Inspection Reports for
California Care Center
1106 SOUTH OAK, ROUTE 3, CALIFORNIA, MO, 65018-1462
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
42% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
48% occupied
Based on a May 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 14, 2024
Visit Reason
Annual licensure inspection and health facility survey of California Care Center to assess compliance with state and federal regulations.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited during this inspection.
Inspection Report
Life Safety
Deficiencies: 0
Date: Aug 14, 2024
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and Emergency Preparedness regulations.
Findings
The facility met the applicable provisions of the 2012 edition of the Life Safety Code and related reference documents. No deficiencies were cited in the Emergency Preparedness portion or the licensure inspection.
Inspection Report
Deficiencies: 0
Date: Aug 14, 2024
Visit Reason
The inspection was conducted as a regulatory survey of the California Care Center facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 4
Date: May 3, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication errors and failure to notify the physician about a resident's significant change in condition.
Complaint Details
The complaint investigation substantiated that the facility failed to notify the physician immediately after a medication error involving Resident #1, which led to an adverse reaction and hospital admission. The facility also failed to ensure residents were free from significant medication errors.
Findings
The facility failed to notify the physician immediately after a medication error involving Resident #1, which resulted in a hospital stay. Staff also failed to ensure residents were free of significant medication errors, leading to adverse effects for Resident #1.
Deficiencies (4)
F580: The facility failed to notify the resident's physician immediately after a medication error involving Resident #1, resulting in a hospital admission. Staff did not follow policies for timely notification and documentation.
F760: The facility failed to ensure residents remained free of significant medication errors, as evidenced by Resident #1 receiving another resident's medication causing adverse effects and hospitalization.
A4060: Medication errors and adverse reactions were not reported immediately to the nursing supervisor and physician as required by regulation.
A4087: The facility failed to notify the physician in accordance with emergency treatment policies following an accident or significant change in condition.
Report Facts
Facility census: 29
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 2
Date: May 3, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error where Resident #1 was given another resident's medication, resulting in an adverse reaction and hospital admission.
Complaint Details
The complaint investigation found that the medication error was substantiated, with Resident #1 receiving Resident #2's medications leading to an adverse reaction and hospital admission. The physician was not notified immediately as required.
Findings
The facility failed to notify the physician immediately after the medication error occurred, delaying notification until Resident #1 exhibited adverse effects and was sent to the hospital. Staff did not follow medication administration policies, leading to Resident #1 receiving Resident #2's medications.
Deficiencies (2)
Facility staff failed to notify Resident #1's physician immediately after a medication error where Resident #1 was given another resident's medication, resulting in actual harm.
Facility staff failed to ensure residents remained free from significant medication errors when Resident #2's medication was administered to Resident #1, resulting in hospital admission.
Report Facts
Facility census: 29
Medication pass time: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Monitored Resident #1 after medication error, delayed physician notification |
| CMT A | Certified Medication Technician | Administered medications to Resident #2 and did not verify medication intake before leaving |
| Dietary Aide B | Dietary Aide | Noticed medication cups left on table and gave medication cup to RN C |
| DON | Director of Nursing | Expected immediate physician notification after medication errors |
| Administrator | Facility Administrator | Expected immediate physician notification after medication errors |
Inspection Report
Plan of Correction
Census: 28
Deficiencies: 2
Date: Jun 14, 2023
Visit Reason
The inspection was conducted to identify deficiencies related to the facility's environment and maintenance, specifically focusing on the safety, cleanliness, and homelike environment of resident areas.
Findings
The facility failed to maintain a comfortable and homelike environment as evidenced by debris buildup, black marks, chipped paint, missing trim, rust, and other maintenance issues in multiple resident rooms. Staff interviews revealed a lack of a full-time maintenance person and incomplete maintenance documentation.
Deficiencies (2)
F 584: The facility failed to provide a comfortable and homelike environment, with multiple rooms showing debris buildup, black marks, chipped paint, missing trim, rust, and other maintenance issues. Staff interviews confirmed the absence of a full-time maintenance person and incomplete maintenance logs.
A3001: The building was not substantially constructed and maintained in good repair as required by 19 CSR 30-85.032(2), with deficiencies classified as Class III.
