Inspection Reports for
Artesia Christian Home
11614 183rd St. Artesia, CA 90701, CA, 90701
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
113% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
56% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 16
Date: Jan 23, 2026
Visit Reason
Routine inspection of Artesia Christian Home Inc. to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity, advance directives, wound care notification, medication administration, range of motion services, restorative nursing aide competency and documentation, pharmaceutical services, medication timing, medication labeling, food storage, therapy orders, medical record accuracy, infection control practices, water testing, COVID-19 vaccination documentation, and room size compliance.
Deficiencies (16)
F 0550: The facility failed to ensure Resident 45 was treated with dignity when a trash bag was placed on the resident's bed during treatment.
F 0578: The facility failed to ensure an Advance Directive was formulated for Resident 26, risking conflict with resident's healthcare wishes.
F 0580: The facility failed to notify the physician when Resident 45's pressure injury worsened from stage 1 to stage 2.
F 0658: The facility failed to ensure two residents (16 and 31) did not receive crushed oral medications combined, risking drug interactions and incorrect dosage.
F 0688: The facility failed to provide or document range of motion exercises and assessments properly for Residents 1, 2, and 8, risking functional decline and contractures.
F 0726: The facility failed to ensure Restorative Nursing Aides were competent to provide active assistive range of motion exercises and observe hip precautions for Resident 8.
F 0755: The facility failed to verify the correct dosage of Vitamin B-12 for Resident 35, risking medication errors.
F 0760: The facility failed to administer psychotropic medications to Resident 39 in a timely manner, with multiple late doses documented.
F 0761: The facility failed to label an opened Tuberculin PPD vial with the date opened, risking loss of medication potency.
F 0812: The facility failed to label raw meats and prepared foods with dates in the kitchen refrigerator, risking foodborne illness.
F 0826: The facility failed to ensure Physical and Occupational Therapy evaluations were performed under physician orders for Resident 1.
F 0842: The facility failed to maintain accurate medical records for Residents 2 and 8 by incomplete RNA documentation and failure to update RNA orders after discontinuation of hip precautions.
F 0880: The facility failed to ensure staff performed hand hygiene before entering Resident 16 and 30's rooms, failed to wear isolation gown when required for Resident 8 on Enhanced Barrier Precautions, and failed to properly disinfect cloth gait belts used in therapy.
F 0880 (continued): The facility failed to conduct monthly water temperature testing to prevent Legionella growth, risking resident exposure to Legionnaire's disease.
F 0887: The facility failed to provide documented evidence of COVID-19 education and vaccination status for four sampled employees.
F 0912: The facility failed to ensure bedrooms met minimum size requirements of 80 square feet per resident in multiple rooms.
Report Facts
Deficiencies cited: 15
Resident rooms with less than 80 sq ft per resident: 6
Late medication administrations: 8
Missing RNA documentation days: 20
RNA sessions missed: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNA 2 | Restorative Nursing Aide | Named in deficient RNA competency and documentation findings |
| RNA 1 | Restorative Nursing Aide | Named in deficient RNA documentation findings |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication, RNA, infection control |
| Director of Rehabilitation | Physical Therapist | Interviewed regarding therapy orders and RNA program |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication and infection control |
| Licensed Vocational Nurse 2 | LVN | Observed and interviewed regarding hand hygiene and medication administration |
| Certified Occupational Therapist Assistant 1 | COTA | Interviewed regarding cleaning of gait belts |
| Director of Staff Development | Director of Staff Development | Interviewed regarding RNA supervision and documentation |
| Infection Prevention Nurse | Infection Prevention Nurse | Interviewed regarding infection control practices |
| Licensed Vocational Nurse 4 | LVN | Interviewed regarding medication administration timing |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 18, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control regulations, specifically regarding reporting a suspected scabies outbreak to the California Department of Public Health.
Findings
The facility failed to report a suspected scabies outbreak involving three residents to the California Department of Public Health, resulting in delayed investigation and increased risk of spread. The Infection Prevention Nurse was unaware of the reporting requirement, and the facility's policies required reporting such outbreaks within 24 hours.
