Deficiencies (last 6 years)
Deficiencies (over 6 years)
15.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
288% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
66% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 8, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of physical abuse by a Certified Nursing Assistant (CNA) against a resident during care.
Complaint Details
The complaint was substantiated based on interviews, record reviews, and investigation. CNA 1 admitted to hitting Resident 1, and CNA 2 witnessed the incident and reported it. The Executive Director confirmed the findings.
Findings
The investigation substantiated that CNA 1 hit Resident 1 on the right side of his face while changing the resident's adult brief, causing redness and distress. The facility failed to ensure the resident was free from physical abuse.
Deficiencies (1)
F 0600: The facility failed to protect Resident 1 from physical abuse when CNA 1 hit the resident on the right side of his face during care. This incident caused actual harm, including redness and crying.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in physical abuse finding for hitting Resident 1. |
| CNA 2 | Certified Nursing Assistant | Witnessed and reported the physical abuse incident. |
| LVN 1 | Licensed Vocational Nurse | Notified and involved in evaluation after the abuse incident. |
| Administrator | Administrator | Conducted interviews and investigation related to the abuse incident. |
| Executive Director | Executive Director | Interviewed and confirmed substantiation of abuse. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 4, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding resident rights violations, failure to provide proper notification of roommate changes, failure to timely report and investigate allegations of abuse, and failure to ensure resident safety related to hot liquid burns.
Complaint Details
The complaint investigation involved allegations that a resident's right to refuse care was violated, residents were not given proper written notice before roommate changes, abuse allegations were not reported timely or investigated properly, and a resident was burned due to unsafe food temperature practices. The allegations were substantiated with findings of minimal to actual harm.
Findings
The facility was found to have multiple deficiencies including failure to respect a resident's right to refuse care, failure to provide 72-hour written notice before roommate changes, failure to timely report and investigate abuse allegations, and failure to ensure safe food temperature leading to a resident burn injury.
Deficiencies (5)
F 0550: The facility failed to ensure one resident's right to refuse care was respected, resulting in a violation of dignity and respect.
F 0559: The facility failed to provide two residents with 72-hour written notice prior to roommate changes, violating residents' rights.
F 0609: The facility failed to timely report allegations of abuse within 24 hours to the state agency and local ombudsman for one resident.
F 0610: The facility failed to investigate and protect a resident when allegations of physical abuse were made, allowing continued care by the accused staff.
F 0689: The facility failed to ensure the temperature of hot soup was taken before serving, resulting in a resident sustaining a second degree burn to the left-hand pointer finger.
Report Facts
Deficiencies cited: 5
Wound size: 2
Wound size width: 2
Wound size depth: 0.2
Food temperature: 165
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 5 | Certified Nursing Assistant | Named in findings related to failure to respect resident's right to refuse care and abuse allegations. |
| Administrator | Interviewed regarding abuse investigation and facility policies. | |
| CNA 7 | Certified Nursing Assistant | Named in findings related to heating soup and failure to check temperature before serving. |
| LVN 5 | Licensed Vocational Nurse | Interviewed regarding burn injury and food temperature practices. |
| Physical Therapist | Physical Therapist | Observed resident's burn injury and provided statements. |
| Registered Dietician | Registered Dietician | Provided information on food heating and temperature policies. |
Inspection Report
Routine
Deficiencies: 13
Date: Dec 4, 2025
Visit Reason
Routine inspection of Brookdale Riverwalk Skilled Nursing Facility to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, call light accessibility, abuse reporting and investigation, care planning, assistance with activities of daily living, food safety and handling, infection control, medication storage, and antibiotic stewardship. Several residents experienced harm or potential harm due to these deficiencies.
Deficiencies (13)
F 0550: The facility failed to respect Resident 133's right to refuse care, resulting in a violation of dignity and respect.
F 0558: The facility failed to ensure call lights were accessible for three residents, resulting in unmet care needs.
F 0609: The facility failed to timely report allegations of abuse for Resident 133 to proper authorities.
F 0610: The facility failed to investigate and protect Resident 133 following abuse allegations.
F 0656: The facility failed to develop and implement a comprehensive care plan for Resident 12 receiving TPN.
F 0676: The facility failed to ensure Resident 119 had dentures in place and was assisted with meals.
F 0689: The facility failed to ensure soup temperature was checked before serving, resulting in Resident 81 sustaining a second degree burn.
F 0698: The facility failed to complete Skilled Nursing Dialysis Center Communication Forms for Resident 131.
F 0761: The facility failed to properly label and dispose of expired and opened medications and biologicals.
F 0804: The facility failed to ensure a meal was served at a palatable and appetizing appearance for Resident 74.
F 0812: The facility failed to follow professional standards for food safety and sanitary kitchen conditions, including improper storage and labeling of food and utensils.
F 0880: The facility failed to implement effective infection prevention and control practices, including inadequate infection surveillance, dirty linen containers, improper floor disinfection, and breaches in isolation tray handling and hand hygiene.
F 0881: The facility failed to implement an effective antibiotic stewardship program for four sampled residents.
Report Facts
Residents sampled: 46
Residents affected: 3
Burn wound size: 2
Burn wound size: 2
Burn wound size: 0.2
Medication expiration: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 5 | Certified Nursing Assistant | Named in findings related to Resident 133's abuse allegations and dignity violation |
| Administrator | Interviewed regarding abuse investigation and facility policies | |
| RN 2 | Registered Nurse | Interviewed regarding Resident 12's care plan and dialysis communication form |
| LVN 5 | Licensed Vocational Nurse | Interviewed regarding dialysis communication form and Resident 81's burn |
| CNA 7 | Certified Nursing Assistant | Interviewed regarding heating soup and failure to check temperature |
| IPN | Infection Prevention Nurse | Interviewed regarding infection control deficiencies and antibiotic stewardship |
| IDON | Interim Director of Nursing | Interviewed regarding antibiotic stewardship program |
| CDM | Certified Dietary Manager | Interviewed regarding food safety and meal appearance |
| CNA 1 | Certified Nursing Assistant | Observed and interviewed regarding isolation tray handling |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding hand hygiene and meal tray delivery |
Inspection Report
Complaint Investigation
Capacity: 376
Deficiencies: 0
Date: Sep 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2025-06-10 regarding resident hygiene needs and billing for services not rendered.
Complaint Details
The complaint investigation was unsubstantiated for the allegation that staff did not meet residents' hygiene needs. The allegation that staff charged a resident for services not rendered was found to be unfounded and dismissed.
Findings
The investigation found insufficient evidence to substantiate the allegation that staff did not ensure residents' hygiene needs were met, resulting in an unsubstantiated finding. The allegation that staff charged a resident for services not rendered was found to be unfounded and dismissed. No deficiencies were issued during the complaint visits.
Report Facts
Facility capacity: 376
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during complaint investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sergiy Pidgirny | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 248
Capacity: 376
Deficiencies: 0
Date: Sep 25, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-07-25 regarding allegations that staff did not provide resident records to the resident's authorized representative and a questionable death.
Complaint Details
The complaint was unsubstantiated for the allegation of failure to provide resident records and unfounded for the allegation of questionable death. The department found no preponderance of evidence to prove the allegations.
Findings
The investigation found insufficient evidence to substantiate the allegation regarding resident records, and the allegation of questionable death was found to be unfounded based on medical records. No deficiencies were issued during the complaint visit.
Report Facts
Capacity: 376
Census: 248
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during complaint visit |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sergiy Pidgirny | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 376
Deficiencies: 0
Date: Sep 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2025-06-10 regarding resident hygiene needs and billing for services not rendered.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Melinda Medina. The hygiene allegation was unsubstantiated due to lack of preponderance of evidence. The billing allegation was unfounded based on record review and interviews. No deficiencies were cited.
Findings
The investigation found insufficient evidence to substantiate the allegation that staff did not ensure residents' hygiene needs were met, and the billing complaint was found to be unfounded as the additional service was removed from billing per resident and responsible party request. No deficiencies were issued during the complaint visits.
Report Facts
Facility capacity: 376
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visits |
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during complaint visits |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 248
Capacity: 376
Deficiencies: 0
Date: Sep 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2025-07-25 regarding staff not providing resident records to the resident's authorized representative and a questionable death.
Complaint Details
The complaint investigation was unsubstantiated for the allegation that staff did not provide resident records to the resident's authorized representative. The allegation of questionable death was found to be unfounded, meaning it was false or without reasonable basis.
Findings
The investigation found insufficient evidence to substantiate the allegation regarding resident records, resulting in an unsubstantiated finding. The allegation of questionable death was found to be unfounded based on medical records, and no deficiencies were issued during the complaint visit.
Report Facts
Capacity: 376
Census: 248
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the complaint visit |
Inspection Report
Complaint Investigation
Census: 248
Capacity: 376
Deficiencies: 2
Date: Sep 10, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff did not properly dispose of resident medications upon termination of services and did not dispense medications as prescribed.
Complaint Details
The complaint was substantiated based on evidence that medications were not properly disposed of upon termination of services and medications were not dispensed as prescribed. Staff involved in the incident were terminated and additional training was provided.
Findings
The investigation found that resident R1 was administered medication belonging to residents R2 and R3, and that medication for R3, who had left the facility, was still on site. The allegations were substantiated and deficiencies were cited related to medication disposal and administration.
Deficiencies (2)
Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident.
Basic services shall at a minimum include care and supervision including assistance with taking medications. This was not met as evidenced by R1 being administered medication belonging to both R2 and R3.
Report Facts
Capacity: 376
Census: 248
Deficiencies cited: 2
Plan of Correction Due Date: Sep 26, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during complaint investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 246
Capacity: 376
Deficiencies: 0
Date: Aug 6, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to complaints received on 2025-07-30 regarding medication management and timely dispensing, as well as pest control issues at the facility.
Complaint Details
The complaint investigation was triggered by allegations that staff did not ensure medications were dispensed timely or properly managed, and that the facility was not kept free of pests. The medication-related allegations were unsubstantiated due to lack of preponderance of evidence. The pest control allegation was unfounded as pest control services were confirmed to be timely and adequate.
Findings
The investigation found insufficient evidence to substantiate the medication-related allegations, resulting in an unsubstantiated finding. The pest control allegation was found to be unfounded based on service receipts and timely pest control actions. No deficiencies were issued during the complaint visit.
Report Facts
Complaint Control Number: 24-AS-20250730140347
Capacity: 376
Census: 246
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Administrator/Executive Director | Met with Licensing Program Analysts during complaint visit |
| Martha Fernandez | Health & Wellness Director | Met with Licensing Program Analysts during complaint visit |
| Melinda Medina | Licensing Program Analyst | Conducted complaint investigation |
| J. Duarte | Licensing Program Analyst | Conducted complaint investigation |
Inspection Report
Deficiencies: 1
Date: Jul 29, 2025
Visit Reason
The inspection was conducted to assess compliance with care planning requirements for residents, specifically focusing on the development and implementation of care plans addressing residents' needs.
