Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
95% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
50% occupied
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Capacity: 151
Deficiencies: 0
Date: Dec 4, 2025
Visit Reason
This was a required 1-Year Annual unannounced inspection conducted to evaluate compliance with licensing requirements.
Findings
The Licensing Program Analysts toured the facility and reviewed resident and staff records. No deficiencies were observed or cited during this visit.
Report Facts
Resident records reviewed: 5
Staff records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the inspection |
| David Doidge | Licensing Program Analyst | Conducted the inspection |
| Iryn Macamay | Assistant Executive Director (AED) | Met with Licensing Program Analysts during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 15, 2025
Visit Reason
The inspection was conducted following a complaint investigation regarding a resident fall incident where a dependent resident slipped out of bed during incontinence care and sustained injuries.
Complaint Details
The investigation was complaint-driven, triggered by a fall incident involving Resident 1 on 11/4/24. The complaint was substantiated as the resident sustained injuries requiring emergency care and hospital treatment.
Findings
The facility failed to provide adequate safety measures and supervision to prevent Resident 1 from slipping out of bed and falling, resulting in a laceration requiring stitches and a fractured shoulder. The investigation included record reviews, interviews with staff and the resident, and hospital documentation confirming injuries and treatment.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent Resident 1 from slipping out of bed and falling during incontinence care, resulting in injury.
Report Facts
Stitches required: 15
Antibiotic dosage: 500
Pain intensity: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 (LVN 1) | Assisted in helping Resident 1 after the fall and documented the incident in Nursing Progress Notes. | |
| Certified Nursing Assistant 1 (CNA 1) | Was present during the fall incident and assisted Resident 1 during incontinence care when the fall occurred. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 151
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation of wrongful eviction of a resident.
Complaint Details
The complaint alleged wrongful eviction of Resident R1. The investigation included review of documentation and interviews with witnesses and facility staff. The allegation was found to be unsubstantiated.
Findings
The investigation found that the resident required a higher level of care than the facility could provide. Although the allegation may have occurred, there was not a preponderance of evidence to substantiate the claim; therefore, the allegation was unsubstantiated.
Report Facts
Capacity: 151
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| David Doidge | Licensing Program Analyst | Conducted the complaint investigation |
| Iryn Macamay | Assistant Executive Director | Met with investigators during the complaint investigation |
| Graciela Canseco | Assisted Living Director | Interviewed during the complaint investigation |
| Ricardo Romero | Administrator | Facility administrator named in the report |
Inspection Report
Annual Inspection
Census: 76
Capacity: 151
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
The inspection was a required 1-Year Annual inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The Licensing Program Analysts toured the facility and reviewed resident and staff records, finding no deficiencies. The facility was found to be in compliance with safety, environmental, and record-keeping standards.
Report Facts
Resident records reviewed: 5
Staff records reviewed: 5
Fire extinguisher last serviced: Dec 22, 2023
Emergency disaster drill last conducted: Oct 11, 2024
Hot water temperature: 118.6
Hallway temperature: 78
Food supply: 7
Food supply: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Iryn Macamay | Assistant Executive Director | Met with Licensing Program Analysts during inspection |
| David Doidge | Licensing Program Analyst | Conducted the inspection |
| J. Sampair | Licensing Program Analyst | Conducted the inspection |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 151
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
The inspection visit was conducted to investigate a complaint alleging wrongful eviction of a resident at the facility.
Complaint Details
The complaint alleged wrongful eviction of Resident R1. The allegation was investigated through document review and interviews with witnesses and facility staff. The allegation was determined to be unsubstantiated due to insufficient evidence.
Findings
The investigation found that the resident required a higher level of care than the facility could provide. Although the allegation may have occurred, there was not a preponderance of evidence to substantiate the wrongful eviction claim; therefore, the allegation was unsubstantiated.
Report Facts
Capacity: 151
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| David Doidge | Licensing Program Analyst | Conducted the complaint investigation |
| Iryn Macamay | Assistant Executive Director | Interviewed during the investigation |
| Graciela Canseco | Assisted Living Director | Interviewed during the investigation |
Inspection Report
Capacity: 151
Deficiencies: 0
Date: Aug 1, 2024
Visit Reason
The visit was an unannounced case management inspection concerning a 7/25/2024 incident involving a missing debit card reported by Resident R1.
Findings
During the visit, the Executive Director and Resident R1 were interviewed. An internal investigation was initiated, and local police departments were involved. No citations were issued during this visit.