Deficiencies (1)
F 0880: The facility failed to report a suspected scabies outbreak involving three residents to the California Department of Public Health as required by policy and regulations. This failure delayed investigation and increased risk of transmission to residents, staff, and visitors.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Prevention Nurse | Interviewed regarding awareness of reporting requirements for scabies outbreak | |
| Director of Nursing | Interviewed regarding reporting of suspected scabies outbreak |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 26, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident rights and meal service.
Findings
The facility failed to ensure the safety of a resident's personal belongings, resulting in the loss of a necklace. Additionally, the facility did not serve requested menu items to a resident, potentially causing loss of appetite and unplanned weight loss.
Deficiencies (2)
F 0557: The facility failed to protect Resident 1's personal belongings, resulting in the loss of a necklace of sentimental value. The facility's policy requires labeling and safeguarding resident valuables.
F 0806: The facility failed to serve Resident 1 requested menu items, including coleslaw and roasted vegetables, contrary to the diet order and resident preferences. This had the potential to cause loss of appetite and unplanned weight loss.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Associate Director of Social Services | Interviewed regarding lost resident belongings | |
| Director of Staff Development | Interviewed regarding meal service and resident diet | |
| Registered Dietician | Interviewed regarding diet tickets and resident food preferences |
Inspection Report
Annual Inspection
Census: 80
Capacity: 143
Deficiencies: 0
Date: Aug 12, 2025
Visit Reason
The inspection was an unannounced required 1-year visit to evaluate compliance with licensing requirements using the full Care Compliance and Regulatory Enforcement (CARE) Tools.
Findings
The inspection covered 12 CARE tool domains including infection control, physical plant safety, staffing, resident rights, and more. No deficiencies were observed during the inspection, and all regulatory requirements were met.
Report Facts
Employees providing care and supervision: 63
Resident files reviewed: 6
Staff files reviewed: 5
Bathrooms tested for hot water temperature: 11
Residents with active physician orders and medications reviewed: 8
Licensed capacity: 143
Non-ambulatory residents capacity: 95
Bedridden residents capacity: 8
Hospice waiver approved residents: 8
Hospice waiver requested residents: 15
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly assess and report a resident's left arm bruise as a change of condition.
Complaint Details
The complaint investigation found that the bruise on Resident 1's left arm was not properly assessed or reported as a change of condition despite being reported by a Certified Nurse Assistant to licensed nursing staff. The issue was substantiated with interviews from CNA, LVN, RN, and the Director of Nursing confirming the failure to assess and notify the physician.
Findings
The facility staff failed to ensure that Resident 1's left arm bruise was assessed and reported as a change of condition after being reported to a licensed nurse, resulting in delayed care and potential harm. Interviews and record reviews confirmed that the bruise was noted but not properly assessed or documented as a change of condition.
Deficiencies (1)
F 0580: The facility failed to assess and report Resident 1's left arm bruise as a change of condition after it was reported to licensed nursing staff. This delay in care had the potential to cause pain, infection, and hospitalization.
Report Facts
Bruise size on admission: 8.5
Bruise size on 6/28/2025: 25
Date of admission: Jun 2, 2025
Date of bruise report: Jun 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nurse Assistant | Reported bruise on Resident 1's left arm to LVN 1 |
| LVN 1 | Licensed Vocational Nurse | Received bruise report from CNA 1 and told CNA to notify treatment nurse |
| RN 1 | Registered Nurse | Treatment nurse who did not assess bruise, stating it was not a change of condition |
| Director of Nursing | Director of Nursing | Acknowledged failure to assess bruise and stated it was a learning experience for staff |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 143
Deficiencies: 0
Date: May 23, 2025
Visit Reason
The inspection was conducted as a 24-hour case management visit following an allegation by Resident #1 that Staff #1 touched her inappropriately.
Complaint Details
The visit was complaint-related due to an allegation by Resident #1 of inappropriate touching by Staff #1. No substantiation status is stated in the report.
Findings
No health and safety concerns were observed during the inspection. Records for Resident #1 and Staff #1 were reviewed, and the LA Sheriff Department officer was present during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Colleen Levi | Director of Nursing | Accompanied the Licensing Program Analyst on health and safety checks during the inspection. |
| Michelle Lehde | LVN | Conducted health and safety checks with the Licensing Program Analyst on the second floor. |
| Jimenez | LA Sheriff Department Officer | Arrived during the visit and was present at the facility. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 31, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to assess and evaluate a resident after an unwitnessed fall on 12/7/2024.