Report Facts
Facility census: 28
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debra Dunham | Administrator | Signed the plan of correction and involved in oversight |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding maintenance and facility conditions |
| Certified Nurse Aide | Certified Nurse Aide (CNA) D | Interviewed about maintenance reporting |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) E | Interviewed about maintenance reporting |
Inspection Report
Life Safety
Census: 28
Capacity: 60
Deficiencies: 5
Date: Jun 14, 2023
Visit Reason
The inspection was a life safety code survey to assess compliance with fire safety regulations including sprinkler system maintenance, smoke barrier integrity, fire door inspections, and electrical system safety.
Findings
The facility failed to provide complete and verifiable documentation for quarterly sprinkler system inspections and testing, maintain smoke barrier walls free of openings, inspect and document fire door assemblies, and conduct required electrical system maintenance and testing. These deficiencies have the potential to affect all facility occupants.
Deficiencies (5)
K353 Sprinkler System - Maintenance and Testing: The facility failed to inspect, test, and maintain the wet sprinkler system quarterly with complete and verifiable documentation, risking system failure and delayed fire suppression.
K372 Smoke Barrier Construction: The facility failed to maintain smoke barrier walls free of openings, allowing unsealed holes and joints that could prevent containment of smoke and fire between zones.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to inspect and document fire door assemblies and their fire-ratings, risking equipment failure and delayed evacuation.
K917 Electrical Systems - Essential Electric System Receptacles: The facility failed to identify and mark emergency electrical outlets and maintain the emergency generator and electrical receptacles as required.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to conduct required load tests and inspections of the emergency generator and electrical panels, risking system reliability.
Report Facts
Facility census: 28
Total capacity: 60
Inspection Report
Routine
Census: 28
Deficiencies: 1
Date: Jun 12, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding maintaining a safe, clean, comfortable, and homelike environment for residents, specifically focusing on the condition and repair of resident areas.
Findings
The facility failed to maintain resident areas in good repair, with multiple observations of debris buildup, stains, damaged walls, missing baseboards, rust, and peeling materials across various rooms. Maintenance issues were not adequately reported or addressed, and the facility lacked a full-time maintenance person.
Deficiencies (1)
Failure to ensure resident areas were in good repair, including debris buildup, stains, damaged walls, missing baseboards, rust, and peeling materials.
Report Facts
Facility census: 28
Date of last documented needed repairs: Jan 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aide | Interviewed regarding maintenance reporting and facility maintenance staffing |
| LPN E | Licensed Practical Nurse | Interviewed about maintenance reporting and observations of facility conditions |
| Director of Nursing | Director of Nursing | Interviewed about maintenance reporting and facility conditions |
Inspection Report
Life Safety
Census: 30
Capacity: 60
Deficiencies: 5
Date: Apr 20, 2022
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations, including sprinkler system maintenance, fire drills, electrical systems, oxygen storage, and emergency generator testing.
Findings
The facility failed to meet several provisions of the Life Safety Code, including inadequate monthly inspections of the sprinkler system, incomplete fire drills, unsecured electrical panels, improper oxygen storage, and incomplete emergency generator testing documentation. These deficiencies have the potential to affect all facility occupants.
Deficiencies (5)
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to conduct all monthly inspections of the wet pipe sprinkler system and maintain documentation of inspections and testing as required by NFPA 25.
K712 Fire Drills: Facility staff failed to conduct fire drills at various times on each shift quarterly, potentially delaying response procedures in the event of a fire.
K911 Electrical Systems - Other: Facility staff failed to maintain electrical panels locked to prevent unauthorized access, exposing breakers and electrical components.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: Facility staff failed to inspect, test, and maintain the emergency generator and provide documentation of weekly inspections and monthly load tests.
K923 Gas Equipment - Cylinder and Container Storage: Facility staff failed to maintain proper storage of combustible materials within five feet of oxygen cylinders, increasing fire hazard risk.
Report Facts
Facility census: 30
Facility capacity: 60
Deficiencies cited: 5
Inspection Report
Plan of Correction
Census: 30
Deficiencies: 5
Date: Apr 20, 2022
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations, including care plan timing and revision, nurse staffing information posting, infection prevention and control, and communicable disease policies.
Findings
The facility failed to revise care plans for five residents with interventions to prevent falls, failed to post required nurse staffing information daily, and did not implement adequate infection prevention and control policies including TB screening for employees. The facility also failed to ensure communicable disease policies and clinical record assessments met regulatory requirements.
Deficiencies (5)
F657 Care Plan Timing and Revision: Facility staff failed to revise care plans for five residents with interventions to prevent falls. The care plans lacked measurable goals, ongoing assessment, and specific interventions such as helmet use and fall risk precautions.
