegations of inadequate care and supervision, insufficient supplies, withholding food or drinks, poor room maintenance, broken lights, and sharing residents' personal supplies were not supported by evidence.
§ 87465(a)(4)
§ 87411(a)
31 Dec 2024
31 Dec 2024
Verified that the allegation of electrical problems in four residents' rooms was resolved.
20 May 2024
20 May 2024
Found staff failed to properly manage a resident's medications, including not administering scheduled insulin as ordered. A penalty was imposed for the second repeat violation.
§ 87465(a)(5)
04 Feb 2025
04 Feb 2025
Confirmed administrator clearance and association with the site, and the front entrance was functioning. Found heat in the resident room had been cleared previously, and deficiencies from 01/07/2024 were cleared.
09 Jan 2025
09 Jan 2025
Found that residents and their responsible parties were not timely notified about the sale of the property; the 11/20/24 letter to residents did not come from the current management company, and no change of ownership application had been received.
§ 1569.191(1)
31 Dec 2024
31 Dec 2024
Found that morphine was prescribed for hospice pain after a fall and that the resident died on 11/9/2024; the health and wellness director denied giving morphine prescribed for another resident and said it was administered for this resident. The death certificate lists Alzheimer's Disease as the cause with other contributing factors not related to medication, no autopsy was performed, and there was not enough evidence to prove or disprove the allegation that morphine prescribed for another resident was administered, so the allegation remains unresolved.
30 Jan 2025
30 Jan 2025
Investigated allegations about bathing timeliness, medication management, recordkeeping, clothing, and pressure injuries. Found that bathing assistance was not provided in a timely manner due to staffing shortages; found insufficient evidence to determine whether medications were dispensed as prescribed; found insufficient evidence to determine whether resident records were accurately maintained; found insufficient evidence to determine whether residents were provided with clean clothing; and found insufficient evidence to determine whether residents developed pressure injuries.
§ 87464(f)(4)
05 Dec 2024
05 Dec 2024
Identified ongoing electrical problems in four units; repairs had not been completed by the due date, and an additional civil penalty of $1,400 was assessed for 11/22–12/5/2024, with daily penalties of $100 accruing until corrected.
15 Jul 2025
15 Jul 2025
Found the site comfortable, exits unobstructed, and doors locking properly; 21 residents were on the east side while the west side was under renovation. Noted ample meals, functioning alarms and safety features, a repaired fire panel, and no citations issued; the Fire Dept inspection passed.
§ 9058
09 Jun 2022
09 Jun 2022
Found infection control measures in place with PPE use and staff training. Identified deficiencies included a fire extinguisher last charged in 2021 and hot water temperatures in most bathrooms outside the required range; several administrative documents were requested.
§ 87303(e)(2)
09 Dec 2024
09 Dec 2024
Identified ongoing financial distress based on solvency audit results. Found no evidence to prove unsafe client transport, mismanagement of medications, inadequate staff training, non-working phone service, disrepair or cleanliness concerns, uncomfortable temperatures, nutrition concerns, insufficient supplies, or failure to follow reporting requirements.
§ 87213
21 Nov 2024
21 Nov 2024
Found that electrical repairs in four resident apartments were not completed by the 10/22/2024 deadline, resulting in additional civil penalties including $900 for 11/13–11/21/2024 and ongoing penalties of $100 per day until the deficiency is corrected.
23 Sept 2021
23 Sept 2021
Found that a resident who required hourly checks fell on 5/31/2021, was assessed by medical staff, and was admitted to the hospital. Found insufficient evidence to prove the allegation that the resident was not adequately supervised; no deficiencies or citations were issued.
23 Sept 2021
23 Sept 2021
Investigated the allegation that staff negligence and lack of timely care contributed to a resident's fall; records and interviews showed hourly checks and routine care were provided, and the concerns that staff did not assist promptly, did not transfer properly, and did not follow the care plan were not supported.
21 Mar 2025
21 Mar 2025
Identified that a resident's room smelled of urine and had no clean linens, and that staff did not provide clean linens or ensure the room was odor-free.