Report Facts
Incident date: Jul 25, 2024
Staff termination date: Jul 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Executive Director | Interviewed regarding the incident and internal investigation |
| James Sampair | Licensing Program Analyst | Conducted the inspection visit |
| David Doidge | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Census: 172
Capacity: 151
Deficiencies: 0
Date: Aug 1, 2024
Visit Reason
The visit was an unannounced case management inspection concerning a reported incident on 2024-07-25 involving a resident's missing debit card.
Findings
During the visit, the Executive Director and resident were interviewed about the incident. An internal investigation and police investigations were ongoing, with a former staff member identified as the main suspect. No citations were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Executive Director | Interviewed during the visit regarding the incident. |
| James Sampair | Licensing Program Analyst | Conducted the inspection visit. |
| David Doidge | Licensing Program Analyst | Conducted the inspection visit. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jun 20, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely hygiene care and infection control practices.
Complaint Details
The complaint investigation focused on Resident 43's delayed hygiene care and the facility's infection control practices related to residents with Clostridioides difficile. The complaint was substantiated with findings of delayed care and improper infection prevention measures.
Findings
The facility failed to provide timely hygiene care to Resident 43, resulting in a 45-minute wait while soiled, and failed to ensure proper infection control practices for residents with Clostridioides difficile, including inadequate hand hygiene and use of ineffective germicidal wipes. Additional deficiencies included expired medical supplies, illegible medication expiration dates, poor kitchen sanitation practices, and incomplete freezer temperature logs.
Deficiencies (5)
F 0676: The facility failed to provide hygiene care in a reasonable time for Resident 43, who waited 45 minutes while soiled, risking skin breakdown and emotional distress.
F 0755: The facility failed to ensure expired supplies in the medication storage room were removed, including Luer Lock Caps, catheter devices, IV catheter, and feeding bags.
F 0761: The facility failed to ensure a stock medication bottle of Senna had a legible expiration date and was removed from use.
F 0812: The facility failed to follow kitchen practices to prevent cross-contamination, with poor condition chopping boards and missing freezer temperature log entries for two days.
F 0880: The facility failed to ensure staff followed infection control procedures for residents with C. difficile, including inadequate handwashing, use of ineffective germicidal wipes, and insufficient staff training.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 117
Wait time: 45
BIMS score: 14
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 3 | CNA | Named in delayed hygiene care and infection control findings |
| Registered Nurse 1 | RN | Interviewed regarding call light response expectations |
| Director of Staff Development | DSD | Interviewed regarding staff expectations and orientation |
| Director of Nursing | DON | Interviewed regarding nursing staff responsibilities and infection control |
| Licensed Vocational Nurse 1 | LVN | Interviewed regarding expired supplies and medication handling |
| Certified Nursing Assistant 1 | CNA | Named in infection control training and hand hygiene deficiencies |
| Case Manager | CM | Named in infection control training and hand hygiene deficiencies |
| Infection Preventionist | IP | Interviewed regarding infection control expectations and staff training |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 17, 2024
Visit Reason
The inspection was conducted following a complaint regarding a resident rolling out of bed and falling during a bed linen change.
Complaint Details
The complaint was substantiated. Resident 1 rolled off the bed during a bed linen change, resulting in a fall with a brief loss of consciousness and a headache lasting about two weeks. The resident was transported to the emergency room for evaluation. The facility's fall risk policy was reviewed.
Findings
The facility failed to provide adequate supervision and safety measures to prevent a dependent resident from rolling off the bed, resulting in a fall that caused a brief loss of consciousness and a prolonged headache requiring emergency department evaluation.
Deficiencies (1)
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent a resident from rolling out of bed and falling during a bed linen change.
Report Facts
Fall height: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Named in progress notes and telephone interview regarding the fall incident |
| CNA 1 | Certified Nursing Assistant | Named in interviews and observations related to the fall incident |
Inspection Report
Annual Inspection
Capacity: 151
Deficiencies: 0
Date: Feb 23, 2024
Visit Reason
The inspection was conducted as a continuation of the annual inspection that began on 2024-02-13, to fulfill the required annual evaluation of the facility.
Findings
The annual inspection was completed with no citations issued. The Licensing Program Analyst reviewed records of staff and residents and interviewed staff and residents without identifying any deficiencies.