Findings
The facility failed to develop and implement a complete care plan for a resident with visual hallucinations, which could result in unmet care needs and potential psychological harm. Interviews and record reviews confirmed the absence of a care plan for the resident's hallucinations despite staff awareness.
Deficiencies (1)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs, including measurable timetables and actions, for a resident experiencing visual hallucinations. This failure had the potential to result in unmet care needs and psychological harm.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) 1 | Provided information about the resident's hallucinations and care needs. | |
| Certified Nursing Assistant (CNA) 1 | Reported awareness of the resident's hallucinations and attempts to enter her room. | |
| Administrator | Reviewed the resident's medical record and confirmed no care plan was developed for hallucinations. | |
| Social Services Director (SSD) | Was not aware of the resident's hallucinations and stated she should have been informed. |
Inspection Report
Annual Inspection
Census: 253
Capacity: 376
Deficiencies: 0
Date: May 21, 2025
Visit Reason
The inspection was an unannounced Case Management Annual Continuation visit conducted to complete items from a previous visit on 2025-05-14, including staff file review, resident records review, and completion of the care tool.
Findings
No deficiencies were cited during this visit. The visit was completed with an exit interview and the facility report was signed by the Administrator.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the inspection visit. |
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced Case Management Annual Continuation visit. |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 253
Capacity: 376
Deficiencies: 0
Date: May 21, 2025
Visit Reason
The visit was a Case Management visit conducted following receipt of a Death Report for a resident. The purpose was to conduct case management information review and follow-up after the death report.
Findings
No deficiencies were observed or cited during the visit. The Licensing Program Analyst reviewed the resident's last physician report and facility progress note, and noted the presence of residents on hospice and receiving home health services.
Report Facts
Residents on hospice: 21
Residents receiving home health services: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the visit |
| Sarah Archuelta-Weaver | Met with Licensing Program Analyst during the visit | |
| Melinda Medina | Licensing Program Analyst | Conducted the Case Management visit |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 253
Capacity: 376
Deficiencies: 0
Date: May 21, 2025
Visit Reason
An unannounced Case Management Annual Continuation visit was conducted to complete items from a previous visit on 2025-05-14, including staff file review, resident records review, and completion of the care tool.
Findings
No deficiencies were cited during this visit. The visit was a continuation of the annual inspection to complete outstanding items from the prior visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the inspection visit. |
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced Case Management Annual Continuation visit. |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 253
Capacity: 376
Deficiencies: 0
Date: May 21, 2025
Visit Reason
The visit was a Case Management visit conducted after the Department received a Death Report for a resident on 5/20/2025.
Findings
No deficiencies were observed or cited during the visit. The Licensing Program Analyst reviewed the resident's last physician report and facility progress note.
Report Facts
Residents on hospice: 21
Residents receiving home health services: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the visit |
| Sarah Archuelta-Weaver | Met with Licensing Program Analyst during the visit | |
| Melinda Medina | Licensing Program Analyst | Conducted the Case Management visit |
| Sergiy Pidgirny | Licensing Program Manager | Named in the report |
Inspection Report
Annual Inspection
Census: 253
Capacity: 376
Deficiencies: 0
Date: May 14, 2025
Visit Reason
An unannounced annual inspection was conducted by Licensing Program Analyst M. Medina to evaluate the facility's compliance with licensing requirements.
Findings
The facility was observed to be clean, odor free, and comfortable with residents participating in activities. No deficiencies were observed during the inspection.
Report Facts
Food supply duration: 2
Perishable food supply: 2
Non-perishable food supply: 7
Water temperature range (Fahrenheit): 108
Water temperature range (Fahrenheit): 114
Fire extinguisher service date: Jan 2, 2025
Last fire drill date: Apr 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Toomer | Executive Director | Met with Licensing Program Analyst during facility tour |
| Sarah Archuleta-Weaver | Health and Wellness Director | Accompanied Licensing Program Analyst during facility tour |
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 253
Capacity: 376
Deficiencies: 0
Date: May 14, 2025
Visit Reason
An unannounced annual inspection was conducted by Licensing Program Analyst M. Medina to evaluate the facility's compliance with licensing requirements.
Findings
The facility was observed to be clean, odor free, and comfortable with residents participating in activities. No deficiencies were observed during the inspection.
Report Facts
Water temperature range: 110
Fire extinguisher service date: 2025
Fire drill date: Apr 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Toomer | Executive Director | Met with Licensing Program Analyst during facility tour. |
| Sarah Archuleta-Weaver | Health and Wellness Director | Participated in facility tour with Licensing Program Analyst. |
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced annual inspection. |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report. |
Inspection Report
Complaint Investigation
Census: 253
Capacity: 376
Deficiencies: 0
Date: May 14, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-02-24 alleging that staff left residents soiled for extended periods and other concerns including unqualified staff checking glucose and administering insulin and pest control issues.
Complaint Details
The complaint investigation was unsubstantiated for the allegation that staff left residents soiled for extended periods. Another complaint regarding unqualified staff checking glucose and administering insulin and pest control was found unfounded. No deficiencies were cited.
Findings
The investigation found insufficient evidence to substantiate the allegations of residents being left soiled, unqualified staff administering insulin, and pest control issues. The allegations were determined to be unsubstantiated or unfounded, and no deficiencies were issued during the complaint visits.
Report Facts
Capacity: 376
Census: 253
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during complaint investigation |
| Sarah Archuelta-Weaver | Health and Wellness Director | Met with Licensing Program Analyst during complaint investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 253
Capacity: 376
Deficiencies: 0
Date: May 14, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint alleging that facility staff do not follow infection control requirements.
Complaint Details
The complaint alleged that facility staff do not follow infection control requirements. The investigation found these allegations to be unfounded, meaning they were false, could not have happened, and/or were without reasonable basis.
Findings
The investigation determined that infection control practices are in place and proper procedures are followed to protect the health and safety of residents. The allegations were found to be unfounded and the complaint was dismissed.
Report Facts
Complaint Control Number: 24
Complaint Control Number Full: 24-AS-20250225145623
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 253
Capacity: 376
Deficiencies: 0
Date: May 14, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2025-02-24 alleging staff left residents soiled for extended periods, unqualified staff checking glucose and administering insulin, and failure to ensure the facility was free of insects.
Complaint Details
The complaint investigation was unsubstantiated for the allegation of staff leaving residents soiled. The other allegations regarding unqualified staff and pest control were found unfounded and dismissed.
Findings
The investigation found insufficient evidence to substantiate the allegation that staff left residents soiled, resulting in an unsubstantiated finding. The allegations regarding unqualified staff checking glucose and administering insulin and failure to ensure the facility was free of insects were found to be unfounded and dismissed.
Report Facts
Capacity: 376
Census: 253
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met during complaint investigation and named in findings |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Archuelta-Weaver | Health and Wellness Director | Met during complaint investigation |
Inspection Report
Complaint Investigation
Census: 253
Capacity: 376
Deficiencies: 0
Date: May 14, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that facility staff do not follow infection control requirements.
Complaint Details
The complaint alleged that facility staff do not follow infection control requirements. The investigation found the allegations to be unfounded, meaning they were false, could not have happened, and/or were without reasonable basis.
Findings
The investigation determined that infection control practices are in place and proper procedures are followed to protect the health and safety of residents. The allegations were found to be unfounded and the complaint was dismissed.
Report Facts
Complaint Control Number: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the complaint investigation visit |
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Sergiy Pidgirny | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and investigate an allegation of psychological/mental abuse involving a resident.
Complaint Details
The complaint involved an allegation of psychological/mental abuse of Resident 1. The facility did not report the allegation within 24 hours and failed to submit the 5-day investigation report within 5 days. The deficiency was substantiated based on interviews and record review.
Findings
The facility failed to implement its Abuse, Neglect & Exploitation Policy by not reporting the psychological/mental abuse allegation timely to the California Department of Public Health and local ombudsman, and by not submitting the required 5-day investigation report within the mandated timeframe.
Deficiencies (1)
F 0607: The facility failed to report an allegation of psychological/mental abuse timely to the California Department of Public Health and local ombudsman for Resident 1. The 5-day investigation report was also not sent within 5 days as required.
Report Facts
Residents Affected: 1
Inspection Report
Monitoring
Census: 255
Capacity: 376
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
The visit was an unannounced Case Management visit to verify that a specific staff member (S1) is not on the property, as S1 is excluded and not permitted on the grounds.
Findings
No deficiencies were cited during the visit. The Executive Director confirmed there is no record of the excluded staff member employed at the facility.
Report Facts
Capacity: 376
Census: 255
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the visit and confirmed no record of excluded staff member employed |
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Census: 255
Capacity: 376
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
The visit was an unannounced Case Management visit to verify that Staff (S1) is not on the property, following a Decision and Order regarding exclusion.
Findings
The Executive Director confirmed that Staff (S1) is excluded and not permitted on the grounds, and there was no record of any employee by that name employed at the facility. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the visit and confirmed no record of excluded staff employed. |
Inspection Report
Complaint Investigation
Census: 247
Capacity: 376
Deficiencies: 0
Date: Apr 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-01-21 regarding concerns about resident safety, cleanliness of resident rooms, and facility odors.
Complaint Details
The complaint involved allegations that staff did not ensure a safe environment for residents, did not adequately clean resident rooms, and did not maintain the facility free from odors. The investigation concluded these allegations were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. No deficiencies were issued during this complaint visit, and the allegations were determined to be unsubstantiated.
Report Facts
Capacity: 376
Census: 247
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the investigation and exit interview |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sarah Aruchelta-Weaver | Health & Wellness Director | Participated in subsequent facility tour during investigation |
Inspection Report
Complaint Investigation
Census: 247
Capacity: 376
Deficiencies: 0
Date: Apr 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-01-21 regarding concerns about resident safety, cleanliness of rooms, and facility odors.
Complaint Details
The complaint allegations included staff not ensuring a safe environment, inadequate cleaning of resident rooms, and the facility not being free from odors. The investigation concluded these allegations were unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations. No deficiencies were issued during this complaint visit, and the allegations were determined to be unsubstantiated.
Report Facts
Capacity: 376
Census: 247
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sarah Aruchelta-Weaver | Health & Wellness Director | Participated in subsequent facility tour during investigation |
Inspection Report
Census: 242
Capacity: 376
Deficiencies: 0
Date: Feb 7, 2025
Visit Reason
The visit was an unannounced Case Management visit to verify that Staff (S1) is not on the property, as S1 is excluded and not permitted to be on the grounds at any time.
Findings
The Executive Director confirmed that Staff (S1) has not been employed at the facility since 04/18/2020 and was disassociated from the facility on 05/04/2021. No citations were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during visit and provided information about excluded staff. |
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 242
Capacity: 376
Deficiencies: 0
Date: Feb 7, 2025
Visit Reason
The visit was an unannounced Case Management visit to verify that Staff (S1) is not on the property, as S1 is excluded and not permitted to be on the grounds at any time.