F732 Posted Nurse Staffing Information: Facility staff failed to post required nurse staffing information daily, including total number of staff and hours worked by licensed and unlicensed nursing staff responsible for resident care.
F880 Infection Prevention & Control: Facility failed to implement an infection prevention and control program including timely TB screening and documentation for employees, and failed to ensure communicable disease policies were followed.
A4031 Communicable Disease-Employees: Facility failed to develop and implement policies ensuring employees are screened for communicable diseases and do not expose residents to such diseases.
A4108 Clinical Records - assessment/interventions: Facility failed to ensure clinical records contained sufficient information reflecting initial and ongoing assessments and interventions by each discipline involved in resident care.
Report Facts
Facility census: 30
Deficiencies cited: 5
Inspection Report
Routine
Census: 30
Deficiencies: 3
Date: Apr 20, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, nurse staffing postings, and infection prevention and control, including tuberculosis screening of employees.
Findings
The facility failed to revise care plans for five residents with fall prevention interventions, failed to post required nurse staffing information daily, and failed to ensure timely and complete two-step tuberculosis testing for employees.
Deficiencies (3)
Failure to revise care plans for five residents with interventions to prevent falls.
Failure to post required nurse staffing information daily, including total staff and hours worked.
Failure to implement infection prevention program ensuring two-step tuberculosis testing was completed and documented for employees.
Report Facts
Residents affected: 5
Facility census: 30
Employee files reviewed: 10
Employee files missing second PPD: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant G | CNA | Interviewed regarding helmet use and care plan interventions for falls |
| Registered Nurse B | RN | Interviewed regarding helmet checks and nurse staffing postings |
| Director of Nursing | DON | Interviewed regarding care plan expectations, nurse staffing postings, and tuberculosis testing policy |
| Administrator | Interviewed regarding care plan breakdown and nurse staffing postings | |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed regarding tuberculosis testing procedures and compliance |
Inspection Report
Routine
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with emergency preparedness and infection control practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 2
Date: Oct 27, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of resident abuse involving a staff member and a resident.
Complaint Details
The complaint involved an incident where a resident accused a CNA of punching and hitting them. The facility's investigation concluded the allegation was unsubstantiated. Staff failed to notify the Department of Health and Senior Services of the allegation as required.
Findings
The facility failed to follow its policy to report an allegation of resident abuse to the Department of Health and Senior Services. The investigation found the abuse allegation unsubstantiated, but staff did not notify the DHSS as required.
Deficiencies (2)
F607: The facility failed to develop and implement policies to prohibit, investigate, and report abuse. Staff did not report an allegation of resident abuse to the Department of Health and Senior Services as required.
A8023: The facility did not meet the requirement to develop and implement policies prohibiting mistreatment, neglect, and abuse, and to report such incidents to the department and Department of Mental Health. Refer to F607.
Report Facts
Facility census: 24
Inspection Report
Routine
Deficiencies: 0
Date: Oct 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 15, 2019
Visit Reason
The inspection was conducted as a licensure inspection for the California Care Center.
Findings
No state licensure deficiencies or health facility survey deficiencies were cited as a result of this inspection.
Inspection Report
Life Safety
Census: 34
Capacity: 60
Deficiencies: 7
Date: Feb 15, 2019
Visit Reason
The inspection was conducted to evaluate compliance with the Life Safety Code and related fire safety regulations, including sprinkler system maintenance, smoke barrier construction, and oxygen storage safety.
Findings
The facility failed to maintain the wet pipe sprinkler system according to NFPA 25 standards, did not maintain smoke barrier walls with required fire resistance, and improperly stored oxygen cylinders. Additionally, night lights were not functional in many resident and toilet rooms.
Deficiencies (7)
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to test and maintain the sprinkler system's gauges and conduct complete monthly inspections for several months. The sprinkler system gauges were outdated and not calibrated as required.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: Facility staff failed to maintain smoke barrier walls with at least a one half hour fire resistance rating, including sealing holes and penetrations in the walls.
K923 Gas Equipment - Cylinder and Container Storage: Facility staff failed to store oxygen tanks in accordance with NFPA 99, resulting in mixed storage of full and empty cylinders and lack of monitoring.
A1132 Night-lights-Required Locations: Facility staff failed to maintain functional night lights in 29 of 31 resident and toilet rooms, impairing illumination of the path to light switches.