§ 87625(b)(3)
§ 87307(a)(3)
09 Apr 2021
09 Apr 2021
Identified that staff did not answer the main phone line after a shift-change error, causing calls to go unanswered and voicemail to fill for about four hours. This addressed the allegation that staff did not answer the main phone line.
§ 87411(a)(e)
17 May 2022
17 May 2022
Found no documentation of R1's personal property inventory, later corrected by administration.
§ 87218
21 Sept 2023
21 Sept 2023
Identified multiple concerns at the home, including insufficient staffing during the PM shift to meet residents' needs and the inability to supply properly fitting incontinence products. Also observed issues such as residents wandering off-site, medication mismanagement, lack of activities, transportation problems, and some food/equipment concerns, with some allegations supported by evidence and others not conclusively proven.
§ 87411(a)
§ 87705(c)(4)
§ 87465(i)
§ 87219(a)
§ 87312
23 Jul 2021
23 Jul 2021
Identified that a discontinued medication was still administered to the resident through 1/29/21, contrary to physician orders. Identified that home health care supplies left in the resident's room went missing and were not safeguarded.
§ 87465(c)(2)
§ 87468.1(a)(12)
03 May 2022
03 May 2022
Investigated an April 22, 2022 incident in which a bullet was found in a resident's room after a window broke; police findings pending, no further action was needed.
27 Mar 2024
27 Mar 2024
Identified the solvency-related non-compliance allegation as supported by evidence. Repeated requests for financial documentation were not fulfilled.
§ 87213
06 Dec 2022
06 Dec 2022
Identified a resident with dementia who left unassisted twice, first on 11/25/2022 and again on 12/5/2022, and was returned by a neighbor and by law enforcement; a 12/5/22 medication change to reduce wandering was noted. Observed deficiencies related to elopement prevention.
§ 87705
15 Nov 2022
15 Nov 2022
Found no deficiencies after reviewing several incident reports involving aggressive behavior between residents and a fall with a temporary change in condition; staff notified families and authorities, and affected residents returned to baseline.
13 Nov 2024
13 Nov 2024
Identified failures to timely submit written incident and death reports to licensing, with reports sent to the wrong fax and no confirmation records. Found restricted access to electronic medication authorization records and centrally stored medications, and narcotics not destroyed promptly; noted missing board minutes for administrator paperwork and an upcoming management change.
09 May 2024
09 May 2024
Identified the allegation that staff did not ensure residents with dementia received their annual medical assessments. Records showed those residents were overdue by two to six years for updated physician’s reports, and turnover in management contributed to the scheduling gaps.
§ 87705(c)(5)
27 Jul 2022
27 Jul 2022
Identified an allegation of verbal abuse and possible slapping by a caregiver toward a resident on 7/21/22, with no injuries observed. Police were contacted and spoke with the resident by phone; no formal report was filed, and an internal investigation was initiated with plans to submit findings by 8/21/22.
20 Feb 2024
20 Feb 2024
Identified a resident elopement after removing window safety devices and deactivating the alarm, with the resident found unharmed a few blocks away. Noted that a dementia-related physician’s note had not been updated within 12 months, observed hallway fire doors malfunctioning due to broken magnets, and civil penalties totaling $1,000 were issued for a second repeat elopement within 12 months.
§ 87705(b)(2)
§ 87705(c)(5)
§ 87303(a)
12 Nov 2024
12 Nov 2024
Identified electrical problems in four resident apartments that were not repaired by the 10/22 deadline. Issued a prior penalty of $300 and, today, an additional $1,800 penalty for 10/26 through 11/12, with further penalties at $100 per day until corrected.
13 Aug 2024
13 Aug 2024
Identified safety concerns at the home, including personal hygiene items accessible to residents, a large hole in the kitchen ceiling, and a pilot light that wouldn’t stay lit, with medications securely locked and dispensed by staff using two locked carts.
File reviews for five residents and five staff members, as well as the medication review, could not be completed during the visit.
§ 87705(f)(1)
§ 87303(a)
04 Nov 2022
04 Nov 2022
Identified the allegation of a medication error involving three residents who did not receive their morning insulin due to miscommunication among nursing staff. A citation for the medication error was issued.