Complaint Details
The complaint investigation found that Resident 1 was not assessed with a fall risk evaluation after an unwitnessed fall on 12/7/2024. The facility did not follow policy requiring monitoring every 30 minutes after suppository administration, contributing to the resident's fall and injury. The complaint was substantiated with findings of deficient practice.
Findings
The facility failed to ensure Resident 1 was assessed and evaluated after an unwitnessed fall, resulting in the resident sustaining multiple skin tears. Interviews and record reviews revealed no fall risk evaluation was done after the fall, and staff did not adequately monitor the resident after administration of a suppository, increasing fall risk.
Deficiencies (1)
F 0689: The facility failed to ensure Resident 1 was assessed and evaluated after an unwitnessed fall on 12/7/2024. This resulted in Resident 1 falling in bed and sustaining multiple skin tears to the left forearm.
Report Facts
Date of fall: Dec 7, 2024
Date of survey completion: Dec 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Provided information about Resident 1's behavior and monitoring after suppository administration |
| CNA 2 | Certified Nursing Assistant | Reported finding Resident 1 on the floor after fall |
| LVN 1 | Licensed Vocational Nurse | Described monitoring requirements after suppository administration and fall circumstances |
| ADON | Assistant Director of Nurses | Discussed fall risk evaluation requirements and Resident 1's fall history |
| DON | Director of Nurses | Acknowledged missed fall risk evaluation and emphasized nursing staff responsibilities |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 15, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report and investigate injuries of unknown origin, failure to ensure resident safety during use of assistive devices, and failure to provide adequate monitoring and notification of abnormal clinical conditions.
Complaint Details
The complaint investigation focused on failure to report and investigate injuries of unknown origin for Resident 210, failure to prevent injury during use of assistive devices, and failure to monitor and notify the physician of Resident 58's abnormal urine output. The findings substantiated these issues with minimal to actual harm.
Findings
The facility failed to timely report and investigate a 1.5 cm by 1.5 cm injury of unknown origin on Resident 210's forehead, failed to prevent injury caused by use of a stand-up lift despite resident agitation, and failed to monitor and notify the physician of Resident 58's abnormally low urine output leading to dehydration and acute kidney injury.
Deficiencies (4)
F 0609: The facility failed to timely report suspected abuse, neglect, or injury of unknown origin for Resident 210, resulting in delayed onsite inspection and potential ongoing injury.
F 0610: The facility failed to investigate injuries of unknown origin for Resident 210, which had potential for undetected abuse.
F 0689: The facility failed to ensure Resident 210 was free from accident hazards by continuing to use a stand-up lift despite agitation, resulting in a 1.5 cm by 1.5 cm injury.
F 0692: The facility failed to inform the physician and initiate a change of condition when Resident 58 had abnormally low urine output of 50 cc over 8 hours, resulting in dehydration and acute kidney injury requiring hospitalization.
Report Facts
Injury size: 1.5
Urine output: 50
Hospitalization duration: 11
Episodes of agitation: 5
Blood urea nitrogen (BUN): 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Licensed Vocational Nurse | Documented Resident 58's low urine output but did not notify physician or initiate change of condition |
| DON | Director of Nursing | Interviewed regarding failure to investigate injury on Resident 210 and failure to notify physician of Resident 58's dehydration |
| CNA 4 | Certified Nurse Assistant | Described procedure for using stand-up lift and requirements when resident is uncooperative |
| ADON | Assistant Director of Nursing | Interviewed regarding Resident 58's care plan and failure to monitor dehydration signs |
Inspection Report
Deficiencies: 16
Date: Nov 15, 2024
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to resident care, medication management, infection control, facility environment, and staff qualifications.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for restraints, failure to report and investigate injuries of unknown origin, failure to develop and revise comprehensive care plans, failure to prevent pressure injuries, failure to provide appropriate range of motion care, failure to ensure resident safety during transfers, failure to provide emergency dialysis supplies, failure to ensure psychiatric evaluations for residents on psychotropic medications, failure to secure controlled medications, failure to monitor antibiotic use, failure to maintain infection control programs, failure to monitor COVID-19 vaccination status of staff, and failure to maintain adequate room sizes.