Findings
The Executive Director confirmed that Staff (S1) has not been employed at the facility since 04/18/2020 and was disassociated from the facility on 05/04/2021. No citations were issued during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director | Met with during visit; provided information about excluded staff member. |
Inspection Report
Deficiencies: 1
Date: Jan 28, 2025
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical services regulations, specifically to ensure accurate controlled medication drug records and proper medication administration.
Findings
The facility failed to ensure the controlled medication drug record was accurate for one sampled resident, resulting in a medication error involving an undocumented extra dose of Percocet. This failure posed a potential risk for unaccounted diversion of controlled medications.
Deficiencies (1)
F 0755: The facility failed to maintain an accurate controlled medication drug record for Resident 1, resulting in an undocumented extra dose of Percocet given. The medication administration record did not reflect this dose, indicating a medication error and potential for diversion.
Report Facts
Tablet count discrepancy: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) 2 | Interviewed regarding medication count discrepancy |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 17, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of abuse involving a Certified Nursing Assistant (CNA) and Resident 1.
Complaint Details
The complaint was substantiated. The facility delayed reporting an allegation of abuse by CNA 1 towards Resident 1 to the state agency, which was reported eight days after the initial complaint.
Findings
The facility failed to report an allegation of abuse to the California Department of Public Health within the required timeframe, resulting in delayed investigation and potential continued abuse of Resident 1. Interviews and record reviews confirmed that the Clinical Manager did not report the concerns to leadership as required.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse of Resident 1 by a Certified Nursing Assistant, resulting in delayed investigation and potential for continued abuse.
Inspection Report
Complaint Investigation
Census: 205
Capacity: 376
Deficiencies: 0
Date: Nov 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-08-19 regarding staff behavior, timely response to resident alerts, adequate care and supervision, and staff training.
Complaint Details
The complaint investigation addressed allegations including staff behavior posing risks to residents, failure to address resident alerts timely, inadequate care and supervision, and improper staff training. The findings concluded the allegations were unsubstantiated or unfounded due to lack of preponderance of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations, resulting in the complaints being unsubstantiated or unfounded. No deficiencies were issued during the visit.
Report Facts
Capacity: 376
Census: 205
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the complaint investigation visit |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 205
Capacity: 376
Deficiencies: 0
Date: Nov 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-08-21 regarding staff not meeting residents' toileting needs and staff not maintaining accurate resident records.
Complaint Details
The complaint was unsubstantiated for the allegation that staff were not meeting residents' toileting needs. The allegation that staff did not maintain accurate records for a resident was found to be unfounded and dismissed.
Findings
The investigation found insufficient evidence to substantiate the allegations regarding residents' toileting needs, and the allegation about inaccurate resident records was found to be unfounded. No deficiencies were issued during the complaint visit.
Report Facts
Capacity: 376
Census: 205
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the complaint investigation visit |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 205
Capacity: 376
Deficiencies: 0
Date: Nov 15, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations including staff behavior posing risks to residents, untimely response to resident alerts, and inadequate care and supervision.
Complaint Details
The complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove or disprove the allegations. Allegations included staff behavior risks, untimely response to alerts, and inadequate care and supervision. Additionally, allegations of improper staff training were investigated and found to be unfounded.
Findings
The investigation found insufficient evidence to substantiate the allegations; the complaints were deemed unsubstantiated with no deficiencies issued during the visit.
Report Facts
Capacity: 376
Census: 205
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melinda Hoffmann | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 205
Capacity: 376
Deficiencies: 0
Date: Nov 15, 2024
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2024-08-21 regarding staff not meeting residents' toileting needs and maintaining accurate resident records.
Complaint Details
The complaint was unsubstantiated for toileting needs and unfounded for inaccurate resident records after review of resident records and interviews.
Findings
The investigation found insufficient evidence to substantiate the allegations regarding toileting needs, and the allegation about inaccurate resident records was found to be unfounded. No deficiencies were issued during this complaint visit.
Report Facts
Complaint Control Number: 24
Complaint Control Number Suffix: 20240821164448
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director/Administrator | Met with Licensing Program Analyst during the complaint investigation visit. |
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced complaint investigation visit. |
Inspection Report
Routine
Deficiencies: 17
Date: Nov 7, 2024
Visit Reason
Routine inspection of Brookdale Riverwalk Skilled Nursing Facility to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to assess residents for self-administration of medications, malfunctioning call light systems, unmet care plan needs, inadequate pressure ulcer care, delayed response to call lights, failure to honor resident preferences, missing advance directives, medication management issues, infection control lapses, and maintenance deficiencies impacting resident safety and quality of life.
Deficiencies (17)
F 0554: Facility failed to assess three sampled residents for self-administration of medications, risking resident safety.
F 0558: Call light system was not functioning for Resident 269, causing delayed assistance and unmet needs.
F 0561: Facility failed to honor Resident 84's request to not be assigned a specific CNA, causing emotional distress.
F 0578: Four sampled residents lacked advance directives in their medical records, risking non-compliance with healthcare wishes.
F 0656: Care plans were not developed for two residents, resulting in unmet care needs including pain management and catheter care.
F 0686: Resident 1 did not receive appropriate pressure ulcer care including use of prescribed Prevalon boots and specialty mattress.
F 0689: Fall precautions were not properly implemented for Resident 48, including improper placement of fall mats.
F 0755: Three medication carts contained unaccounted controlled medication envelopes, risking drug diversion and inaccurate documentation.
F 0757: Physician medication orders for two residents lacked clinical condition or symptoms, risking unnecessary medication use.
F 0760: Resident 87 received expired morphine sulfate medication, risking adverse health outcomes.
F 0790: Resident 18 did not receive timely dental services and oral care monitoring, risking nutritional and health complications.
F 0803: Resident 269's meal tray ticket incorrectly listed tomato juice as a preference despite gout diagnosis, risking negative health outcomes.
F 0812: Facility failed to properly clean, dry, and store dishes, risking food contamination and resident illness.
F 0880: Infection prevention program failures included poor hand hygiene, inadequate linen cart coverage, and lack of enhanced barrier precautions for a resident with a Foley catheter.
F 0881: Facility failed to monitor antibiotic use for three residents, risking inappropriate antibiotic administration.
F 0919: Resident 269's call light system was not working, resulting in delayed care and unmet needs.
F 0921: Three residents' rooms had maintenance issues including ceiling tile discoloration and broken blinds, impacting resident quality of life.
Report Facts
Medication envelopes: 18
Medication envelopes: 2
Medication envelopes: 1
Call light response times: 34
Call light response times: 30
Call light response times: 28
Call light response times: 30
Call light response times: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CM 2 | Clinical Manager | Named in findings related to medication self-administration and resident care plans. |
| DON | Director of Nursing | Named in findings related to call light system and medication management. |
| LVN 4 | Licensed Vocational Nurse | Named in findings related to medication administration and pressure ulcer care. |
| CNA 4 | Certified Nursing Assistant | Named in findings related to call light system and resident care. |
| IPN | Infection Preventionist Nurse | Named in findings related to antibiotic stewardship and infection control. |
| CDM | Certified Dietary Manager | Named in findings related to food service and dishwashing procedures. |
| MD | Maintenance Director | Named in findings related to facility maintenance and repair issues. |
Inspection Report
Complaint Investigation
Census: 238
Capacity: 376
Deficiencies: 0
Date: Jul 8, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2024-06-28 alleging that the facility was in disrepair.
Complaint Details
The complaint alleging the facility was in disrepair was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Findings
The investigation found the allegation of the facility being in disrepair to be unfounded. Observations showed thermostats were within regulation and only a few parking lights needed repair. No deficiencies were cited and the complaint was dismissed.
Report Facts
Parking lights needing repair: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Toomer | Executive Director | Met with Licensing Program Analyst during the complaint investigation. |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 238
Capacity: 376
Deficiencies: 0
Date: Jul 8, 2024
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2024-06-28 alleging that the facility was in disrepair.
Complaint Details
The complaint alleging the facility was in disrepair was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis.
Findings
The investigation found the allegation of facility disrepair to be unfounded. Observations showed thermostats were within regulation and only a few parking lights needed repair. The complaint was dismissed.
Report Facts
Parking lights needing repair: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Toomer | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 28, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to comprehensive care planning and clinical documentation for residents.
Findings
The facility failed to develop and implement comprehensive care plans for a resident's impaired skin integrity and failed to properly document routine clinical care activities such as turning and repositioning. These deficiencies posed potential risks for worsening skin conditions and unmet resident needs.
Deficiencies (2)
F 0656: The facility failed to develop and implement a complete care plan for Resident 1's impaired skin integrity, including the right elbow, right hip, and scrotum, as required by the resident's treatment administration record.
F 0842: The facility failed to maintain proper clinical documentation for Resident 1, with multiple undocumented turning and repositioning times, potentially compromising resident care.
Report Facts
Braden Scale Score: 13
Undocumented turns and repositions: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding missing care plans and documentation issues for Resident 1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 5, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow their weight management policy for a resident.
Complaint Details
The complaint investigation found that the facility did not carry out the weekly weight monitoring order for Resident 1, which was substantiated by interviews and record reviews.
Findings
The facility failed to monitor weekly weights as ordered for one resident, resulting in significant unmonitored weight loss. The facility's policy required weekly and monthly weight monitoring and intervention for residents with significant weight variance, which was not followed.
Deficiencies (1)
F 0692: The facility failed to provide enough food/fluids to maintain a resident's health by not monitoring weekly weights as ordered, leading to potential continued weight loss for Resident 1.
Report Facts
Weight loss: 11.8
Weight loss: 9.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding failure to implement weekly weights order | |
| Registered Dietitian | Interviewed regarding potential weight loss if weights were not monitored |
Inspection Report
Annual Inspection
Census: 210
Capacity: 376
Deficiencies: 0
Date: May 29, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted by Licensing Program Analysts to evaluate compliance with licensing requirements.
Findings
The inspection found that staff and resident files contained the required documentation and staff trainings, and the Emergency Disaster plan was up to date. No deficiencies were cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Toomer | Executive Director | Met with Licensing Program Analysts during the inspection and conducted the facility tour. |
Inspection Report
Annual Inspection
Census: 210
Capacity: 376
Deficiencies: 0
Date: May 29, 2024
Visit Reason
An unannounced annual inspection was conducted by Licensing Program Analysts to evaluate compliance with regulatory standards at the facility.
Findings
The facility was observed to be clean, odor free, and well maintained with adequate seating and lighting. Resident apartments and common areas were in good condition, safety equipment was current and operational, and no deficiencies were observed during the inspection.