Report Facts
Staff records reviewed: 9
Resident records reviewed: 8
Staff interviewed: 5
Residents interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Administrator | Facility Administrator present during inspection and exit interview |
| James Sampair | Licensing Program Analyst | Conducted the inspection and evaluation |
| Bennett Fong | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 162
Capacity: 151
Deficiencies: 0
Date: Feb 23, 2024
Visit Reason
The visit was conducted to continue the annual inspection that began on 2024-02-13, as part of the required annual inspection process.
Findings
The annual inspection was completed with no citations issued. The Licensing Program Analyst reviewed records of staff and residents and conducted interviews with both groups.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Administrator | Met with during inspection and mentioned in the narrative. |
| James Sampair | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Bennett Fong | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Capacity: 151
Deficiencies: 0
Date: Feb 13, 2024
Visit Reason
The inspection was a required annual unannounced inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be appropriately furnished, well lit, and maintained with professional grade equipment. No citations were issued during the inspection, but the annual inspection was incomplete and will be continued at a later date.
Report Facts
Fire extinguisher last service date: Dec 22, 2023
Facility temperature: 72.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Administrator | Met with Licensing Program Analyst during inspection |
| James Sampair | Licensing Program Analyst | Conducted the inspection |
| Bennett Fong | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Capacity: 151
Deficiencies: 0
Date: Feb 13, 2024
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be appropriately furnished, well lit, and maintained with professional grade equipment. Food supplies, emergency lighting, medication storage, and safety measures such as fire extinguishers and pool fencing were all in compliance. No citations were issued during this incomplete inspection, which will be continued at a later date.
Report Facts
Facility capacity: 151
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Administrator | Met with Licensing Program Analyst during inspection |
| James Sampair | Licensing Program Analyst | Conducted the inspection |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Capacity: 151
Deficiencies: 0
Date: Jan 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation conducted due to an allegation that the facility was not maintaining a comfortable temperature for residents.
Complaint Details
The complaint alleged that staff were not maintaining a comfortable temperature for residents. The allegation was found to be unsubstantiated after investigation.
Findings
The investigation found that although the allegation may have happened or be valid, there was not a preponderance of evidence to prove it; therefore, the allegation was unsubstantiated. The temperature in the main dining room was measured at 69.5 degrees Fahrenheit, and most residents interviewed did not find it uncomfortably cold.
Report Facts
Temperature measurement: 69.5
Capacity: 151
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Executive Director | Met with during the investigation and informed of the visit purpose |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 160
Capacity: 151
Deficiencies: 0
Date: Jan 12, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the facility was not maintaining a comfortable temperature for residents.
Complaint Details
The complaint alleged that staff were not maintaining a comfortable temperature for residents. The allegation was unsubstantiated after investigation.
Findings
The investigation found that the temperature in the main dining room was 69.5 degrees Fahrenheit during mealtime, and most residents interviewed did not find it uncomfortably cold. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Temperature: 69.5
Residents interviewed: 6
Residents responding 'No' to uncomfortable temperature: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Executive Director | Met with during investigation and explained efforts to resolve temperature issue |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 151
Deficiencies: 0
Date: Sep 19, 2023
Visit Reason
The visit was an unannounced case management inspection concerning an incident on 09/12/2023 involving resident R1 and worker W1, as described in the 09/15/2023 unusual incident report.
Complaint Details
The visit was triggered by a complaint related to the 09/12/2023 incident involving resident R1 and worker W1. The report does not state substantiation status.
Findings
During the visit, the Assisted Living Director retold the incident and provided an update on the resident's status, who had returned to the facility after hospitalization and skilled nursing with 24/7 private caregiver support. No citations were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Gurnack | Assisted Living Director | Interviewed during the visit and provided details about the incident and resident status. |
| Ricardo Romero | Executive Director | Stated purpose of visit upon arrival. |
| Iryn Macamay | Assistant Executive Director | Met with during the visit and exit interview conducted. |
| James Sampair | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Complaint Investigation
Capacity: 151
Deficiencies: 0
Date: Sep 19, 2023
Visit Reason
The visit was an unannounced case management inspection concerning an incident that occurred on 2023-09-12 involving residents R1 and W1, as described in an unusual incident report dated 2023-09-15.
Complaint Details
The visit was triggered by a complaint related to an incident involving residents R1 and W1. The report does not state whether the complaint was substantiated.