Deficiencies (16)
F0604: The facility failed to ensure residents were assessed for pressure pad alarms and given informed consent, violating resident rights to be free from restraints.
F0609: The facility failed to timely report suspected abuse and injuries of unknown origin for Resident 210, resulting in delayed onsite inspection and potential ongoing injury.
F0610: The facility failed to investigate injuries of unknown origin for Resident 210, risking undetected abuse.
F0656: The facility failed to develop and implement a comprehensive person-centered care plan addressing noncompliance for Resident 1, risking delayed care.
F0657: The facility failed to revise Resident 50's care plan after development and progression of a pressure injury from Stage 1 to Stage 4.
F0686: The facility failed to provide appropriate pressure ulcer care for Resident 50, including repositioning, nutritional assessment, care plan updates, and change of condition documentation.
F0688: The facility failed to provide appropriate care to maintain or improve range of motion for Resident 41, including failure to provide upper extremity ROM and follow physician's splint order.
F0689: The facility failed to ensure Resident 210 was free from accidents by continuing to use a stand-up lift despite agitation, resulting in a head injury.
F0698: The facility failed to have emergency dialysis supplies at the bedside for Resident 6, risking complications during dialysis emergencies.
F0741: The facility failed to ensure psychiatric services were provided to residents on psychotropic medications, resulting in lack of psychiatric evaluations and oversight for Residents 2, 17, 19, and 51.
F0755: The facility failed to ensure the consulting pharmacist conducted monthly drug regimen reviews and made recommendations for gradual dose reductions for residents on psychotropic medications.
F0836: The facility failed to provide documented evidence of 10 hours of continuing education in Infection Prevention and Control for key nursing leadership.
F0880: The facility failed to implement its infection control program for residents with suspicious skin rashes, including failure to isolate affected residents, conduct surveillance, implement precautionary measures, and coordinate with public health.
F0881: The facility failed to implement its antibiotic stewardship program by not monitoring and addressing triple antibiotic ointment use for Residents 1 and 60.
F0887: The facility failed to document employee COVID-19 vaccination status and education, risking staff and resident exposure.
F0912: The facility failed to provide rooms with at least 80 square feet per resident in multiple rooms and 100 square feet for single rooms, but no negative impact was observed.
Report Facts
Deficiencies cited: 14
Residents on psychotropic medications: 25
Facility staff with unknown COVID-19 status: 128
Room square footage: 305.5
Room square footage: 151
Room square footage: 152
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD 1 | Medical Director | Notified of suspicious rashes and involved in dermatology consult orders. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including infection control, psychiatric services, and medication management. |
| ADON | Assistant Director of Nursing | Interviewed regarding multiple deficiencies including infection control, psychiatric services, and medication management. |
| DSD | Director of Staff Development | Conducted staff in-services related to psychiatric medication and infection control. |
| PH | Pharmacist Consultant | Did not conduct drug regimen reviews or make gradual dose reduction recommendations. |
| ADSS | Assistant Director of Social Services | Participated in IDT meetings and behavior management reviews. |
| TN 2 | Treatment Nurse | Interviewed regarding pressure injury care and assessments. |
| LVN 3 | Licensed Vocational Nurse | Interviewed regarding dialysis emergency supplies and medication administration. |
| CNA 3 | Certified Nursing Assistant | Observed Resident 17 sleeping in wheelchair. |
| CNA 4 | Certified Nurse Assistant | Interviewed regarding use of stand-up lift and resident injury. |
| MS | Maintenance Supervisor | Interviewed regarding room sizes and facility environment. |
| HK | Housekeeper | Interviewed regarding cleaning routines in dementia unit. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 25, 2024
Visit Reason
The inspection was conducted to assess the accuracy of resident assessments, specifically reviewing the Minimum Data Set (MDS) for compliance and accuracy.
Findings
The facility failed to ensure that Resident 1's MDS accurately reflected dental issues, as the MDS incorrectly indicated no dental problems despite the resident missing two front lower teeth. This resulted in an inaccurate depiction of the resident's current health status.
