Vine Ridge Senior Living

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location... and to licensing agency staff.This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that three (3) of three (3) residents (R1, R2, R3) MARs were not initialed by staff on dates noted in findings which poses a potential health, safety or personal rights risk to persons in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted to the licensing agency...(B) Any serious injury...while the resident is under facility supervision.This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that an Incident Report was not Submitted for R1 for an injury sustained at the facility which poses a potential health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (a) A plan for incidental medical... shall be developed...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 & record review, the licensee did not comply with the section cited above in that on 3/8/2026 medication prescribed for resident R2 was given to resident R1 which poses an immediate health, safety or personal rights risk to persons in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed...(19)To have prompt access to review all of their records and to purchase photocopies...shall be provided within two (2) business days... This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that R1's representatives were not provided copies of documents in R1's file within the regulated time frame which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in that staff member S1 had no proof of annual training in their file and staff member S3 had only completed 9.75 hours of annual training which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in that Staff Member S1 did not receive Guardian Background Clearance prior to employment at the facility which poses a potential health, safety or personal rights risk to persons in care.

87303 Maintenance and Operation(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance...for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by: Based on observation & interview, the licensee did not comply with the section cited above in that a large portion of the floor in the memory care dining/common area floor was in disrepair. The flooring strips were bubbled and loose which poses a potential health, safety or personal rights risk to persons in care.

87211 (g) Reporting Requirements: The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. This requirement is not met as evidenced by: Based on records review, the licensee did not notify the Department of the change of administrator in writing within thirty (30) days of the hiring of a new administrator back in December 2023, which is a potential risk to the health and safety of residents in care.

Based on LPAs record review, the licensee did not comply with the section cited above in 5 out of 5 staff records did not maintain in the personnel records verification of required staff training and orientation, which poses/posed a potential health, safety or personal rights risk to persons in care.

87208 Plan of Operation:(a) Each facility shall have and maintain a current, written definitive plan of operation. This requirement was not met as evidenced by: Based on record review and interviews, Licensee did not ensure that their plan of operation was followed by changing care level fees to reflect services provided immediately following a resident’s significant change in condition. This is a potential risk to the health and safety of residents in care.

87463 Reappraisals:(c) The licensee shall arrange a meeting with the resident, the resident’s representative,...when there is significant change in the resident’s condition, or once every 12 months. This requirement was not met as evidenced by: Based on record review and interviews, Licensee did not ensure that a documented reassessment was completed following the 8/29/2022 Physician’s Report indicating a significant change in condition. This is a potential risk to the health and safety of residents in care.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful & comfortable accommodations, furnishings and equipment. This requirement hasn't been met based on LPA observation that 2 of 7 staff did not have a mask on while in common areas of the facility, in violation of official government orders requiring the wearing of face coverings while working under specified conditions. This is a potential risk to health & safety of residents.

Based on interview and record review, the licensee did not comply with the section cited above in one out of one instance of a memory care resident eloping the facility which poses an immediate health, safety or personal rights risk to persons in care.

*Amended*87464 Basic Services (f) Basic services shall at a minimum include:...(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications ... This requirement was not met based on: Per interviews & document review, Licensee did not ensure that resident's needs were being met. This is an immediate risk to the health and safety of residents in care.

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, & competent to provide services necessary to meet resident needs. In facilities licensed for 16 or more, sufficient support staff shall be employed to ensure provision of personal assistance & care as required.. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, & maintenance of buildings, equipment and grounds. This requirement was not met based on: Per interviews & document review, Licensee did not ensure sufficient staffing. This is an immediate risk to the health and safety of residents in care.

87705 Care of Persons with Dementia (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (5) Interior and exterior space shall be available on the facility premises to permit residents with dementia to wander freely and safely. This requirement has not been met based on LPA observation showing that the door that goes into the outdoor area automatically locks which does not allow resident to wander freely. This is a potential risk to the personal rights of residents in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement has not been met based on interviews and LPA observation showing that the delayed egress doors in Memory Care are not functioning correctly and there is visible evidence of a plumbing leak on the cealing in Assisted Living. This is an immediate risk to the health asnd safety of residents in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations... This requirement has not been met as evidenced by interviews confirming that a resident in memory care goes into other resident's rooms and goes through their personal items. This is a potential risk to the personal rights of residents in care.

87705 Care of Persons with Dementia(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement has not been met as evidenced by interview and document review indicating that a resident in Memory Care eloped the facility and staff did not respond to the delayed egress alarm. This is an immediate risk to the health and safety of residents in care.

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs. In facilities licensed for 16 or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608... This requirement has not been met based on document review and interviews indicating that facility is short staffed resulting in needs being delayed or not met. This is an immediate risk to the health and safety of residents in care.

87309(a) STORAGE SPACE. Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. ***Based upon observation, this requirement has not been met as evidenced by: Laundry products and cleanser observed accessible to residents. This posed an immediate risk to the health of residents in care.

87465(h)(2) Incidental Medical and dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. ***Based upon observation, this requirement has not been met as evidenced by: LPA observed prescription eye drops in unlocked resident’s room on September 02, 2021. This posed an immediate risk to health and safety of residents in care.

87405(h)(4) Administrator – Qualifications and Duties. The administrator shall have the responsibility to: ….(4) Recruit, employ and train qualified staff, and terminate employment of staff who perform in an unsatisfactory manner. ***Based upon statements and records review, this requirement has not been met as evidenced by: S3 and S5 have provided care to residents without all required training. This posed an immediate risk to the residents in care.