A2010 Oxygen Storage: Oxygen storage was not in compliance with NFPA 99 standards, as detailed in deficiency K923.
A2034 Sprinkler System-Test/Maintain: Facility failed to inspect, maintain, and test sprinkler systems as required, as detailed in deficiency K353.
A2054 Smoke Section Walls/Doors: Facility failed to maintain smoke section walls and doors with required fire ratings and self-closing mechanisms, as detailed in deficiency K372.
Report Facts
Facility census: 34
Total capacity: 60
Non-functional night lights: 29
Oxygen cylinders stored: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding sprinkler system testing, smoke barrier inspections, and oxygen storage monitoring | |
| Administrator | Interviewed regarding responsibility for sprinkler system inspections, smoke barrier maintenance, and oxygen storage policies | |
| Maintenance Supervisor | Named in Plan of Correction for sprinkler system maintenance, smoke barrier inspections, and oxygen storage monitoring | |
| Director of Nursing | DON | Named in Plan of Correction regarding nursing department involvement in oxygen storage |
Inspection Report
Follow-Up
Census: 34
Deficiencies: 9
Date: May 11, 2018
Visit Reason
This follow-up inspection was conducted to verify correction of previously cited deficiencies related to accuracy of assessments, comprehensive care plans, care plan timing and revision, treatment and services to prevent and heal pressure ulcers, infection control, clinical records, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including inaccurate coding of residents' mental health and skin conditions, failure to develop and implement comprehensive care plans timely, inadequate treatment and monitoring of pressure ulcers, insufficient infection control practices, and incomplete clinical records. The facility submitted a plan of correction with completion dates.
Deficiencies (9)
F641 Accuracy of Assessments. The facility failed to accurately code mental health diagnoses and skin conditions for sampled residents, including failure to document pressure ulcers correctly.
F656 Develop/Implement Comprehensive Care Plan. The facility failed to develop measurable goals and interventions for comprehensive care plans for residents related to psychotropic medications and other needs within seven days of assessment.
F657 Care Plan Timing and Revision. The facility failed to update care plans timely and revise them after assessments and changes in residents' conditions for sampled residents.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to promote healing of pressure ulcers, perform timely skin assessments, and notify physicians of changes for a resident with an unhealed pressure ulcer.
F689 Free of Accident Hazards/Supervision/Devices. The facility failed to ensure hazardous items were secured and the environment was free of accident hazards, including unlocked utility rooms and accessible razors.
F695 Respiratory/Tracheostomy Care and Suctioning. The facility failed to provide oxygen therapy at accurate flow rates, store oxygen equipment properly, and maintain infection control for residents requiring respiratory care.
F883 Influenza and Pneumococcal Immunizations. The facility failed to develop and follow policies to ensure residents received recommended immunizations and education regarding benefits and side effects.
F4082 Infection Control/Communicable Disease. The facility failed to follow infection control procedures to prevent spread of infection and report communicable diseases timely.
F4107 Clinical Records - assessment/interventions. The facility failed to maintain clinical records with sufficient information reflecting assessments and interventions by all disciplines.
Report Facts
Facility census: 34
Plan of Correction completion date: June 21, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in findings related to wound assessment, care plan updates, and staff interviews |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Named in interviews regarding care plan completion and wound care |
| Certified Medication Technician | Certified Medication Technician (CMT) | Named in observation of medication administration for wound treatment |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Named in interviews regarding wound status and care plan information |
Inspection Report
Life Safety
Census: 34
Capacity: 60
Deficiencies: 2
Date: May 11, 2018
Visit Reason
The inspection was conducted to evaluate compliance with fire drill requirements and emergency preparedness under the NFPA 101 Life Safety Code and Missouri fire drill regulations.
Findings
The facility failed to conduct fire drills under various conditions as required, including documentation deficiencies and lack of unannounced drills. The fire drills did not meet the minimum frequency and conditions mandated by regulations.
Deficiencies (2)
K712 Fire Drills: Facility staff failed to conduct fire drills under various conditions from May 2017 through April 2018, and records lacked documentation of simulated fire conditions for 10 of 12 drills. The facility census was 34 with a capacity of 60.
A2061 Fire Drill Requirements, Evacuation: The facility did not meet the requirement to conduct at least twelve fire drills annually with at least one every three months per shift, including unannounced drills involving simulated resident evacuation.
Report Facts
Facility census: 34
Total capacity: 60
Fire drills conducted: 12
Fire drills reviewed: 12
Fire drills lacking documentation: 10
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