Findings
During the visit, the Assisted Living Director retold the incident and provided an update on the status of resident R1, who had returned to the facility after hospitalization and skilled nursing, currently receiving 24/7 private caregiver assistance. No citations were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Gurnack | Assisted Living Director | Interviewed during the visit and provided details about the incident and resident status. |
| Ricardo Romero | Executive Director | Facility administrator and recipient of the stated purpose of the visit. |
| Iryn Macamay | Assistant Executive Director | Met during the visit and participated in the exit interview. |
| James Sampair | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding inaccurate documentation of a resident's wound location in the clinical record and Treatment Administration Record (TAR).
Complaint Details
The complaint investigation found that Resident 1's wound was incorrectly documented as a right lower leg ulcer instead of a right heel ulcer. The Director of Nursing confirmed the error and noted it as a learning opportunity for staff to maintain accurate documentation.
Findings
The facility failed to accurately document Resident 1's right heel ulcer in the TAR, mistakenly recording it as a right lower leg ulcer. This documentation error had the potential to result in uncoordinated care.
Deficiencies (1)
F 0842: The facility failed to safeguard resident-identifiable information and maintain accurate medical records for Resident 1 by documenting a right heel ulcer as a right lower leg ulcer in the Treatment Administration Record. This error could lead to uncoordinated care.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse (TN) 1 | Interviewed regarding Resident 1's wound treatment and TAR documentation. | |
| Director of Nursing (DON) | Interviewed regarding the wound documentation error and facility policy. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 16, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide necessary treatment and services to Resident 1, including failure to notify the physician, monitor oxygen levels, and administer pain medications as ordered.
Complaint Details
The complaint investigation substantiated that the facility failed to provide necessary treatment and services to Resident 1, including failure to notify the physician, monitor oxygen saturation, administer pain medications, and properly document narcotic medications. Resident 1 had to call 9-1-1 himself due to lack of staff response.
Findings
The facility failed to respond appropriately to Resident 1's change of condition, resulting in untreated pain, emotional distress, and delayed treatment of a pulmonary embolism. Additionally, the facility failed to accurately record narcotic medications on both the controlled substances sheet and Medication Administration Record, preventing accurate reconciliation.
Deficiencies (2)
F600: The facility failed to notify the physician or respond to Resident 1's request for hospital transfer, monitor blood oxygen as ordered, and administer pain medications per physician orders, resulting in untreated pain and delayed treatment of a pulmonary embolism.
F0755: The facility failed to ensure Resident 1's narcotics were recorded on both the controlled substances sheet and Medication Administration Record, preventing accurate reconciliation of controlled substances.
Report Facts
Pain level: 10
Oxygen saturation: 87
Vital signs: 12960
Medication doses: 1
Medication doses: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Nursing staff who administered pain medications and documented care for Resident 1 but failed to notify physician or call 9-1-1. |
| Director of Nursing | Interviewed regarding facility policy and Resident 1's care and documentation. |
Inspection Report
Complaint Investigation
Capacity: 151
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
The visit was an unannounced case management inspection concerning an incident reported on 06/29/2023 related to medication errors occurring between 06/12/2023 and 06/23/2023.
Complaint Details
The visit was triggered by a complaint incident reported on 06/29/2023 regarding medication errors. No citations were issued.
Findings
The Administrator explained communication errors that led to running out of and not dispensing a resident's medication for the specified period. Staff retraining and protocol reviews were conducted, and no citations were issued during the visit.
Report Facts
Incident date: Jun 23, 2023
Incident report date: Jun 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Administrator | Met during visit and explained medication error incident |
| Danica Aquino | Resident Care Supervisor | Met during visit |
| Jessica Gurnack | Assisted Living Director | Met with Medication Technicians to review refill protocol |
Inspection Report
Capacity: 151
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
Unannounced case management visit concerning an incident reported on 06/29/2023 related to medication errors occurring between 06/12/2023 and 06/23/2023.
Findings
The Administrator explained communication errors that led to running out of and not dispensing a resident's medication for the specified period. Staff retraining and protocol review were conducted, and no citations were issued during the visit.
Report Facts
Incident date: Jun 23, 2023
Medication non-dispensing period start: Jun 12, 2023
Medication non-dispensing period end: Jun 23, 2023
Staff meeting date: Jul 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ricardo Romero | Administrator | Explained medication errors during visit |
| Danica Aquino | Resident Care Supervisor | Met with Licensing Program Analyst during visit |
| Jessica Gurnack | Assisted Living Director | Met with Medication Technicians to review refill protocol |
Inspection Report
Follow-Up
Census: 86
Capacity: 151
Deficiencies: 0
Date: Apr 18, 2023
Visit Reason
The visit was an unannounced follow-up to the 04/10/2023 Post-Licensing inspection visit to verify compliance and corrections.