Report Facts
Water temperature range: 111
Water temperature range: 117
Fire extinguisher service date: Jan 8, 2024
Last fire drill date: Apr 18, 2024
Food delivery frequency: 2
Perishable food supply: 2
Non-perishable food supply: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analysts during facility tour |
| Melinda Medina | Licensing Evaluator | Conducted facility inspection and evaluation |
Inspection Report
Annual Inspection
Census: 210
Capacity: 376
Deficiencies: 0
Date: May 29, 2024
Visit Reason
The visit was an unannounced annual inspection conducted by Licensing Program Analysts to evaluate compliance with licensing requirements.
Findings
The inspection found that staff and resident files contained the required documentation and training, and the Emergency Disaster plan was up to date. No deficiencies were cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Toomer | Executive Director | Met with Licensing Program Analysts and conducted the facility tour. |
| Lisa Salazar | Licensing Evaluator | Conducted file reviews and signed the report. |
| Melinda Hoffmann | Supervisor | Named as supervisor overseeing the inspection. |
Inspection Report
Annual Inspection
Census: 210
Capacity: 376
Deficiencies: 0
Date: May 29, 2024
Visit Reason
An unannounced annual inspection was conducted by Licensing Program Analysts to evaluate the facility's compliance with licensing requirements.
Findings
The facility was observed to be clean, odor free, and well maintained with adequate seating and lighting. Safety features such as grab bars, nonskid mats, fire extinguishers, and carbon monoxide detectors were in place and operational. No deficiencies were observed during the inspection.
Report Facts
Water temperature range: 111
Water temperature range: 117
Fire extinguisher service date: Jan 8, 2024
Last fire drill date: Apr 18, 2024
Food supply duration: 2
Food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Toomer | Executive Director | Met with Licensing Program Analysts during the inspection and participated in facility tour |
| Melinda Medina | Licensing Program Analyst | Conducted facility tour and inspection |
| L. Salazar | Licensing Program Analyst | Conducted file review for residents and staff |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Routine
Deficiencies: 2
Date: May 24, 2024
Visit Reason
The inspection was conducted to assess compliance with food safety and sanitation standards in the facility's kitchen and food storage areas.
Findings
The facility failed to maintain the dry food storage room and clean water pitcher storage cabinets in a sanitary condition, as lifeless and live roaches were found in these areas, posing a risk for foodborne illnesses.
Deficiencies (2)
F 0812: The facility failed to ensure the dry food storage room was maintained in a sanitary condition when lifeless roaches were found on the floor and drain.
F 0812: The facility failed to ensure the clean water pitcher storage cabinets were cleaned and free from pests, with live roaches and white residues observed on shelves.
Report Facts
Number of lifeless roaches: 5
Number of live roaches: 2
Date of last pest control check: May 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Dining Supervisor | Reported seeing roaches last week and reported to maintenance. | |
| Dietary Dining Supervisor | Observed lifeless roaches and live roach in storage areas; noted lack of cleaning logs. | |
| Administrator | Reported last pest control check and no prior roach reports. | |
| Certified Nurse Assistant | Observed live roach on wall and reported to licensed nurse. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 29, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding medication administration errors at the nursing facility.
Complaint Details
The investigation was complaint-driven, focusing on medication administration errors for Resident 1. The complaint was substantiated with findings of missed and incorrect medication administration.
Findings
The facility failed to ensure medications were administered according to physician orders for one sampled resident. Specifically, Resident 1 did not receive Sodium Chloride IV fluids as ordered, and a medication error occurred with Amiodarone dosing resulting in an overdose.
Deficiencies (1)
F0658: The facility failed to administer Resident 1's Sodium Chloride IV solution as ordered, with documentation blanks indicating doses were not given. The facility also administered an incorrect total dose of Amiodarone, giving 300 mg instead of the ordered 200 mg, posing potential adverse health effects.
Report Facts
Medication dosage: 300
Medication dosage: 200
Medication dosage: 100
IV fluid rate: 75
IV fluid volume: 2000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Clinical Nurse Specialist | Interviewed regarding medication administration and record review for Resident 1 | |
| Director of Nursing | Interviewed and provided statements about medication errors and facility policies | |
| Nurse Practitioner | Consulted regarding medication orders and errors for Resident 1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 19, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a physician of a resident's change in condition and improper documentation of neurological checks.
Complaint Details
The investigation was triggered by a complaint concerning failure to notify the physician about Resident 1's declining oxygen levels and improper neurological check documentation. The deficiencies were substantiated with interviews and record reviews.
Findings
The facility failed to notify the physician when Resident 1's oxygen saturation dropped below normal and oxygen was increased without a physician's order. Additionally, neurological checks were inaccurately documented, resulting in inaccurate clinical records and potential for unidentified neurological decline.
Deficiencies (1)
F 0658: The facility failed to notify the physician of Resident 1's oxygen saturation below 93% and increased oxygen without a physician's order. The neurological checks for Resident 1 were inaccurately documented, with repeated identical vital signs and incorrect timing of evaluations.
Report Facts
Oxygen saturation level: 80
Oxygen saturation threshold: 93
Oxygen flow rate: 4
Vital signs times: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Stated she did not call the doctor when oxygen was below 90% and did not get an order for increasing oxygen. |
| LVN 2 | Licensed Vocational Nurse | Interviewed regarding neurological evaluation and documentation errors. |
| LVN 3 | Licensed Vocational Nurse | Performed vital signs but did not document them; neurological evaluation documentation errors noted. |
| Director of Clinical Services | Interviewed regarding failure to notify physician about oxygen saturation below 93%. |
Inspection Report
Deficiencies: 2
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to evaluate compliance with facility policies and procedures related to resident care, specifically focusing on call light response and pain medication administration.
Findings
The facility failed to ensure timely response to a resident's call light, resulting in delayed positioning of a therapeutic knee pillow. Additionally, the facility failed to administer pain medications as ordered for another resident, causing a delay in pain management.
Deficiencies (2)
F 0558: The facility failed to follow its Resident Call System and Door Alarm Response policy for one resident, resulting in a 38-minute delay in responding to a call light and delayed positioning of a therapeutic knee pillow.
F 0697: The facility failed to administer pain medications as ordered for one resident, resulting in delays of up to 8 hours for Morphine Sulfate and over 2 hours for Dilaudid after pain was reported.
Report Facts
Call light response time: 38
Pain medication delay: 8
Pain medication delay: 2.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Provided information about call light response and resident positioning | |
| Licensed Vocational Nurse (LVN) | Provided statements regarding call light response expectations and pain medication administration | |
| Director of Clinical Services (DCS) | Commented on expected call light response times |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 12, 2024
Visit Reason
The inspection was conducted in response to a complaint regarding inadequate care and grievance handling for Resident 1, including failure to change the resident after urinary incontinence and failure to follow grievance procedures.
Complaint Details
The complaint involved Resident 1 being left wet with urine overnight, failure to respond to call lights, and inadequate grievance handling. The complaint was substantiated based on interviews and record reviews.
Findings
The facility failed to follow its grievance policy and procedure, leaving a grievance form blank and unresolved. The facility also failed to change Resident 1 after urinary incontinence, resulting in potential infection and skin issues. Additionally, the facility failed to maintain a clean environment for Resident 1, with stained linens and pillowcases.
Deficiencies (3)
F 0585: The facility failed to follow its Resident Grievance Procedure policy for one of three sampled residents, leaving a grievance form blank and not addressing grievances within the required timeframe.
F 0684: The facility failed to change one sampled resident after urinary incontinence, potentially causing infection, skin issues, wounds, and low self-esteem.
F 0921: The facility failed to provide a clean environment for one sampled resident, with red to brownish stains on linens and pillowcases, negatively affecting the resident's self-respect.
Report Facts
BIMS score: 15
Date of incident: Nov 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development | Director of Staff Development | Interviewed regarding grievance procedure and Resident 1's care |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Reported Resident 1 was left wet overnight and communicated concerns to Director of Staff Development |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Identified as assigned to Resident 1 during the night of the incident; hesitant to answer questions about care |
| Director of Nursing | Director of Nursing | Provided expectations for shift reporting and resident care |
| Executive Director | Executive Director | Observed stained linens and pillowcases in Resident 1's room |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 6, 2024
Visit Reason
The inspection was conducted due to complaints regarding pain medication administration and controlled substance management at the nursing facility.
Complaint Details
The complaint investigation focused on allegations of improper pain medication administration and controlled substance management. The findings substantiated that medications were administered outside of physician orders and that controlled substances were not properly documented, indicating noncompliance with facility policies.
Findings
The facility failed to ensure pain medications were administered according to physicians' orders for six of nine sampled residents, resulting in ineffective pain management and potential discomfort. Additionally, the facility failed to follow its controlled substances policy, leading to discrepancies in narcotic medication documentation and potential diversion risks.
Deficiencies (3)
F 0658: The facility failed to ensure pain medications were administered according to physicians' orders for six of nine sampled residents, causing ineffective pain management and potential harm.
F 0697: The facility failed to maintain effective pain management for six of nine sampled residents, resulting in potential delays in treatment and resident discomfort.
F 0755: The facility failed to follow its Controlled Substances Policy for six of nine sampled residents, resulting in undocumented administration of controlled medications and potential for diversion.
Report Facts
Residents sampled: 9
Residents affected: 6
Dates of medication errors: 20
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 7, 2023
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to promptly assist a resident with toileting and to administer pain medication timely.
Complaint Details
The investigation was triggered by complaints that Resident 1 was left on a bedpan for about 30 minutes and experienced a delay of approximately two hours in receiving pain medication. The complaints were substantiated based on interviews and record reviews.
Findings
The facility failed to ensure timely assistance with toileting for one resident, resulting in undignified treatment. Additionally, the facility failed to administer pain medication promptly, causing ineffective and delayed pain management for the same resident.
Deficiencies (2)
F 0558: The facility failed to promptly assist Resident 1 with toileting, resulting in the resident being left on a bedpan for about 30 minutes and not treated with dignity.
F 0658: The facility failed to administer pain medication timely to Resident 1, resulting in pain not being treated effectively and timely.
Report Facts
BIMS score: 14
Pain medication administration delay: 120
Bedpan wait time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Interviewed regarding bedpan assistance delays |
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding pain medication delay |
| Interim Director of Nursing | Interim Director of Nursing | Interviewed regarding facility protocols for bedpan and pain medication |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 1, 2023
Visit Reason
The inspection was conducted due to complaints regarding ineffective pain management and medication errors at the facility.
Complaint Details
The investigation was complaint-driven based on reports from residents and family members about pain medication delays and a medication overdose incident. The complaints were substantiated by interviews, medication records, and staff admissions.
Findings
The facility failed to provide effective pain management for two residents, resulting in delayed or inconsistent administration and follow-up of pain medication. Additionally, a medication error occurred where a resident received a discontinued and excessive dose of Morphine, causing confusion and hallucinations.
