Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to assess compliance with staffing requirements, specifically to verify that the facility had a registered nurse on duty for at least eight hours a day, seven days a week, as required by policy.
Findings
The facility failed to ensure registered nurse coverage for eight hours a day, seven days a week, with payroll data confirming no RN coverage on June 3, 10, and 17, 2023. This failure had the potential to endanger resident health and safety.
Deficiencies (1)
Failure to have a registered nurse on duty eight hours a day, seven days a week.
Report Facts
Dates without RN coverage: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding importance of RN coverage and resident safety risk |
| Administrator | Administrator | Interviewed and confirmed no RN coverage on specified dates |
Inspection Report
Routine
Deficiencies: 8
Date: Dec 14, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and vaccination protocols at Bellaken Skilled Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to follow physician orders for oxygen administration, inconsistent quality control testing of blood glucose meters, improper medication disposal documentation, expired medications storage, unsafe food preparation practices, infection control lapses including improper catheter care and blood glucose meter use, failure to provide pneumococcal and COVID-19 vaccinations to some residents, and inadequate cleaning and disinfection procedures.
Deficiencies (8)
Failed to follow physician's order for oxygen administration for two residents when oxygen flow rates were not set as ordered.
Quality control tests for blood glucose meters were not done consistently and no remedial actions were taken for out-of-range results.
Unused or discontinued medications were disposed without required signatures of a pharmacist or nurse and one other witness.
An opened, used, multi-dose vial of influenza vaccine was not removed after 28 days of first use; expired medications and items were stored and not removed.
Low temperature dishwasher did not reach proper sanitation level; dietary staff did not wear hair restraints properly; staff did not wash hands upon kitchen entry; food tray dropped on floor was placed in food cart.
Urinary catheter drainage bag touched the floor; soiled towels not stored properly; laundry room daily task checklists not consistently completed; blood glucose meters not cleaned per manufacturer's instructions; single-patient use blood glucose meter used on multiple residents.
Failed to provide pneumococcal immunizations for three residents after consent was obtained.
Failed to offer and provide COVID-19 immunizations for two residents despite consent and policy.
Report Facts
Missing quality control test dates: 4
Expired medication dates: 7
Residents requiring blood glucose checks: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in oxygen administration and blood glucose meter cleaning findings. |
| LVN 2 | Licensed Vocational Nurse | Named in blood glucose meter quality control and medication cart inspection. |
| LVN 3 | Licensed Vocational Nurse | Named in blood glucose meter cleaning and disinfection interview. |
| LVN 4 | Licensed Vocational Nurse | Named in medication refrigerator inspection and expired vaccine finding. |
| DON | Director of Nursing | Named in multiple interviews confirming deficiencies and policy adherence. |
| DSS | Dietary Service Supervisor | Named in food safety and sanitation findings. |
| IP | Infection Preventionist | Named in infection control and blood glucose meter cleaning findings. |
| HS | Housekeeping Supervisor | Named in laundry room cleanliness and checklist findings. |
Inspection Report
Routine
Deficiencies: 8
Date: Feb 4, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements for nursing home care and services.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach for residents, lack of posting Ombudsman contact information, failure to notify residents timely about Medicare coverage ending, failure to provide podiatry services, failure to provide ordered range of motion exercises, incomplete dialysis assessments, failure to obtain informed consent for bed rail use, and inadequate infection prevention and control practices during a COVID-19 outbreak.
Deficiencies (8)
Failed to ensure call lights were within reach for three of 17 sampled residents.
Failed to post Ombudsman Program contact information.
Failed to inform Resident 32 and Responsible Party timely about Medicare services ending.
Failed to provide podiatry services for one resident for five months.
Failed to provide range of motion exercises as ordered for one resident.
Failed to perform complete assessments before dialysis treatments for one resident.
Failed to obtain informed consent from residents or family representatives prior to use of bed rails for four residents.
Failed to ensure staff followed proper infection control standards and transmission-based precautions during COVID-19 outbreak, including inadequate PPE availability and improper hand hygiene during medication administration.
Report Facts
Residents sampled: 17
Residents affected: 3
Residents affected: 1
Months: 5
Residents affected: 1
Residents affected: 1
Residents affected: 4
Isolation gowns: 4
Resident rooms: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 3 | CNA | Mentioned in relation to call light placement for Resident 217 and Resident 17's toenail care |
| Certified Nursing Assistant 1 | CNA | Mentioned regarding call light cord length for Resident 50 |
| Social Services Director | SSD | Interviewed about Ombudsman contact information |
| Social Worker | SW | Interviewed about Medicare notification for Resident 32 and podiatry scheduling for Resident 17 |
| Licensed Vocational Nurse 2 | LVN | Interviewed about Resident 17's toenail care |
| Certified Nursing Assistant 4 | CNA | Interviewed about toenail care documentation for Resident 17 |
| Restorative Nurse Aide | RNA | Interviewed about failure to provide ROM exercises to Resident 50 |
| Director of Nursing | DON | Interviewed about ROM exercises for Resident 50 and bed rail consent for Resident 64 |
| Administrator | ADM | Interviewed about dialysis assessments and PPE supply |
| MDS Coordinator | MDSC | Interviewed about bed rail consent and resident cognition |
| Licensed Vocational Nurse 1 | LVN | Observed and interviewed about hand hygiene during medication administration |
| Registered Nurse 1 | RN | Observed and interviewed about hand hygiene during medication administration |
| Infection Preventionist | IP | Interviewed about infection control practices and PPE availability |
| Certified Nursing Assistant 2 | CNA | Observed and interviewed about PPE use and glove availability |
| Housekeeper | HSKP | Observed and interviewed about PPE use and glove changing |
Report
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February 8, 2023
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January 23, 2023
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March 24, 2022
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