Deficiencies (1)
F0641: The facility failed to ensure each resident receives an accurate assessment. Resident 1's MDS was erroneously coded to indicate no dental issues despite missing two front lower teeth.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN)1 | Interviewed regarding Resident 1's nursing admission assessment and MDS discrepancies. | |
| Director of Nursing (DON) | Interviewed regarding the importance of accurate resident assessments. |
Inspection Report
Census: 52
Capacity: 143
Deficiencies: 0
Date: Oct 4, 2024
Visit Reason
Licensing Program Analyst Jewel Baptiste conducted an unannounced case management visit to follow up on an incident report submitted by the Executive Director regarding one of its residents and a staff member.
Findings
During the visit, the analyst interviewed staff and a resident regarding an incident where a staff member made an inappropriate comment to a resident. The facility reprimanded the staff member and no citations were issued at this time.
Inspection Report
Annual Inspection
Census: 80
Capacity: 143
Deficiencies: 0
Date: Jul 30, 2024
Visit Reason
The visit was an unannounced required annual inspection to evaluate compliance with licensing and operational requirements.
Findings
The facility was found to be in compliance with no deficiencies observed. Infection control, operational requirements, physical plant safety, staffing, resident rights, food services, medical and dental assistance, disaster preparedness, and resident records were all satisfactory.
Report Facts
Residents on hospice services: 8
Residents on home health services: 7
Residents on soft food diet: 5
Residents on puree food diet: 1
Staff files reviewed: 8
Resident medication files inspected: 8
Fire drill dates: Last fire drills conducted on 2024-07-13 for Assisted Living and 2024-07-15 for Memory Care Unit
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Walsh | Director of Residential Services | Met with Licensing Program Analyst during inspection |
| Michelle Robison | Administrator | Facility administrator mentioned with expired certificate pending renewal |
| Christine Wong | Licensing Program Analyst | Conducted the unannounced required annual inspection |
| David Sicairos | Supervisor | Supervisor overseeing the inspection process |
Inspection Report
Routine
Deficiencies: 7
Date: Nov 17, 2023
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory standards in multiple areas including resident rights, care services, food safety, infection control, antibiotic stewardship, room size, and call light functionality.
Findings
The facility was found deficient in honoring resident rights regarding refusal of care, providing restorative nursing services to prevent decline in range of motion, food storage and labeling practices, hand hygiene during medication administration, antibiotic use monitoring, room size compliance, and maintaining functional call light systems.
Deficiencies (7)
F 0550: The facility failed to honor one resident's right to refuse care when nursing staff transferred the resident to the bathroom despite refusal, causing distress and resistance.
F 0688: The facility failed to provide restorative nursing services to two residents, placing them at risk for further decline in range of motion and contractures.
F 0812: The facility failed to label open food items with open and use-by dates and improperly stored a bag of Panko Breadcrumbs on the floor, risking foodborne illness.
F 0880: The facility failed to ensure hand hygiene was performed before and after resident contact and glove use during medication administration for four residents, increasing infection risk.
F 0881: The facility failed to monitor and address inappropriate antibiotic use for one resident treated for a urinary tract infection without meeting clinical criteria, risking antibiotic resistance.
F 0912: The facility provided resident rooms with less than the required minimum square footage per resident but reported no negative impact on care or resident access.
F 0919: The facility failed to maintain a functional call light for one resident, potentially delaying assistance and increasing risk of falls and accidents.
Report Facts
Residents sampled: 15
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 1
Resident rooms with less than 80 sq ft per resident: 6
Room measurements: 305.5
Room measurements: 151
Room measurements: 152
Urine culture colony count: 20000
Urine culture colony count: 49000
Inspection Report
Annual Inspection
Census: 81
Capacity: 143
Deficiencies: 0
Date: Oct 5, 2023
Visit Reason
The visit was an unannounced annual continuation inspection conducted by the Licensing Programming Analyst to evaluate compliance and facility operations.
Findings
The inspection included review of resident and staff files and medication checks. No deficiencies were cited during the visit.
Inspection Report
Complaint Investigation
Census: 82
Capacity: 143
Deficiencies: 1
Date: Oct 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit regarding an allegation that a resident was being financially abused while in care.
Complaint Details
The complaint alleged financial abuse of a resident. The investigation found the allegation substantiated based on interviews, document review, and law enforcement findings. Staff members admitted to stealing and misusing resident funds. The case was referred to the District Attorney's office for felony charges.