Deficiencies (2)
F 0697: The facility failed to ensure effective pain management for two residents. Resident 2 experienced delays in receiving pain medication, sometimes waiting over 10 hours, and Resident 4's pain was not consistently followed up after medication administration.
F 0760: The facility failed to prevent a medication error when Resident 5 was given a discontinued Morphine dose of 100 mg instead of the ordered 30 mg, resulting in confusion, hallucinations, and inability to perform usual activities.
Report Facts
Pain medication delay: 10
Pain medication delay: 2.75
Morphine overdose dose: 100
Morphine ordered dose: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 2 | Licensed Vocational Nurse | Mentioned in relation to medication cart confusion causing delays in Resident 2's pain medication. |
| LVN 3 | Licensed Vocational Nurse | Admitted to delays in administering pain medication to Resident 2 and being busy. |
| LVN 4 | Licensed Vocational Nurse | Admitted to administering the wrong dose of Morphine to Resident 5 and apologized for the error. |
| LVN 1 | Licensed Vocational Nurse | Verified findings related to Resident 4's pain medication administration without follow-up. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 21, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide appropriate care and services related to the use of a left knee splint (LKS) for Resident 1, including lack of physician's order, incomplete change of condition documentation, and absence of a care plan.
Complaint Details
The investigation was complaint-driven, focusing on Resident 1's care related to the left knee splint. The complaint was substantiated with findings of failure to obtain physician's order, incomplete change of condition documentation, and lack of care plan development.
Findings
The facility failed to obtain a physician's order before applying the left knee splint on Resident 1, resulting in an unstageable pressure injury and discoloration above the left knee. Additionally, the facility did not complete accurate change of condition documentation or develop a care plan for the use of the LKS, potentially delaying necessary care.
Deficiencies (3)
F 0686: The facility failed to obtain a physician's order for the left knee splint prior to application on Resident 1, resulting in an unstageable pressure injury and discoloration above the left knee.
F 0686: The facility did not complete an accurate change of condition for Resident 1's left knee discoloration and unstageable pressure injury, risking poor wound healing and deterioration.
F 0686: The facility failed to develop a care plan for Resident 1's use of the left knee splint, delaying or lacking necessary care and services.
Report Facts
Residents Affected: 3
Discoloration size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 2 | Licensed Vocational Nurse | Interviewed regarding absence of physician's order and change of condition documentation |
| LVN 4 | Licensed Vocational Nurse | Reviewed Resident 1's care plans and order summary |
| RNA 1 | Restorative Nursing Assistant | Interviewed about knowledge of physician's order for LKS |
| CNA 1 | Certified Nursing Assistant | Interviewed about Resident 1's use of LKS and shift observations |
| CNA 2 | Certified Nursing Assistant | Interviewed about care for Resident 1 and LKS use |
| Administrator | Interviewed regarding facility policies and physician order requirements | |
| Rehabilitation Manager | Interviewed regarding rehab evaluation and treatment for Resident 1 | |
| RN 1 | Registered Nurse | Reviewed comprehensive care plan policy and care plan requirements |
Inspection Report
Complaint Investigation
Census: 236
Capacity: 376
Deficiencies: 0
Date: Oct 11, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to a complaint received on 2023-09-21 alleging staff did not prevent residents from falling, did not meet residents' hygiene needs, and did not adequately supervise residents resulting in wandering.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to prevent falls, inadequate hygiene care, and insufficient supervision leading to residents wandering. The investigation found no evidence to prove the alleged violations occurred.
Findings
The investigation included a facility tour, interviews, and record reviews. Staffing was found adequate, exits were secure, shower schedules and refusals were documented. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were issued.
Report Facts
Complaint control number: 24-AS-20230921081034
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melinda Hoffmann | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 236
Capacity: 376
Deficiencies: 0
Date: Oct 11, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2023-09-21 regarding staff not preventing resident falls, not meeting hygiene needs, and inadequate supervision resulting in residents wandering out of the facility.
Complaint Details
The complaint allegations were unsubstantiated based on interviews and record review. Although the allegations may have occurred or be valid, there was insufficient evidence to prove the violations.
Findings
The investigation included a facility tour, interviews, and record review. Staffing was found adequate, exits were secure, shower schedules and refusals were documented, and the allegations were determined to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were issued.
Report Facts
Capacity: 376
Census: 236
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Melinda Medina | Licensing Program Analyst | Conducted complaint investigation visit |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 16, 2023
Visit Reason
The inspection was conducted due to a complaint regarding insufficient nursing staff and delayed response to call lights for residents.
Complaint Details
The complaint was substantiated based on interviews and record reviews indicating delayed call light responses and insufficient staffing levels on specific dates, including 7/8/23 when CNA hours per patient day were below the minimum required.
Findings
The facility failed to provide sufficient nursing staff to meet residents' needs, resulting in delayed response times to call lights for one sampled resident. Additionally, the facility was unable to provide a policy and procedure on sufficient staffing.
Deficiencies (2)
F 0725: The facility failed to provide enough nursing staff daily to meet residents' needs and have a licensed nurse in charge on each shift. Call lights took 30 minutes to three hours to be answered, causing potential unmet care needs for Resident 1.
The facility was unable to provide a policy and procedure on sufficient staffing.
Report Facts
Actual CNA Direct Care Hours Per Patient Day: 2.33
Actual CNA Direct Care Hours Per Patient Day: 2.39
Resident BIMS Score: 13
Number of residents assigned to CNA: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA 1) | Reported staffing and call light response issues during 2-10 PM shift | |
| Certified Nursing Assistant (CNA 2) | Reported staffing and call light response issues during 2-10 PM shift | |
| Executive Director (EDIII) | Reviewed census and staffing data, confirmed staffing shortfall | |
| Administrator | Acknowledged staffing shortfall on 7/8/23 |
Inspection Report
Complaint Investigation
Census: 233
Capacity: 376
Deficiencies: 1
Date: Jul 27, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations including a questionable death and failure of staff to conduct safety checks on a resident after a fall.
Complaint Details
The complaint investigation was triggered by allegations of questionable death and failure of staff to conduct safety checks after a fall. The questionable death allegation was unsubstantiated. The allegation regarding safety checks was substantiated with a deficiency cited.
Findings
The complaint regarding questionable death was unsubstantiated as the cause of death was due to medical conditions. The complaint that staff did not conduct safety checks after a resident's fall was substantiated, resulting in a cited deficiency for violation of Title 22, Section 87468.2(a)(4).
Deficiencies (1)
Staff did not conduct safety checks following a resident's fall on 1/14/23, which is required procedure.
Report Facts
Capacity: 376
Census: 233
Deficiencies cited: 1
Plan of Correction due date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 233
Capacity: 376
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that staff did not ensure the facility was free from bed bugs.
Complaint Details
The complaint alleged that staff did not ensure the facility was free from bed bugs. The allegation was unsubstantiated based on interviews and record review.
Findings
The investigation found that although there was a report of bed bugs, the facility had the problem professionally treated prior to the complaint being received. The allegation was determined to be unsubstantiated and no deficiencies were issued.
Report Facts
Capacity: 376
Census: 233
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during the investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melinda Hoffmann | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 233
Capacity: 376
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to allegations that a resident had access to a knife and that the facility was not kept free of pests.
Complaint Details
The complaint was unsubstantiated based on interviews, record reviews, and a facility tour. Allegations included resident access to a knife and pest infestation, both found unsubstantiated.
Findings
The investigation found the allegations unsubstantiated. The resident's apartment was treated for pests prior to the complaint, and there was no evidence that the resident had access to a knife. No deficiencies were cited.
Report Facts
Complaint Control Number: 24-AS-20230613152947
Capacity: 376
Census: 233
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jeffrey Toomer | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 233
Capacity: 376
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 07/24/2023 alleging that staff did not ensure the facility was free from bed bugs.
Complaint Details
The complaint alleging staff did not ensure the facility was free from bed bugs was investigated and found to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that although there was a report of bed bugs by a resident, the facility had the problem professionally treated prior to the complaint. The allegation was determined to be unsubstantiated and no deficiencies were issued.
Report Facts
Complaint received date: Jul 24, 2023
Complaint control number: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 233
Capacity: 376
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2023-06-13 regarding allegations that a resident had access to a knife and that the facility was not kept free of pests.
Complaint Details
Complaint investigation was unsubstantiated based on interviews, record reviews, and facility tour. Allegations of resident access to a knife and pest infestation were not supported by evidence.
Findings
The investigation found the allegations to be unsubstantiated. The resident's apartment had been treated for pests prior to the complaint, and there was no evidence that the resident had access to a knife. No deficiencies were cited.
Report Facts
Complaint Control Number: 24
Capacity: 376
Census: 233
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jeffrey Toomer | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 233
Capacity: 376
Deficiencies: 1
Date: Jul 27, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations including a questionable death and failure of staff to conduct safety checks on a resident after a fall.
Complaint Details
The complaint investigation was triggered by allegations of questionable death and failure to conduct safety checks after a fall. The questionable death allegation was unsubstantiated. The failure to conduct safety checks allegation was substantiated with a deficiency cited.
Findings
The complaint regarding questionable death was unsubstantiated as the cause of death was due to medical conditions. The complaint that staff did not conduct safety checks after a resident's fall was substantiated, resulting in a cited deficiency for violation of Title 22, Section 87468.2(a)(4).
Deficiencies (1)
Staff did not conduct safety checks following a resident's fall on 1/14/23, violating Title 22, Division 6, Chapter 8, Article 08, Section 87468.2(a)(4).
Report Facts
Capacity: 376
Census: 233
Deficiency count: 1
Plan of Correction Due Date: Aug 4, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Annual Inspection
Census: 233
Capacity: 376
Deficiencies: 0
Date: Jul 20, 2023
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and assess the facility's conditions and operations.
Findings
The facility was observed to be clean, odor free, and well maintained with adequate accommodations, lighting, and safety features. Medications were properly secured and administered as prescribed. No deficiencies were observed during the inspection.
Report Facts
Food delivery frequency: 2
Fire extinguisher service date: Jan 18, 2023
Last fire drill date: Jul 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Jeffrey Toomer | Executive Director | Facility representative who toured the facility with the Licensing Program Analyst |
| Daniel Devine | Administrator | Facility Administrator named in the report |
Inspection Report
Annual Inspection
Census: 233
Capacity: 376
Deficiencies: 0
Date: Jul 20, 2023
Visit Reason
An unannounced Annual Inspection was conducted as a required 1-year visit to evaluate the facility's compliance with regulations.
Findings
The facility was observed to be clean, odor free, and well maintained with adequate accommodations and safety measures. No deficiencies were observed during the inspection.
Report Facts
Food supply duration: 2
Food supply duration: 7
Fire extinguisher service date: Jan 18, 2023
Last fire drill date: Jul 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced Annual Inspection |
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during inspection |
| Daniel Devine | Administrator | Facility Administrator |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 30, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding inaccurate documentation and collaborative care review following a fall incident involving Resident 1.
