Ivy Park of Belmont

According to the Health Services Director and Resident Care Coordinator, the facility's main phone was not working because on 3/2/26, when the receptionist handed the phone to the med-tech, they did not transfer the phone line properly. In addition, the Resident Care Coordinator confirmed she fixed the phone system on 3/3/26 before 9:30am. Based on documents reviewed, an in-service training was provided on 3/4/26 with med-techs and the receptionists regarding phone hand off. Regarding the allegation, staff provided a resident an inappropriate heating device, according to the reporting party, the administrator provided Resident 1 (R1) a space heater while the heating in R1's room needed to be fixed, however the space heater did not turn off when tipped over. During the investigation, LPA interviewed the administrator, maintenance director, and observed R1's room. According to the Maintenance Director and Administrator, R1's responsible party complained about the temperature gage on the thermostat in R1's room and wanted the room temperature to be 80 degrees F. According to the maintenance director, she checked the room temperature several times and notified R1's responsible party that R1's room was reading between regulatory requirements, however R1's responsible party still complained, so the Maintenance Director not only replaced R1's thermostat but also provided R1 with a space heater to put in his/her room. The administrator indicated when she observed the space heater in R1's room, she had to remove it as the facility does not allow heating devices in resident rooms. Furthermore the administrator stated, even after removing the space heater from R1's room and notifying R1's responsible party that it was not allowed, R1's responsible party brought another heating device to the facility to place in R1's room. During the visit, LPA did not observe a space heater in R1's room. Regarding the allegation, staff did not provide a comfortable temperature for a resident, according to the reporting party, the administrator refused to call an HVAC company to fix the heating in R1's room for over a week. During the investigation, LPA interviewed the administrator, maintenance director, observed R1's room. According to the administrator, she denied this allegation and indicated that she told R1's responsible party that she wanted to try to fix R1's room temperature in house, if possible, prior to calling HVAC. The administrator and the maintenance director, confirmed that R1's thermostat was in good working condition, however R1's responsible party wanted R1's room to read at 80 degrees F. The maintenance director worked with R1 and R1's responsible party by reading R1's room temperature multiple times and replacing the thermostat. (continue to 9099C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 According to the maintenance director and administrator, the temperature readings in R1's room were within regulatory requirements, however R1's responsible party still complained so HVAC was called and they came out to do service in R1's room. During the visit, LPA observed R1's room to be at 76 degrees F. Based on interviews conducted, documents reviewed, and information collected, the department has determined that although the above allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Administrator, Anne Buerhaus and a copy is provided.

Regarding the allegation, staff did not ensure residents medications were dispensed as prescribed, according to the reporting party, because R1 and R2's physician's report was not completed, the administrator indicated that the staff have not been giving R1 and R2 any of their medication. During the investigation, LPA interviewed staff, reviewed charting notes and reviewed fax documentation that was sent to R1 and R2's physician. Based on charting notes reviewed notes on 1/6/26, the facility was awaiting a signed medication and notified R1 and R2's responsible party. Facility staff notified R1 and R2's responsible party to assist with medication administrator until the medication list was signed. According to staff interviewed and fax documentation, the facility sent multiple faxes to R1 and R2's physician to sign R1 and R2's current medication list so medication can be administered by the facility. Additional fax sheets dated 1/9/26-1/12/26 sent to the physician reports that R1 and R2 missed their medication because there were missing medication, missing a signed medication list and needed reconciliation. Regarding the allegation, staff did not ensure care and supervision was provided to resident resulting in an elopement from the facility, according to the reporting party, on 1/10/26, R1 eloped out of the memory care unit and was found at the grocery store and brought back to the facility. During the investigation, LPA interviewed staff and reviewed documents. According to staff interviewed and charting notes reviewed, R1 did not elope from the facility on 1/10/26. On 1/10/26, R1 attempted to elope from the facility, however he/she was found on the facility premises at the back gate and was redirected back to the facility. Based on interviews conducted, documents reviewed, and information collected, the department has determined that although the above allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Administrator, Anne Buerhaus and a copy is provided.