Findings
The investigation substantiated that staff members S1 and S2 financially abused resident R1 by stealing and cashing checks totaling over $50,000. The facility failed to prevent this abuse, posing an immediate risk to residents' health, safety, and personal rights.
Deficiencies (1)
CCR 87468.2(a)(8) Additional Personal Rights of Residents: The facility failed to ensure residents were free from financial exploitation, as staff members financially abused resident R1 while in care.
Report Facts
Resident census: 82
Facility capacity: 143
Amount stolen: 50000
Number of checks cashed: 50
Check amounts: 2000
Additional theft by second staff: 2800
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Anne Walsh | Director of Residential Services | Facility representative interviewed during investigation and exit interview |
| Michelle Robison | Administrator | Facility administrator involved in investigation and notified of findings |
| Kyle Crowley | Detective, Lakewood Sheriff Station Detective Bureau | Conducted law enforcement investigation related to financial abuse allegations |
Inspection Report
Annual Inspection
Census: 81
Capacity: 143
Deficiencies: 0
Date: Aug 14, 2023
Visit Reason
An unannounced annual/required inspection was conducted to evaluate compliance with licensing regulations for Artesia Christian Home.
Findings
The inspection included review of the assisted living and memory care campuses, food supply, safety equipment, staff and resident interviews, and facility conditions. The facility was found to have working safety detectors, sufficient food supplies, clean and sanitary conditions, and adequate PPE supplies.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anne Walsh | Director of Residential Care Services | Met with during inspection and exit interview. |
| Jewel Baptiste | Licensing Program Analyst | Conducted the inspection. |
| Lisa Hicks | Supervisor | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 14, 2023
Visit Reason
The inspection was conducted following a complaint regarding a resident's fall from a recliner due to unsafe placement of the recliner's remote control and lack of a care plan addressing safety concerns.
Complaint Details
The complaint investigation found that Resident 1, who had severely impaired cognitive skills and was at high risk for falls, fell from a recliner after the remote control was left within reach. The fall caused a 3 cm forehead laceration and a hematoma, requiring five sutures and transfer to an acute care hospital. The facility did not have a care plan with safety interventions prior to the fall.
Findings
The facility failed to ensure the recliner's remote control was placed out of reach of a high fall-risk resident, resulting in the resident falling and sustaining head trauma. Additionally, the facility did not develop or implement a care plan with safety interventions after identifying risks related to the recliner use.
Deficiencies (1)
F0689: The facility failed to ensure the recliner's remote control was placed away from Resident 1's reach, leading to the resident changing recliner positions and falling out, causing head trauma. The facility also failed to create and implement a care plan addressing safety concerns related to the recliner use.
Report Facts
Fall Risk Assessment Score: 14
Length of laceration: 3
Hematoma size: 2
Number of sutures: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nurse Assistant | Placed recliner remote control within Resident 1's reach leading to fall |
| DSD | Director of Staff Development | Observed fall incident and provided staff education on remote control placement |
| LVN 1 | Licensed Vocational Nurse | Assisted Resident 1 after fall and confirmed remote control placement within reach |
| DON | Director of Nursing | Confirmed lack of care plan and improper remote control placement contributing to fall |
Inspection Report
Annual Inspection
Census: 88
Capacity: 143
Deficiencies: 0
Date: Jul 21, 2022
Visit Reason
An unannounced annual inspection was conducted using the Infection Control Evaluation Tool to evaluate compliance with regulations.
Findings
The facility was toured including common areas and resident rooms. No deficiencies were observed. Safety features, medication storage, food supply, and infection control measures were all found to be in compliance.
Report Facts
Resident medications reviewed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Sicairos | Licensing Program Analyst | Conducted the unannounced annual visit |
| Michelle Robison | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 85
Capacity: 143
Deficiencies: 0
Date: Jul 15, 2021
Visit Reason
The visit was an unannounced required annual inspection to complete the required inspection of the facility.
Findings
The inspection included review of infection control, food supply, medication administration, and criminal clearance checks. The facility was found to have sufficient supplies, proper signage, staff training, and COVID-19 safety protocols in place.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the unannounced inspection visit. |
| Michelle Robison | Executive Administrator | Facility administrator present during inspection and involved in the tour. |
| Anne Walsh | Administrator | Facility administrator present during inspection and involved in the tour. |
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