§ 87465(a)(5)
23 May 2024
23 May 2024
Found staff not current on required trainings, including CPR/First Aid, dementia care, and medication training.
Reviewed training records and interviewed staff across several roles to identify gaps.
§ 1569.62(a)
21 Nov 2024
21 Nov 2024
Found the allegation of inadequate staffing, inadequate hydration for residents, and lack of accessible harmful products for memory care residents to be unproven by the available evidence. Observations during visits showed staffing sufficient, hydration stations available, and no harmful products accessible.
08 Oct 2024
08 Oct 2024
Identified electrical problems in four resident apartments with ceiling lights not operating; management had requested authorization for repairs, but approval had not yet been granted and the lighting had been inoperable for at least two weeks. Exit interview conducted and appeal rights provided.
§ 87303(a)
25 Oct 2024
25 Oct 2024
Identified electrical problems in four resident apartments; repairs were not completed by 10/22/2024, and a civil penalty of $300 was issued for 10/23–10/25 at $100 per day, with additional penalties accruing until the issue is corrected.
23 Jan 2024
23 Jan 2024
Found a medication error where a PRN dose for agitation was given twice in one day. It was caught in review and reported to health services, who notified the primary care physician and psychiatrist; the resident had no adverse effects and remained at baseline.
§ 87465(c)(2)
10 Sept 2024
10 Sept 2024
Found that 30 new hires between April and September 2024 were trained or scheduled for training in medications and dementia care. Also identified overdue licensing fees, an ongoing investigation into care and medication errors, and a new administrator slated to oversee, with related documents due by 09/23/2024.
21 Aug 2024
21 Aug 2024
Found no evidence to support the allegation that staff did not provide a resident with water for an extended period. Observations showed water, juice, and other beverages available at multiple stations, and hydration checks were performed regularly every 1-2 hours.
23 Jan 2024
23 Jan 2024
Identified that residents' rooms were not consistently kept clean, safe, and sanitary, with cleaning sometimes handled by an outside party after requests. Found concerns about care and supervision contributing to a resident’s decline, and that evidence did not prove belongings were routinely lost during laundry.
§ 87303(a)
02 Oct 2023
02 Oct 2023
Identified that the allegation of a personal rights violation occurred when a resident's door was not kept locked, enabling another resident to enter and assault them. Noted this was a repeat issue from a prior complaint and a $250 civil penalty was issued.
§ 1569.269(a)(5)
12 Sept 2023
12 Sept 2023
Identified two insulin administration errors: on 09/04/2023, the 8:00 AM insulin dose was not given as prescribed and notification to the resident’s family was delayed until 09/06/2023; on 09/06/2023, the 11:30 AM dose was not dispensed as prescribed, with the issue reported later that day, and penalties of $250 were issued for repeated violations within 12 months.
§ 87465(a)(5)
07 Jan 2025
07 Jan 2025
Found an unannounced arrival by a licensing program analyst; the front door did not lock and remained unrepaired; a $400 penalty for failure to correct was issued, with an additional $100 per day to be assessed until the deficiency was corrected.
02 Oct 2023
02 Oct 2023
Investigated four allegations regarding a resident’s injuries, medical care, insulin administration, and care needs. Found insufficient evidence to prove or disprove the allegations that the resident sustained injuries while in care, that medical attention was not sought promptly, that insulin was not administered in a timely manner, and that staff did not meet the resident’s care needs.
31 Aug 2023
31 Aug 2023
Found significant delays in responding to pull-cord activations, with seven responses between 10 and 30 minutes and at least 68 between 30 and 60 minutes, and observed pagers left at desks with several pagers inoperable, leading to identified deficiencies.
§ 87144(a)
31 Aug 2023
31 Aug 2023
Investigated safety concerns and found that staff had prior knowledge of a resident's violent behavior and did not update the care plan or install requested safety measures to protect other residents. Found insufficient evidence that staff failed to respond to responsible parties in a timely manner, and not enough evidence to prove belongings were not safeguarded.