Complaint Details
The complaint investigation found that the collaborative care review documentation was inaccurate and incomplete, with the Administrator and Registered Nurse Consultant Specialist failing to ensure accuracy. Resident 1's fall was unwitnessed and occurred in the bathroom, resulting in injury.
Findings
The facility failed to ensure accurate collaborative care review documentation after Resident 1's fall, with the Administrator documenting inaccurate information and the Registered Nurse Consultant Specialist not reviewing or editing the documentation. Resident 1 sustained a fall in the bathroom resulting in a skin tear and an acute fracture.
Deficiencies (1)
F 0842: The facility failed to maintain accurate collaborative care review documentation after Resident 1's fall. The Administrator documented inaccurate information and the Registered Nurse Consultant Specialist did not review or edit the documentation.
Report Facts
Date of fall incident: May 24, 2023
Date of collaborative care review: May 25, 2023
Date of CT scan: May 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Documented inaccurate collaborative care review and acknowledged non-clinical role | |
| Registered Nurse Consultant Specialist (RNCS) | Did not review or edit collaborative care review documentation | |
| Licensed Vocational Nurse (LVN) | Nurse on duty during fall incident and reported details of fall and injury |
Inspection Report
Deficiencies: 2
Date: Jun 26, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with care standards following a review of Resident 1's condition after a fall and pain management.
Findings
The facility failed to accurately assess pain after a change of condition and failed to document the location of pain when administering pain medication for Resident 1. These failures had the potential to result in inappropriate care.
Deficiencies (2)
F 0684: The facility failed to accurately assess pain for Resident 1 after a change of condition following a fall. Pain assessments were not conducted on every shift as required.
F 0684: The facility failed to document the location of pain when administering Hydrocodone to Resident 1 despite documented fractures. Pain location documentation is required when medication is given.
Report Facts
Medication dosage: 5.525
Medication dosage: 5.325
Pain scale rating: 7
Pain scale rating: 5
Inspection Report
Complaint Investigation
Census: 207
Capacity: 376
Deficiencies: 0
Date: Jun 23, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint alleging staff neglect resulting in resident hospitalization.
Complaint Details
The complaint alleged that staff neglect resulted in resident hospitalization. The investigation concluded the complaint was unfounded.
Findings
The investigation found the complaint to be unfounded, meaning the allegation was false, could not have happened, and/or was without a reasonable basis. No deficiencies were issued during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during the complaint investigation. |
| Sarah Weaver | Health and Wellness Director | Met with Licensing Program Analyst during the complaint investigation. |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 207
Capacity: 376
Deficiencies: 0
Date: Jun 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-04-03 alleging that a resident sustained a fall while in care, staff failed to report an incident to the resident's authorized representative, and staff do not answer phone calls.
Complaint Details
The complaint was investigated and found to be unfounded.
Findings
The investigation found that the complaint was unfounded, meaning the allegations were false, could not have happened, or were without a reasonable basis. The resident in question had not been a resident since 2022-04-18.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation. |
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 207
Capacity: 376
Deficiencies: 0
Date: Jun 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to an allegation that staff neglect resulted in resident hospitalization.
Complaint Details
The complaint alleged staff neglect resulting in resident hospitalization. The investigation determined the complaint was unfounded.
Findings
The investigation found the complaint to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis. No deficiencies were issued during this inspection.
Report Facts
Capacity: 376
Census: 207
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during the complaint investigation |
| Sarah Weaver | Health and Wellness Director | Met with Licensing Program Analyst during the complaint investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 207
Capacity: 376
Deficiencies: 0
Date: Jun 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 2023-04-03 regarding a resident fall, failure to report incidents to the resident's authorized representative, and staff not answering phone calls.
Complaint Details
The complaint alleged that a resident sustained a fall while in care, staff failed to report the incident to the resident's authorized representative, and staff did not answer phone calls. The complaint was found to be unfounded.
Findings
The investigation found that the complaint was unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis. The resident in question had not been in the facility since 2022-04-18.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Toomer | Executive Director | Met with Licensing Program Analyst during complaint investigation visit |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation |
| Melinda Hoffmann | Supervisor | Named as supervisor on the report |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 6, 2023
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to ensure the call light was within reach for a resident who recently had a fall with injury.
Complaint Details
The complaint was substantiated based on observation, interviews, and record review showing the call light was not within reach of Resident 1, who was at high risk for falls and had sustained injuries from a fall.
Findings
The facility failed to keep the call light within reach of Resident 1, who had a recent fall resulting in fractures to her left hand. Staff acknowledged the call light was left behind the headboard and not accessible for several hours, despite the resident being at high risk for falls.
Deficiencies (1)
F 0684: The facility failed to ensure the call light was within reach for Resident 1, who had a recent fall with injury. The call light was observed approximately eight feet away and behind the headboard, making it inaccessible for several hours.
Report Facts
Residents sampled: 3
Hours without call light: 5.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Assigned to Resident 1 and acknowledged the call light was not placed within reach |
| LVN 1 | Licensed Vocational Nurse | Assigned to Resident 1 and stated the resident was high risk for falls |
| Director of Nursing | Director of Nursing | Stated expectation that all call lights be within reach of residents |
Inspection Report
Complaint Investigation
Census: 195
Capacity: 376
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that facility staff were not allowing a resident to have visitors.
Complaint Details
The complaint alleged that facility staff were not allowing a resident to have visitors. Upon review, a court order of no contact was found on file, supporting the finding that the complaint was unfounded.
Findings
The investigation found the complaint to be unfounded, meaning the allegation was false or without reasonable basis. No deficiencies were issued during the inspection.
Report Facts
Capacity: 376
Census: 195
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Weaver | Health and Wellness Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 195
Capacity: 376
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that facility staff was not allowing a resident to have visitors.
Complaint Details
The complaint alleged that facility staff was not allowing a resident to have visitors. Upon review, a court order of no contact was found on file, supporting the finding that the complaint was unfounded.
Findings
The investigation found the complaint to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis. No deficiencies were issued during the inspection.
Report Facts
Complaint Control Number: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation |
| Sarah Weaver | Health and Wellness Director | Met with Licensing Program Analyst during investigation |
| Daniel Devine | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Capacity: 376
Deficiencies: 1
Date: Jan 25, 2023
Visit Reason
An unannounced Case Management visit was conducted regarding a self-reported medication error that occurred on 11/26/22 involving an incorrect dosage of Lorazepam administered to resident R1.
Complaint Details
The visit was complaint-related due to a self-reported medication error involving resident R1 receiving an incorrect dosage of Lorazepam. The complaint was substantiated as a deficiency was cited.
Findings
The facility was found to have administered an incorrect medication dosage to a resident. Staff received additional medication training on 11/29/22, and the deficiency was cited but cleared at the time of the visit.
Deficiencies (1)
Incidental Medical and Dental Care: Medication was not given according to physician's directions as evidenced by a medication error reported on 12/02/22.
Report Facts
Facility capacity: 376
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced Case Management visit and cited the deficiency |
| Martha Fernandez de Hoban | Health and Wellness Director | Met with Licensing Program Analyst during the visit and involved in addressing the medication error |
| Melinda Hoffmann | Supervisor | Named as supervisor in the report |
Inspection Report
Complaint Investigation
Capacity: 376
Deficiencies: 1
Date: Jan 25, 2023
Visit Reason
An unannounced Case Management visit was conducted regarding a self-reported medication error received by the Fresno Regional Office on 12/02/22 involving resident R1.
Complaint Details
The visit was complaint-related due to a self-reported medication error involving resident R1. The complaint was substantiated by the cited deficiency.
Findings
The facility reported that on 11/26/22, resident R1 received an incorrect dosage of Lorazepam (.5 mg instead of the ordered .25 mg every 2 hours as needed). The Health & Wellness Director contacted the physician, hospice agency, and responsible party. Staff received additional medication training on 11/29/22. A deficiency was cited related to this medication error.
Deficiencies (1)
Incidental Medical and Dental Care: Medication was not given according to physician's directions as evidenced by a medication error reported on 11/26/22 for resident R1.
Report Facts
Facility capacity: 376
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Fernandez de Hoban | Health and Wellness Director | Met with Licensing Program Analyst during visit and involved in medication error incident |
| Melinda Medina | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Melinda Hoffmann | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Census: 285
Capacity: 376
Deficiencies: 0
Date: Dec 14, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-09-19 regarding allegations of staff inappropriately discarding resident's medication, not responding timely to resident's call button, not administering resident's medication, and not providing an air mattress in a timely manner.
Complaint Details
The complaint was unsubstantiated. Allegations included inappropriate medication disposal, delayed response to call button, failure to administer medication, and failure to provide an air mattress timely. The agency found no evidence to support these claims and dismissed the complaint. The air mattress allegation was referred to the California Department of Public Health as it involved a Skilled Nursing Facility outside Community Care Licensing jurisdiction.
Findings
The investigation found no evidence to substantiate the allegations. The complaint about discarding medication was unsubstantiated as records showed no medications destroyed. The allegation of delayed response to call button could not be confirmed. The medication administration allegation was unsubstantiated due to lack of preponderance of evidence. The allegation regarding the air mattress was forwarded to the appropriate agency and found unfounded.
Report Facts
Capacity: 376
Census: 285
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and follow-up visit |
| Reg Webster | Administrator | Facility administrator met during investigation |
| Serigy Pidgirny | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 285
Capacity: 376
Deficiencies: 0
Date: Dec 14, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-09-19 regarding allegations of staff inappropriately discarding resident's medication, not responding to a resident's call button in a timely manner, and not administering resident's medication.
Complaint Details
The complaint was unsubstantiated. Allegations included inappropriate discarding of medication, untimely response to call button, and failure to administer medication. The agency found no evidence to support these allegations and dismissed the complaint as unfounded or unsubstantiated.
Findings
The investigation found the allegations of discarded medication and delayed call button response to be unsubstantiated or unfounded. The allegation of not administering medication was unsubstantiated due to insufficient evidence. The complaint regarding failure to provide an air mattress was forwarded to the appropriate agency and dismissed by this agency.
Report Facts
Capacity: 376
Census: 285
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation visit |
| Reg Webster | Administrator | Facility administrator met during the investigation |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Dec 8, 2022
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including call light accessibility for residents with hemiplegia, failure to provide a homelike environment due to missing furniture drawers, lack of vision screening for a diabetic resident, inadequate assistance with activities of daily living such as grooming and hygiene, medication errors, unsecured medication carts, improper food storage and labeling, and unsanitary conditions of an ice machine.
Deficiencies (8)
F 0558: The facility failed to ensure call lights were accessible for two residents with hemiplegia, resulting in inability to call staff for assistance.
F 0584: The facility failed to provide a homelike environment for one resident due to missing drawers in the chifforobe, limiting storage for personal belongings.
