Inspection Report Summary
The most recent inspection on September 19, 2025, identified deficiencies related to failure to provide necessary care and medical attention to one resident experiencing pain and vomiting. Earlier inspections in 2025 included substantiated complaints about controlled medication misappropriation and issues with medication storage and supervision, including missing Morphine and Lorazepam from residents’ comfort kits. Inspectors cited failures to follow medication policies, store narcotics securely, and perform consistent shift-to-shift counts. The facility reported these incidents to police and has since implemented enhanced security measures and monitoring protocols for medications. The inspection history shows ongoing challenges with medication management and resident care, with some corrective actions taken after the complaint investigation.
Deficiencies (last 1 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Inspection Report
Original Licensing| Name | Title | Context |
|---|---|---|
| E3 | Caregiver | Named in failure to follow protocol leading to resident pain and vomiting overnight. |
| E1 | Executive Director | Expressed concerns about failure to follow protocol and stated termination of E3. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| E3 | Director of Assisted Living and Memory Care | Provided information about medication storage practices and missing Morphine for resident R17 |
| E4 | Nurse | Provided information about narcotic counts and medication administration during the investigation |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Carlos Bernal | Executive Director | Signed the plan of correction letter addressing medication administration violation. |
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