Findings
During the inspection, the Licensing Program Analyst reviewed the physical plant, kitchen, staff and resident files, and interviewed staff and residents. No citations were issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gia Aron | Resident Relations Director | Assisted the Licensing Program Analyst throughout the inspection and participated in the exit interview. |
Inspection Report
Follow-Up
Census: 86
Capacity: 151
Deficiencies: 0
Date: Apr 18, 2023
Visit Reason
The visit was an unannounced follow-up to the 04/10/2023 Post-Licensing inspection visit to assess compliance and corrective actions.
Findings
During the inspection, the Licensing Program Analyst inspected the physical plant, kitchen, staff and resident files, and interviewed staff and residents. No citations were issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gia Aron | Resident Relations Director | Assisted the Licensing Program Analyst throughout the inspection and participated in the exit interview. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 13, 2023
Visit Reason
The inspection was conducted due to a complaint regarding failure to properly check blood glucose levels and administer insulin medication to Resident 1 before breakfast as ordered by the physician.
Complaint Details
The complaint was substantiated. Resident 1 reported high blood glucose not checked in the morning and insulin not administered before breakfast. Nursing staff interviews confirmed delayed insulin administration and communication failures.
Findings
The facility failed to ensure that Resident 1 was checked for blood glucose and administered insulin before breakfast, resulting in elevated blood glucose levels and potential risk of serious complications. Interviews and record reviews confirmed delayed insulin administration and communication lapses among nursing staff.
Deficiencies (1)
F 0755: The facility failed to provide pharmaceutical services to meet the needs of Resident 1 by not checking blood glucose and administering insulin before breakfast as ordered. This failure had the potential to cause hyperglycemia and life-threatening complications.
Report Facts
Blood glucose level: 266
Blood glucose level: 229
Insulin units administered: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Administered insulin late on 3/30/23 and reported delayed handoff |
| RN 2 | Registered Nurse | Covering nurse responsible for verifying blood glucose and insulin administration |
| Director of Nursing | Director of Nursing | Stated insulin administration should not be delayed and identified responsible nurse |
| CNA 1 | Certified Nurse Assistant | Reported Resident 1 usually informs nurse about insulin needs before breakfast |
Inspection Report
Original Licensing
Census: 88
Capacity: 151
Deficiencies: 1
Date: Apr 10, 2023
Visit Reason
The inspection visit was an unannounced Post-Licensing inspection conducted to evaluate compliance following issuance of a new license for the facility.
Findings
The inspection found one deficiency related to criminal record clearance transfers, where 3 of 72 transfers were not completed after the new license was issued. A citation was issued and the inspection was incomplete, to be continued at a future date.
Deficiencies (1)
Licensee did not comply with criminal record clearance transfer requirements in 3 of 72 cases after new license issuance, posing potential health, safety, or personal rights risk.
Report Facts
Deficiencies cited: 1
Incomplete criminal record clearance transfers: 3
Total criminal record clearance transfers reviewed: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the inspection and issued citation. |
| Gia Aron | Resident Relations Director | Met with the Licensing Program Analyst during inspection and exit interview. |
Inspection Report
Original Licensing
Census: 88
Capacity: 151
Deficiencies: 1
Date: Apr 10, 2023
Visit Reason
The inspection visit was an unannounced Post-Licensing inspection conducted to evaluate compliance following the issuance of a new license for the facility.
Findings
The inspection identified one deficiency related to incomplete criminal record clearance transfers, with 3 of 72 transfers not completed after the new license was issued. The inspection was incomplete and will be continued at a future date.
Deficiencies (1)
Based on record review, the licensee did not comply with criminal record clearance transfer requirements in 3 of 72 cases after new license issuance, posing potential health, safety, or personal rights risks.
Report Facts
Deficiencies cited: 1
Incomplete criminal record clearance transfers: 3
Total criminal record clearance transfers reviewed: 72
Facility capacity: 151
Facility census: 88
Hot water temperature: 118
Room temperature: 75.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Gia Aron | Resident Relations Director | Met with Licensing Program Analyst during inspection and exit interview |
| Harpreet Humpal | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Original Licensing
Census: 88
Capacity: 151
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
The inspection was an unannounced change of ownership prelicensing visit conducted to evaluate the facility for licensing approval.