On January 28, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on 1/17/26. LPA met with Administrator, Anne Buerhaus and explained the purpose of the visit. The Licensee reported on 1/17/26 at around 1:00am, Resident 1 (R1) told the med-tech while doing round that, he/she was sexually assaulted by staff. No injuries were noted. All required parties were notified. Facility conducted an investigation. During the visit, LPA discussed the incident with Administrator, Health Services Director, Memory Care Director, attempted to interview R1, and reviewed R1's file. Based on R1's file reviewed, R1 has a diagnosis of dementia and metabolic encephalopathy . In addition, based on staff interviewed and records reviewed, R1 does not have any prior incidents at the facility making allegations like this. LPA attempted to interview R1 during the visit, however did not respond to LPA due to dementia diagnosis. R1's responsible party was present at the facility during the visit. According to R1's responsible party interviewed, R1 is very happy at the facility and the staff are really great. In addition, R1's responsible party indicated that R1 has a history of making allegations like this and it might be happening more due to R1's dementia diagnosis. No citations are issued during the visit. Report is reviewed with Administrator and a copy is provided.

On August 5, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Business Office Director, Broneesha Bradford and explained the purpose of the visit. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 3 story facility; Assisted Living (AL) on the first, second, and half of the third floor and Memory Care (MC) on the other half of the third floor. LPA toured the facility including but not limited to a random sample of resident rooms on each floor, common areas, and kitchen area. LPA observed residents eating lunch, walking around or participating in activities. A comfortable temperature of 74 degrees F is maintained in the facility and lighting is sufficient for comfort. Hot water temperature measured 111-118 degrees F throughout the facility. Overall facility was in clean, odor-free and free from any tripping hazards. Resident rooms and bathrooms observed had all required furnishings, and grab bars in each bathroom. LPA toured kitchen and observed 2 days for perishables and and 7 days non-perishable. Medications and sharps were locked and inaccessible to residents. Emergency drill are being conducted and logged every 3 months. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of March 2025. First aid kits were observed present and complete. Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. No citations are issued during the visit. Report is reviewed with the Business Office Director and a copy is provided.

On 08/20/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannonced pre-licensing inspection visit. LPA met with administrator Minnie Weber and explained the purpose of today's visit. This is a three level facility with a memory care are named "Evergreen" which currently there are 17 residents currently residing in. There are 58 residents in assisted living. Seven residents are currently on hospice. LPA toured facility and grounds. This is a three level facility. LPA observed resident rooms at random. All rooms observed contained the required furniture items outlined within regulations including flash lights and non-skid mats in resident showers. Personal protective equipment (PPE) is in place in an exterior storage area outside of the facility. Perishable and non-perishable food supplies are in place. Food preparation and service items are present in the main kitchen and in other food serving areas such as the dining rooms for assisted living and memory care. Hot water temperature is tested at 110F. Carbon monoxide and smoke detectors are hard wired and operable. The facility is fully equipped with fire sprinklers through out all areas in the facility. LPA observed multiple fire extinguishers through out the facility, including the kitchen, with inspection/service date of 01/30/2024. Fire pull stations are located at fire exits. Emergency exit routes are observed to be clear of obstructions inside and outside. Medications are secured in the primary medication room on the second floor. Medications are observed to be locked. Toxins, chemicals, and other cleaning supplies are inaccessible to resident in care. Based on observations made LPA did not observed any such items accessible to residents during this inspection visit today. LPA observed two laundry rooms, one on the ground floor and one on the third floor, and both are operational clean and functioning. The third floor of the facility is where secured memory care is located. There is an outdoor patio on this level that is in good condition and a secured perimeter with furnishings. There are an emergency set of keys in place accessible to staff and emergency personnel if needed. The administrator Minnie Weber is the current facility administrator. LPA requested the required items to have her name transferred as administrator. Component III RCFE orientation is provided to the administrator. This pre-licensing is complete and this facility has no deficiencies. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 *** AMENDED SECOND PAGE DUE TO ERROR. THIS PAGE SHOULD NOT HAVE BEEN GENERATED AND IS INTENTIONALLY LEFT BLANK ***