§ 1569.269(a)(5)
21 Aug 2024
21 Aug 2024
Found gaps in staff training and an expired administrator certificate; several required documents and proof of liability insurance needed updating by 9/11/2024. Found all resident records current and a review of centrally stored medications completed.
§ 1569.625
§ 1569.69(b)
31 Dec 2024
31 Dec 2024
Found that the allegation of not having enough food for residents lacked sufficient evidence, with visits showing adequate fresh and non-perishable food and lunches meeting regulations. Found that the allegation of no one in charge and ongoing disrepair was true, noting the administrator resigned with replacement expected on site by 1/1/2024, and a $250 civil penalty was assessed for repeat violations.
§ 87303(a)
§ 87405
04 Jun 2024
04 Jun 2024
Found not enough staff to meet resident needs and that calls to the site were not answered promptly; evidence supported these accusations.
§ 87411(a)
§ 87311
10 Sept 2024
10 Sept 2024
Reviewed documents for employee training, financial status, fire safety, and licensing fees; no deficiencies cited. New Administrator appointed.
21 Aug 2024
21 Aug 2024
Determined staff provided residents with adequate hydration opportunities, and an allegation of not providing water for an extended time was not supported by sufficient evidence.
13 Aug 2024
13 Aug 2024
Identified deficiencies in safety measures and medication storage during the inspection.
§ 87303(a)
§ 87705(f)(1)
04 Jun 2024
04 Jun 2024
Confirmed inadequately staffed and delayed phone response allegations at the facility.
§ 87411(a)
§ 87311
23 May 2024
23 May 2024
Confirmed that staff were not current on required trainings for CPR, First Aid, dementia, and medication.
§ 1569.62(a)
20 May 2024
20 May 2024
Staff were found to be not managing resident's medication properly, resulting in a substantiated allegation and the issuance of civil penalties for repeat deficiencies.
§ 87465(a)(5)
09 May 2024
09 May 2024
Confirmed allegations of staff failing to ensure residents received required annual medical assessments. Residents with dementia diagnosis overdue for assessments.
§ 87705(c)(5)
17 Apr 2024
17 Apr 2024
Identified concerns included financial solvency, fire clearance issues, insufficient care and supervision, medication errors, licensing fees, and staff qualifications. No deficiencies were cited during the conference.
27 Mar 2024
27 Mar 2024
Identified deficiencies in safety maintenance were not corrected by the due date, resulting in civil penalties being assessed.
20 Feb 2024
20 Feb 2024
Identified elopement incident and deficiency related to resident safety. Civil penalties issued for repeat violations.
§ 87705(b)(2)
§ 87303(a)
§ 87705(c)(5)
23 Jan 2024
23 Jan 2024
Confirmed lack of cleanliness in residents' rooms due to minimal housekeeping staff, but insufficient evidence for severe malnutrition and dehydration allegations. Personal belongings safeguarding also not substantiated.
§ 87303(a)
02 Oct 2023
02 Oct 2023
Confirmed an allegation of a resident being assaulted due to a door not being locked as requested.
§ 1569.269(a)(5)
21 Sept 2023
21 Sept 2023
Confirmed issues with insufficient staffing, inadequate incontinent care products, mismanagement of medications, lack of resident activities, and non-operational transportation. Investigated concerns related to resident elopement, food service, and dishwasher functionality, but lacked sufficient evidence to confirm these allegations.
§ 87465(i)
§ 87705(c)(4)
§ 87219(a)
§ 87312
§ 87411(a)
12 Sept 2023
12 Sept 2023
Identified 2 medication errors resulting in immediate civil penalties. Incident reports were reviewed and deficiencies were cited.
§ 87465(a)(5)
31 Aug 2023
31 Aug 2023
Identified deficiencies in response times to resident call cords, resulting in potential risks to resident safety.
§ 87144(a)
22 Jun 2023
22 Jun 2023
Identified deficiencies in the facility's documentation and maintenance were observed during the inspection.
§ 87309(a)
§ 87705(f)(1)
20 Jun 2023
20 Jun 2023
Inspection identified compliance with safety regulations and resident care standards, with some files and medication review pending completion.