Findings
No citations or deficiencies were found during the visit. The pre-licensing process is complete and the facility has no deficiencies.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernesto Navas | Environmental Services Director | Met with Licensing Program Analyst during the inspection visit. |
Inspection Report
Original Licensing
Census: 88
Capacity: 151
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
The inspection was an unannounced change of ownership prelicensing visit conducted to evaluate the facility for licensing approval.
Findings
No citations or deficiencies were found during the visit. The pre-licensing process is complete and the facility has no deficiencies.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ernesto Navas | Environmental Services Director | Met with Licensing Program Analyst during the inspection visit. |
Inspection Report
Original Licensing
Census: 88
Capacity: 151
Deficiencies: 1
Date: Dec 27, 2022
Visit Reason
The visit was an unannounced prelicensing inspection conducted due to a change of ownership application for the facility, which is currently in operation.
Findings
The facility was toured and inspected, including common areas, resident rooms, and safety equipment. The facility was found to be appropriately furnished, well maintained, and equipped with necessary safety features. A citation was issued for fire extinguishers that did not pass inspection.
Deficiencies (1)
Fire extinguishers did not pass inspection
Report Facts
Total capacity: 151
Census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gia Aron | Resident Relations Director | Met with Licensing Program Analyst during inspection |
| James Sampair | Licensing Program Analyst | Conducted the inspection |
| Harpreet Humpal | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Original Licensing
Census: 88
Capacity: 151
Deficiencies: 1
Date: Dec 27, 2022
Visit Reason
The visit was an unannounced prelicensing inspection conducted due to a change of ownership application for the facility, which is currently in operation.
Findings
The facility was toured and inspected thoroughly, including common areas, resident rooms, and safety equipment. Most conditions were satisfactory, including COVID-19 screening, PPE storage, and safety features. However, a citation was issued for fire extinguishers that did not pass inspection.
Deficiencies (1)
Fire extinguishers did not pass inspection
Report Facts
Total capacity: 151
Non-ambulatory capacity: 141
Bedridden capacity: 10
Hot water temperature: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gia Aron | Resident Relations Director | Met with Licensing Program Analyst during the inspection |
| James Sampair | Licensing Program Analyst | Conducted the inspection and signed the report |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Mar 4, 2022
Visit Reason
The inspection was conducted as a comprehensive annual survey of the nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including maintenance issues, personal hygiene care, nutritional monitoring, respiratory care, medication management, infection control, and food quality. Deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (10)
F 0584: The facility failed to ensure a resident room doorknob was properly working and tightly fastened, posing a fall risk for Resident 19.
F 0677: The facility failed to provide showers, bed baths, and personal hygiene to Residents 10 and 48, resulting in poor hygiene and potential infection risk.
F 0692: The facility failed to monitor body weights of Residents 63 and 67 as ordered, risking inadequate nutritional evaluation and intervention.
F 0695: The facility failed to have physician orders for oxygen and CPAP use for Resident 27, risking incorrect treatment administration.
F 0756: The facility failed to act on consultant pharmacist recommendations for gradual dose reduction of psychotropic medications for Resident 33, risking higher medication doses.
F 0758: The facility failed to document indications and clinical rationale for psychotropic medication Quetiapine for Resident 87, risking inappropriate medication use.
F 0759: The facility had an 8% medication error rate for Resident 18, including missed administration of Amlodipine Besylate and wrong dose of Folic Acid.
F 0761: The facility failed to monitor room temperature for one medication storage room for multiple days, risking medication potency and effectiveness.
F 0804: The facility served overcooked, brown peas to Resident 36, resulting in unpalatable food that could impact nutritional status.
F 0880: The facility failed to follow COVID-19 infection control procedures for Resident 101, including lack of testing and PPE signage, risking spread of infection.