F 0676: The facility failed to provide vision screening for one diabetic resident, risking worsening vision.
F 0677: The facility failed to provide grooming, personal, and oral hygiene assistance for two residents, causing physical and psychosocial distress.
F 0759: The facility had a medication error rate of 6.67% for one resident due to incorrect dosing of eye drops.
F 0761: The facility failed to secure the medication cart and medications, allowing potential unauthorized access.
F 0812: The facility failed to follow food storage policies including discarding expired condiments, covering food, labeling opened products, and maintaining refrigerator temperature logs.
F 0908: The facility failed to maintain one ice machine in a safe and sanitary condition, with visible mold and residue posing a risk of foodborne illness.
Report Facts
Residents sampled: 31
Medication error rate: 6.67
Medication error opportunities: 30
Medication errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in call light accessibility finding |
| Maintenance Supervisor | Named in homelike environment and ice machine sanitation findings | |
| Clinical Specialist | Named in call light and oral care findings | |
| Social Services Director | Named in vision screening deficiency | |
| Director of Clinical Services | Named in activities of daily living and oral care findings | |
| LVN 1 | Licensed Vocational Nurse | Named in medication error finding |
| LVN 2 | Licensed Vocational Nurse | Named in medication cart security finding |
| Cook | Named in food storage and labeling deficiencies | |
| Regional Director | Named in ice machine sanitation finding |
Inspection Report
Complaint Investigation
Capacity: 376
Deficiencies: 3
Date: Oct 24, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/17/2022 regarding bed bugs in a resident's room, poor quality of food provided to residents, and improper food storage.
Complaint Details
The complaint investigation was substantiated based on interviews, observations, and record reviews including pest control receipts and maintenance logs confirming bed bugs, and observations of food quality and storage issues. The complaint control number is 24-AS-20220617090359.
Findings
The investigation substantiated the allegations that the facility had bed bugs in multiple rooms and that food was uncovered, undated, stored improperly, and served in rusted/unclean trays, posing potential health, safety, and personal rights risks to residents.
Deficiencies (3)
Facility had bed bugs in rooms 239, 240, 242, and 249, violating residents' rights to safe, healthful, and comfortable accommodations.
Food was uncovered, undated, stored improperly, and served in rusted/unclean trays, violating general food service requirements for good quality food.
Readily perishable foods or beverages were stored uncovered and undated in the refrigerator and on countertops, posing risk of food infections or intoxications.
Report Facts
Facility capacity: 376
Deficiencies cited: 3
Plan of Correction due date: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Reginald Webster | Director | Facility Director met with Licensing Program Analyst during inspection and exit interview |
| See Moua | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 376
Deficiencies: 3
Date: Oct 24, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/17/2022 regarding bed bugs in resident rooms, poor quality of food provided to residents, and improper food storage.
Complaint Details
The complaint investigation was substantiated based on interviews, observations, and record reviews including pest control receipts and maintenance logs confirming bed bugs, and observations of food quality and storage issues.
Findings
The investigation substantiated the allegations that the facility had bed bugs in multiple resident rooms and that food was uncovered, undated, stored in rusted or unclean trays, and left on countertops, posing potential health and safety risks to residents.
Deficiencies (3)
Facility had bed bugs in rooms 239, 240, 242, and 249, posing a potential health, safety, and personal rights risk to residents.
Food prepared for residents was uncovered, undated, stored in rusted/unclean trays, and left on countertops, posing a potential health, safety, and personal rights risk.
Food stored in the refrigerator was uncovered and undated, violating food service requirements.
Report Facts
Facility capacity: 376
Deficiency count: 3
Plan of Correction due date: Nov 4, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Garza | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Reginald Webster | Director | Facility Director met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 240
Capacity: 376
Deficiencies: 0
Date: Sep 23, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not providing residents with activities while in care.
Complaint Details
The complaint alleged that staff were not providing residents with activities. After investigation including interviews with residents and staff and facility tour, the complaint was found to be unfounded.
Findings
The Licensing Program Analyst conducted interviews and observations, finding that residents receive monthly activity calendars and daily reminders, and participate in various activities. The complaint was determined to be unfounded and dismissed.
Report Facts
Capacity: 376
Census: 240
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Reg Webster | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 240
Capacity: 376
Deficiencies: 0
Date: Sep 23, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were not providing residents with activities while in care.
Complaint Details
The complaint alleged that staff were not providing residents with activities while in care. The complaint was investigated and found to be unfounded, meaning the allegation could not have happened or was without reasonable basis.
Findings
The investigation found that residents receive a monthly activities calendar and daily activity reminders are posted in multiple locations. Residents reported participation in various activities, and staff confirmed monitoring attendance. The complaint was determined to be unfounded and dismissed.
Report Facts
Capacity: 376
Census: 240
Number of residents interviewed: 6
Number of staff interviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation visit |
| Reg Webster | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 194
Capacity: 376
Deficiencies: 1
Date: Jul 21, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2022-04-08 regarding medical attention delays, dehydration, neglect, and illegal eviction at the facility.
Complaint Details
The complaint investigation addressed multiple allegations: 1) Medical attention was not sought timely for a resident; 2) Resident became severely dehydrated; 3) Neglect/lack of supervision resulted in pressure injuries; 4) Illegal eviction. The medical attention allegation was substantiated, dehydration allegation was unsubstantiated, and neglect and eviction allegations were unfounded.
Findings
The investigation substantiated that medical attention was not sought in a timely manner for a resident experiencing an emergency change in condition, citing a violation of CCR 87465(g). The allegation of severe dehydration was unsubstantiated due to insufficient evidence. The allegations of neglect resulting in pressure injuries and illegal eviction were found to be unfounded and dismissed.
Deficiencies (1)
The licensee did not immediately telephone 9-1-1 when a resident had an emergency change in condition posing an imminent threat to health and safety.
Report Facts
Capacity: 376
Census: 194
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawna Doucette | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Reg Webster | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Sergiy Pidgirny | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 194
Capacity: 376
Deficiencies: 1
Date: Jul 21, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations including failure to seek timely medical attention, severe dehydration, neglect resulting in pressure injuries, and illegal eviction.
Complaint Details
The complaint investigation was substantiated for failure to seek timely medical attention. The allegation of severe dehydration was unsubstantiated. The allegations of neglect resulting in pressure injuries and illegal eviction were unfounded.
Findings
The investigation substantiated the allegation that medical attention was not sought in a timely manner for a resident, citing failure to call 911 during an emergency. The allegation of severe dehydration was unsubstantiated due to lack of sufficient evidence. The allegations of neglect causing pressure injuries and illegal eviction were found to be unfounded.
Deficiencies (1)
The licensee did not immediately telephone 9-1-1 when a resident had an emergency change in condition posing an imminent threat to health and safety.
Report Facts
Capacity: 376
Census: 194
Deficiencies cited: 1
Plan of Correction Due Date: Jul 22, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawna Doucette | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Reg Webster | Administrator | Facility administrator met with evaluator during investigation |
| Sergiy Pidgirny | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Routine
Census: 220
Capacity: 376
Deficiencies: 0
Date: Jun 14, 2022
Visit Reason
The visit was an unannounced required infection control inspection conducted as part of the facility's 1-year routine compliance check.
Findings
The inspection found the facility in compliance with infection control practices, including proper signage, PPE supply, and staff adherence to face covering protocols. No deficiencies were observed during the visit.
Report Facts
PPE supply duration: 30
Fire extinguisher service date: Jan 26, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the infection control inspection |
| Reg Webster | Administrator | Facility administrator present during inspection and interview |
Inspection Report
Routine
Census: 220
Capacity: 376
Deficiencies: 0
Date: Jun 14, 2022
Visit Reason
The visit was an unannounced required Infection Control Inspection conducted to assess compliance with infection control practices.
Findings
The facility was found to be in compliance with required infection control practices. No deficiencies were observed during the inspection.
Report Facts
PPE supply duration: 30
Fire extinguisher service date: Jan 26, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the infection control inspection |
| Reg Webster | Administrator | Facility administrator involved in the inspection and interview |
Inspection Report
Follow-Up
Census: 210
Capacity: 376
Deficiencies: 0
Date: Jun 3, 2022
Visit Reason
The visit was a Case Management follow-up to an incident report that occurred on 2022-05-23.
Findings
The Licensing Program Analyst conducted interviews and obtained relevant files related to the incident. An exit interview was conducted with the Administrator, and a copy of the report was provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reg Webster | Administrator | Responded to assist with the case management and participated in the exit interview. |
| Karen Lomax | Staff met by Licensing Program Analyst to discuss the purpose of the visit. | |
| Sergiy Pidgirny | Supervisor | Named as supervisor overseeing the licensing evaluation. |
| Shawna Doucette | Licensing Evaluator | Conducted the licensing evaluation and signed the report. |
Inspection Report
Follow-Up
Census: 210
Capacity: 376
Deficiencies: 0
Date: Jun 3, 2022
Visit Reason
The visit was a Case Management follow-up to an incident report that occurred on 2022-05-23.
Findings
The Licensing Program Analyst conducted interviews and obtained relevant files related to the incident. An exit interview was conducted with the facility administrator and a copy of the report was provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reg Webster | Administrator | Responded to assist with the case management and participated in the exit interview. |
| Karen Lomax | Staff member met by Licensing Program Analyst to discuss the purpose of the visit. | |
| Sergiy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Shawna Doucette | Licensing Program Analyst | Conducted the case management visit and signed the report. |
Inspection Report
Complaint Investigation
Census: 175
Capacity: 376
Deficiencies: 0
Date: May 16, 2022
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2022-01-19 alleging the facility was unsanitary.
Complaint Details
The complaint alleging the facility was unsanitary was investigated and found to be unsubstantiated.
Findings
The investigation found the area in wing of building B to be clean and in good repair with no detectable stains or odors from pets. The allegation was determined to be unsubstantiated.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly J. McClurg | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Reg Webster | Executive Director IV | Met with Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 175
Capacity: 376
Deficiencies: 0
Date: May 16, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2022-01-19 alleging that the facility was unsanitary.
Complaint Details
The complaint alleging the facility was unsanitary was investigated and determined to be unsubstantiated.
Findings
The investigation found the area in wing of building B to be clean and in good repair with no detectable stains or odors from pets. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 376
Census: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly J. McClurg | Licensing Program Analyst | Conducted the complaint investigation visit |
| Reg Webster | Executive Director IV | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Capacity: 376
Deficiencies: 0
Date: May 12, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including lack of care and supervision resulting in resident death, failure to provide access to a call button, and inadequate care.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included lack of care and supervision resulting in resident death, failure to provide access to a call button, resident left soiled, and inadequate care and supervision. After review of records and interviews, there was insufficient evidence to prove violations occurred.