19 May 2023
19 May 2023
Confirmed staff gave inaccurate medication dosage to resident, resulting in medication errors and missed doses, leading to substantiated citation and civil penalties.
§ 87465(a)(5)
14 Mar 2023
14 Mar 2023
Investigated an allegation of staff hitting a resident reported to the authorities; confirmed that internal notes and resident charts were reviewed, and further details pending completion of a full internal investigation.
17 Jan 2023
17 Jan 2023
Found multiple incidents of resident-to-resident altercations, including hitting, elopement, and possible abuse reported at the facility.
§ 87705
29 Dec 2022
29 Dec 2022
Investigated incidents
Increased supervision
No deficiencies cited.
06 Dec 2022
06 Dec 2022
Identified deficiencies in care and supervision led to resident leaving unassisted on multiple occasions.
§ 87705
15 Nov 2022
15 Nov 2022
Confirmed two incidents of resident aggression and one incident of significant change in condition, all addressed by facility with no deficiencies cited.
04 Nov 2022
04 Nov 2022
Found a medication error occurred which resulted in three residents not receiving their scheduled morning insulin.
§ 87465(a)(5)
27 Jul 2022
27 Jul 2022
Confirmed suspected verbal abuse incident involving a resident, no injuries observed, police contact made but no report generated. No deficiencies found during visit.
09 Jun 2022
09 Jun 2022
Found deficiencies in infection control, maintenance, and documentation during an inspection.
§ 87303(e)(2)
17 May 2022
17 May 2022
Allegations of theft and inappropriate behavior by residents were investigated, but no evidence was found to substantiate them.
03 May 2022
03 May 2022
Confirmed that appropriate action was taken following an incident involving a bullet found in a resident's room.
20 Jan 2022
20 Jan 2022
Confirmed lack of timely response to resident call bells, but found insufficient evidence to support claims of inadequate staffing, failure to answer phone calls, or lack of incontinence care for residents.
§ 87411(a)
23 Sept 2021
23 Sept 2021
Confirmed that staff did not safeguard resident belongings and that entrance automatic door openers were not working properly.
§ 87303(a)
§ 87468.1(a)(12)
23 Jul 2021
23 Jul 2021
Conducted unannounced inspection focused on infection control procedures. No deficiencies observed, facility compliant with regulations.
09 Apr 2021
09 Apr 2021
Confirmed that staff failed to answer the main phone line, causing calls to be missed and the mailbox to become full.
§ 87411(a)(e)
02 Mar 2021
02 Mar 2021
Found insufficient evidence to prove allegations of care level neglect, pressure injuries, and lack of notification to family. No citations issued.
26 Feb 2021
26 Feb 2021
Reviewed allegations of staff restraining residents, not reporting falls, and lacking proper training; insufficient evidence to prove or disprove. No citations issued.
22 Feb 2021
22 Feb 2021
Investigated multiple allegations regarding incidents involving residents, but found insufficient evidence to prove or disprove the claims. No citations were issued as a result.
31 Dec 2020
31 Dec 2020
Reviewed complaint allegation regarding resident hygiene, including bathing and incontinent care. No sufficient evidence to support the allegation.
14 Oct 2020
14 Oct 2020
Reviewed resident records and conducted interviews with staff, but insufficient evidence to prove or disprove allegations regarding incontinent needs and medication management.
18 May 2020
18 May 2020
Reviewed allegations of improper care, inappropriate behavior, lack of supervision, and inadequate activities at the facility; findings were inconclusive.
11 May 2020
11 May 2020
Reviewed findings of allegations related to resident care, hygiene, diet, and medication at an assisted living facility, with no conclusive evidence found to support or refute the claims.
28 Feb 2020
28 Feb 2020
Found no evidence to support allegations of lack of supervision resulting in falls, delayed response to alerts, inadequate bed linen, or medications not being administered properly during the inspection.
21 Oct 2019
21 Oct 2019
Reviewed resident files and staff records, all in compliance. Identified missing documentation to be updated by a specified date.
30 Sept 2019
30 Sept 2019
Inspection results showed all safety measures were in compliance, including fire extinguisher and smoke alarm checks, adequate food supply, secure medication storage, and staff availability.