Report Facts
Medication error rate: 8
Weight loss: 14
Weight loss percentage: 13.78
Oxygen administration without orders: 34
CPAP use without orders: 22
Residents sampled: 29
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 8 | Registered Nurse | Named in loose doorknob finding for Resident 19 |
| MDIR | Maintenance Director | Named in loose doorknob finding for Resident 19 |
| RN 1 | Registered Nurse | Named in multiple findings including weight monitoring, oxygen orders, medication errors |
| LVN 1 | Licensed Vocational Nurse | Named in weight monitoring deficiency for Resident 67 |
| CNA 1 | Certified Nursing Assistant | Named in hygiene deficiency for Resident 10 |
| DON | Director of Nursing | Named in multiple findings including hygiene, medication management, infection control |
| RN 6 | Registered Nurse | Named in medication error finding for Resident 18 |
| RN 3 | Registered Nurse | Named in psychotropic medication documentation deficiency for Resident 87 |
| LVN 3 | Licensed Vocational Nurse | Named in oxygen/CPAP order deficiency for Resident 27 |
| FSD | Food Service Director | Named in food quality deficiency for Resident 36 |
| IP 1 | Infection Preventionist | Named in COVID-19 infection control deficiency for Resident 101 |
| IP 2 | Infection Preventionist | Named in COVID-19 infection control deficiency for Resident 101 |
Inspection Report
Annual Inspection
Deficiencies: 14
Date: Apr 4, 2019
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including housekeeping and sanitation, accurate resident assessments, care planning, assistance with activities of daily living, medication management, infection control, staff training, and maintenance of a safe and clean environment.
Deficiencies (14)
F 0584: The facility failed to provide adequate housekeeping when dirty commode buckets, used toilet plungers, and soiled under clothing were left in resident bathrooms, creating an unsanitary environment.
F 0641: The facility failed to ensure the Minimal Data Set (MDS) was coded accurately for one resident, omitting dialysis status, potentially affecting person-centered care.
F 0645: The facility failed to accurately complete the PASARR Level I screening for one resident, resulting in no Level II screening for six months.
F 0655: The facility failed to provide a summary of the baseline care plan within 48 hours of admission for two residents, risking their awareness of updated care plans.
F 0657: The facility failed to ensure a resident's family representative participated in care plan development, neglecting preferences for female staff and frequent brief changes.
F 0677: The facility failed to provide scheduled showers to a resident, resulting in discomfort due to poor hygiene.
F 0689: The facility failed to ensure sharps containers on medication carts were replaced timely, posing risk of needle sticks and exposure to medical waste.
F 0692: The facility failed to assess a resident for significant weight gain of 53.4 pounds over five weeks, resulting in lack of nursing interventions.
F 0729: The facility failed to conduct annual performance evaluations for a Certified Nursing Assistant for three consecutive years.
F 0730: The facility failed to ensure a Certified Nursing Assistant completed required annual in-service and dementia training hours.
F 0755: The facility failed to notify the pharmacy of discharge medication disposition and did not reconcile controlled substances every shift for one medication cart.
F 0812: The facility failed to maintain sanitary conditions in the kitchen, with utensils, equipment, and surfaces covered in grease and debris, risking food-borne illness.
F 0880: The facility failed to follow infection control procedures including improper PPE use, unlabeled oxygen and nebulizer equipment, inadequate hand hygiene and glove changes during wound care, and failure to clean shared equipment.
F 0921: The facility failed to maintain a clean and comfortable environment as floors in multiple resident rooms were sticky and dirty, despite resident complaints.
Report Facts
Residents sampled: 26
Weight gain: 53.4
Training hours completed: 8
Training hours required: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 4 (LVN 4) | Confirmed dirty commode buckets and toilet plungers in bathrooms | |
| Housekeeper 1 (HK 1) | Interviewed about housekeeping practices | |
| Housekeeping Supervisor (HKS) | Interviewed about housekeeping procedures | |
| Registered Nurse 4 (RN 4) | Confirmed inaccurate MDS coding and baseline care plan issues | |
| Social Worker 1 (SW 1) | Confirmed PASARR screening inaccuracies | |
| Registered Nurse 1 (RN 1) | Confirmed care plan deficiencies and wound care practices | |
| Certified Nursing Assistant 2 (CNA 2) | Confirmed toileting documentation practices | |
| Licensed Vocational Nurse 3 (LVN 3) | Observed sharps container issues and wound care | |
| Licensed Vocational Nurse 7 (LVN 7) | Confirmed CNA training deficiencies and infection control practices | |
| Administration Staff 1 (Adm Staff 1) | Interviewed about sharps container replacement and CNA work schedule | |
| Dietary Manager (DM) | Interviewed about kitchen sanitation issues | |
| Environmental Services Supervisor (EVS Sup) | Interviewed about housekeeping infection control procedures |
Viewing
Loading inspection reports...