Findings
The investigation found that the resident had a terminal medical condition resulting in death, had access to a call button, was not left soiled, and the facility was providing adequate care and supervision. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 376
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawna Doucette | Licensing Program Analyst | Conducted the complaint investigation |
| Reg Webster | Administrator | Facility administrator involved in the investigation |
| Sergiy Pidgirny | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 376
Deficiencies: 0
Date: May 12, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-01-26 regarding lack of care and supervision, access to call button, and resident hygiene.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included lack of care and supervision resulting in resident death, staff not providing access to a call button, resident left soiled, and inadequate care and supervision. The investigation found no evidence to substantiate these claims.
Findings
After reviewing records, conducting interviews, and examining logs, it was found that the resident had a terminal medical condition resulting in death, had access to a call button, and was not left soiled. The facility was providing adequate care and supervision. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 376
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reg Webster | Administrator | Met with during complaint investigation and exit interview |
| Shawna Doucette | Licensing Evaluator | Conducted complaint investigation |
| Sergiy Pidgirny | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 205
Capacity: 376
Deficiencies: 0
Date: Feb 24, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not properly maintain resident records and were not following the admission agreement.
Complaint Details
The complaint was unsubstantiated and unfounded after investigation.
Findings
The investigation found no evidence to support the allegations; staff maintained resident records properly and followed the admission agreement. The complaint was determined to be unfounded.
Report Facts
Capacity: 376
Census: 205
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reg Webster | Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Melinda Hoffmann | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 205
Capacity: 376
Deficiencies: 0
Date: Feb 24, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not properly maintain resident records and were not following the admission agreement.
Complaint Details
The complaint was investigated and found to be unfounded based on review of resident files and interviews. No deficiencies were cited.
Findings
The investigation found no evidence to support the allegations; staff maintained resident records properly and followed the admission agreement. The complaint was determined to be unfounded and no deficiencies were cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melinda Medina | Licensing Program Analyst | Conducted the complaint investigation visit |
| Reg Webster | Administrator | Met with Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 203
Capacity: 376
Deficiencies: 1
Date: Dec 20, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a questionable death and staff mismanagement of residents' medication.
Complaint Details
The complaint investigation was unannounced and conducted by Licensing Program Analyst Darius Williams. The allegation of questionable death was unsubstantiated. The allegation of medication mismanagement was substantiated. Civil penalties are pending review.
Findings
The allegation regarding a questionable death was found to be unsubstantiated due to lack of preponderance of evidence. The allegation of staff mismanaging residents' medication was substantiated, citing failure to consult a physician before releasing medication to a resident, posing an immediate health and safety risk. A plan of correction was implemented and cleared.
Deficiencies (1)
Failure to ensure staff contacted a physician prior to releasing medication to Resident 1, posing an immediate health and safety risk.
Report Facts
Capacity: 376
Census: 203
Staff trained: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Reg Webster | Administrator | Facility administrator met with Licensing Program Analyst during investigation |
| Serigy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 203
Capacity: 376
Deficiencies: 0
Date: Dec 20, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations including resident neglect, improper medication administration, unmet resident needs, and insufficient staffing.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included neglect, medication errors, unmet needs, and staffing issues. Evidence did not prove violations occurred.
Findings
The investigation included interviews, record reviews, and observations. The allegations were found to be unsubstantiated due to lack of preponderance of evidence. Observations showed the resident had a call pendant, was assisted with feeding, and medication administration records confirmed medications were provided.
Report Facts
Capacity: 376
Census: 203
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Reg Webster | Administrator | Facility administrator met during the investigation |
| Serigy Pidgirny | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 203
Capacity: 376
Deficiencies: 1
Date: Dec 20, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations including a questionable death and staff mismanagement of residents' medication.
Complaint Details
The complaint investigation was triggered by allegations of a questionable death and staff mismanagement of residents' medication. The questionable death allegation was unsubstantiated. The medication mismanagement allegation was substantiated.
Findings
The allegation of a questionable death was found to be unsubstantiated due to lack of preponderance of evidence. The allegation regarding staff mismanagement of residents' medication was substantiated, citing failure to consult the resident's physician before releasing medication, posing an immediate health and safety risk.
Deficiencies (1)
Failure to ensure staff contacted a physician prior to releasing medication to Resident 1, posing an immediate health and safety risk.
Report Facts
Capacity: 376
Census: 203
Deficiency count: 1
Staff training count: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Reg Webster | Administrator | Facility administrator met with evaluator during the investigation and was involved in discussions regarding findings |
| Serigy Pidgirny | Supervisor | Supervisor named in the report overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 203
Capacity: 376
Deficiencies: 0
Date: Dec 20, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 09/22/2021 regarding neglect, improper medication administration, unmet resident needs, and insufficient staffing at the facility.
Complaint Details
The complaint was unsubstantiated after investigation. Allegations included neglect, medication errors, unmet resident needs, and insufficient staffing, but evidence did not support these claims.
Findings
The investigation included interviews, record reviews, and observations, and found no preponderance of evidence to substantiate the allegations. Resident and witness statements, staff observations, and facility records indicated appropriate care and medication administration.
Report Facts
Capacity: 376
Census: 203
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Reg Webster | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Capacity: 376
Deficiencies: 0
Date: Dec 7, 2021
Visit Reason
An unannounced visit was conducted in response to a death report received from the facility on 12/6/2021.
Findings
The facility was observed to be clean, odor-free, and in good repair with staff wearing masks. Residents were engaged in activities and no deficiencies were observed at this time.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reg Webster | Administrator | Met with Licensing Program Analyst during the visit and discussed the purpose of the visit. |
| Darius Williams | Licensing Program Analyst | Conducted the unannounced visit and evaluation. |
| Serigy Pidgirny | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Capacity: 376
Deficiencies: 0
Date: Dec 7, 2021
Visit Reason
The visit was an unannounced case management health check conducted in response to a death report received from the facility on 12/6/2021.
Findings
The facility was observed to be clean, odor-free, and in good repair with staff wearing masks. Residents were engaged in activities and meals. Chemicals and medications were securely stored. No deficiencies were observed during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the unannounced visit and authored the report. |
| Reg Webster | Administrator | Met with Licensing Program Analyst during the visit. |
| Serigy Pidgirny | Licensing Program Manager | Named in the report header. |
Inspection Report
Census: 160
Capacity: 376
Deficiencies: 0
Date: Sep 7, 2021
Visit Reason
An unannounced Health and Safety check visit was conducted to assess the facility's compliance with health and safety standards.
Findings
The Licensing Program Analyst observed staff wearing masks and adequate PPE supplies. Residents were observed in dining and resting areas with no obstructions, insects, or odors noted. No deficiencies were observed during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the unannounced Health and Safety check visit. |
| Silvia Martinez | Health and Wellness Director | Met with Licensing Program Analyst during the visit. |
Inspection Report
Census: 160
Capacity: 376
Deficiencies: 0
Date: Sep 7, 2021
Visit Reason
An unannounced Health and Safety check visit was conducted as part of Case Management - Health Checks.
Findings
The facility was observed to be free of obstructions, insects, and odors. Staff were wearing masks and appropriate PPE was available. Residents were observed in dining and resting areas. No deficiencies were observed at this time.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the unannounced Health and Safety check visit. |
| Silvia Martinez | Health and Wellness Director | Met with Licensing Program Analyst during the visit. |
Inspection Report
Annual Inspection
Census: 180
Capacity: 376
Deficiencies: 0
Date: Jun 23, 2021
Visit Reason
Licensing Program Analyst Darius Williams conducted an unannounced Annual Visit to evaluate the facility's compliance with licensing requirements.
Findings
No deficiencies were observed during the inspection. The facility demonstrated compliance with COVID-19 mitigation measures, including visitor screening, staff mask usage, physical distancing, and adequate supplies of food and personal protective equipment.
Report Facts
Capacity: 376
Census: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the unannounced annual visit and inspection |
| Reg Webster | Executive Director | Met with Licensing Program Analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 376
Deficiencies: 0
Date: Jun 23, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident was being financially abused while in care.
Complaint Details
The complaint alleged financial abuse of a resident. The investigation determined the allegation was false, could not have happened, and/or was without reasonable basis, resulting in dismissal of the complaint.
Findings
The investigation found that the complaint was unfounded. Interviews and verification with the resident, bank representatives, and investigators showed no suspicious activity and that the resident had authorized the transactions.
Report Facts
Capacity: 376
Census: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Reg Webster | Executive Director | Met with Licensing Program Analyst during the investigation |
| Serigy Pidgirny | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 180
Capacity: 376
Deficiencies: 0
Date: Jun 23, 2021
Visit Reason
The inspection was an unannounced annual visit conducted to evaluate the facility's compliance with regulatory requirements.
Findings
No deficiencies were observed during the inspection. The facility demonstrated compliance with COVID-19 mitigation measures, including visitor screening, staff mask usage, and availability of personal protective equipment.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the unannounced annual visit and observed compliance with regulations. |
| Reg Webster | Executive Director | Met with Licensing Program Analyst during the inspection and participated in the facility tour. |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 376
Deficiencies: 0
Date: Jun 23, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident was being financially abused while in care.
Complaint Details
The complaint alleged financial abuse of a resident. After interviews with the resident, bank representatives, and investigation, the complaint was determined to be unfounded and dismissed.
Findings
The investigation found that the complaint was unfounded; the alleged suspect was a family member, not a staff member, and no suspicious activity was found on the resident's bank account during the relevant period.
Report Facts
Capacity: 376
Census: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation visit |
| Reg Webster | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 192
Capacity: 376
Deficiencies: 1
Date: Mar 3, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not meeting supervision needs of residents and other related complaints.
Complaint Details
The complaint investigation was substantiated for the allegation that staff were not meeting supervision needs of residents due to delayed response times exceeding ten minutes. Other allegations were unsubstantiated. The investigation was conducted by Licensing Program Analyst Darius Williams with interviews of staff and residents and document review.
Findings
The allegation that staff were not meeting supervision needs of residents was substantiated based on interviews and document review showing delayed response times to residents' pendant system. Other allegations regarding medication assistance, meal provision, staff qualifications, and resident retention were unsubstantiated.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to provide services necessary to meet resident needs, evidenced by staff not responding to residents in a timely manner.
Report Facts
Census: 192
Total Capacity: 376
Plan of Correction Due Date: Mar 12, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Reg Webster | Administrator | Facility administrator met with Licensing Program Analyst and was involved in the exit interview and plan of correction discussions |
Inspection Report
Census: 193
Capacity: 376
Deficiencies: 0
Date: Dec 15, 2020
Visit Reason
The visit was a Case Management - Incident conducted as a health and safety check due to pre-cautionary Covid-19 measures.
Findings
No deficiencies were noted during the inspection. The Licensing Program Analyst observed two storage rooms stocked with appropriate Personal Protective Equipment.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darius Williams | Licensing Program Analyst | Conducted the Case Management visit and observed PPE storage. |
| Reg Webster | Administrator | Met with Licensing Program Analyst during the Case Management visit. |
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