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Inspection visit

Follow-up on corrections

ROSE GARDEN SENIOR HOUSINGLicense 1958505422 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 09:45 AM. LPA met with facility staff who contacted the facility Administrator Lilit Tonoyan. The Administrator arrived to the facility at approximately 10:15 AM the reason for the visit was explained and entrance interview was conducted. During today’s visit LPA conducted a physical plant tour, reviewed three (3) resident files, three (3) staff files, conducted a medication audit for two (2) residents, and interviewed the Administrator, the Licensee, one (1) staff and two (2) residents between 10:00 AM and 02:30 PM. Interviews with the facility Administrator and resident #1 (R1) revealed that the facility did not have a dedicated internet access device for resident use. Interviews with R1 revealed that in April R1 was unable to attend an in-person appointment with their primary care physician. R1’s physician requested that the appointment be done via Zoom or Face-Time call. R1 revealed that the facility did not provide a device that was capable of video conferencing, so the appointment was conducted over the telephone instead. In the interview with the Administrator they stated that the internet access device for the facility is the Administrator’s personal cell phone. LPA informed the Administrator that the device must always be present at the facility and must be dedicated for resident use. The Administrator agreed to obtain an internet access device to be left at the facility for resident use. Interviews with R1, Witness #1 (W1), and Staff #1 (S1) revealed that the facility has been crushing medications into R1's food. W1 stated that the facility informed them that they had crushed medications into R1's food. An interview with S1 confirmed that the facility has crushed medications and disguised it into R1's foods. The facility Administrator admitted that staff crush medications into R1's foods. The following deficiency was cited (Refer to LIC 809D). Exit interview conducted, appeal rights and a copy of the report were provided.

Citations

4 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87465(a)(5)(D)Type B

    87465Incidental Medical and Dental care(a) ...compliance with the following:(5) ... shall be limited to the following:(D Assistance with self-administration does not include...hiding or camouflaging medications in other substances...This requirement is not met as evidenced by: Based on interview the licensee did not comply with the section cited above as the facility has been crushing R1's medications into their food which poses a potential personal rights risk to clients in care.

  • 87465(a)(2)Type B

    87465 Incidental Medical and Dental Care(a) ... provide for assistance in obtaining such care...(2) ...This includes transportation... the licensee shall do so directly or make arrangements for this service.This requirement is not met as evidenced by: Based on interview and record review the licensee did not comply with the section cited above as R1 has not been to two in-person medical appointments during their care at the facility which poses a potential health risk to clients in care.

  • 87465(a)(4)Type B

    87465 Incidental Medical and Dental Care(a) ...provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on interview and record review the licensee did not comply with the section cited above as R1 has not been receiving 11 medications that were perscribed by their physician which poses a potential health risk to clients in care.

  • 1569.319(a)Type B

    §1569.319(a) A licensee...shall provide at least one internet access device...that can support ... videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above as the facility did not have a resident dedicated internet access device which poses a potential health or personal rights risk to clients in care.

FAQ · About this visit

Common questions about this visit

What happened during the April 21, 2025 inspection of ROSE GARDEN SENIOR HOUSING?

This was a other inspection of ROSE GARDEN SENIOR HOUSING on April 21, 2025. 2 citations were issued: 2 Type B.

Were any citations issued to ROSE GARDEN SENIOR HOUSING on April 21, 2025?

Yes, 2 citations were issued (0 Type A, 2 Type B). The first citation was for: "87465Incidental Medical and Dental care(a) ...compliance with the following:(5) ... shall be limited to the following:(D..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.