Inspection Reports for
Culver West Health Center

The complaint investigation was substantiated for allegations of staff neglect (resident covered in ants), inadequate emergency training, improper use of chemicals on resident, and lack of care and supervision. Allegations of untimely CPR and questionable death were unsubstantiated.

The investigation substantiated allegations of staff neglect resulting in a resident being covered in ants, inadequate emergency training of staff, improper wiping of a resident's body with Lysol, and lack of care and supervision contributing to the resident's death. Two other allegations related to untimely CPR and questionable death were found unsubstantiated.

The complaint investigation was substantiated for allegations of staff neglect, inadequate emergency training, improper chemical use on a resident, and lack of care and supervision. The allegations that staff did not perform CPR timely and questionable death were unsubstantiated due to insufficient evidence.

The investigation substantiated allegations of staff neglect resulting in a resident being covered in ants, inadequate staff emergency training, improper wiping of a resident's body with Lysol, and lack of care and supervision contributing to a resident's death. Allegations that staff did not perform CPR timely and questionable death were found unsubstantiated. Several deficiencies were cited related to personal rights, staff training, and care standards.

The complaint investigation was substantiated based on a preponderance of evidence for allegations including staff neglect, inadequate emergency training, improper chemical use on a resident, and lack of care and supervision. The allegations of staff not performing CPR timely and questionable death were unsubstantiated.

The investigation substantiated several allegations including staff neglect resulting in a resident being covered in ants, inadequate emergency training of staff, improper wiping of a resident's body with Lysol, and lack of care and supervision contributing to a resident's death. Two allegations related to staff not performing CPR timely and questionable death were found unsubstantiated. Deficiencies were cited related to personal rights and personnel requirements.

The complaint alleged the facility sent Resident 2 to the general acute care hospital twice in one week due to missed dialysis treatments related to transportation issues. The complaint was substantiated by findings that Resident 1 missed dialysis on 5/10/2025 due to transportation errors and communication failures.

The facility failed to ensure proper communication and coordination regarding Resident 1's dialysis transportation, resulting in Resident 1 missing a scheduled dialysis treatment on 5/10/2025. The transportation company arrived with a wheelchair instead of a gurney, which was not communicated to nursing staff, causing Resident 1 to be sent to the hospital but not receive dialysis because it was done the day before.

The facility was found deficient in multiple areas including failure to consult appropriate parties regarding vaccinations for a cognitively impaired resident without a representative, failure to ensure physician orders for self-administration of medications, inadequate personal hygiene care for a resident, delays in treatment of urinary tract infections, improper medication administration timing, failure to meet nutritional needs and preferences, incorrect food portioning, infection control breaches including improper use of PPE and unlabeled catheter bags, failure to maintain adequate room size per resident, and failure to provide a working call light system in a resident's room.

The complaint investigation was substantiated for two allegations: failure to respond timely to call buttons and lack of an active administrator on site. The other two allegations about meal nutrition and a barking dog were unsubstantiated.

Two allegations were substantiated: staff did not respond to call buttons in a timely manner, and the facility did not have an active administrator on site five days a week. Two other allegations regarding nutritious meals and a resident's barking dog interfering with others were found unsubstantiated.

The complaint investigation was substantiated for two allegations: staff not responding timely to call buttons and lack of an active administrator on site. The other two allegations about nutritious meals and a barking dog interfering with residents were unsubstantiated.

Two allegations were substantiated: staff did not respond to call buttons in a timely manner, and the licensee did not ensure an active administrator was on site. Two other allegations regarding nutritious meals and a resident's barking dog interfering with others were found unsubstantiated.

The facility failed to maintain functional AED machines at designated nursing stations, resulting in delayed life-saving measures during Resident 1's emergency. Both AED devices were non-functional, missing pads, had expired batteries, and staff were not trained to use or maintain the AEDs. The facility lacked proper maintenance logs and quality checks for the AED equipment.

The complaint investigation found no documented evidence that Resident 1's family member was notified of the change of condition (MASD) in the clinical records or nursing progress notes. Interviews with the Medical Records Director, Treatment Nurse, and Director of Nursing confirmed the lack of notification and emphasized the importance of family involvement in care planning.

The facility failed to ensure that the Licensed Vocational Nurse notified Resident 1's family member about a change of condition involving moisture associated skin damage on 8/6/2024, violating the resident's right to be informed and potentially impacting care.

The facility failed to ensure that Resident 1's call light was within reach, which posed a risk of delayed emergency care or falls. Observations and interviews confirmed the call light was found on the floor behind the resident's bed, and staff acknowledged the importance of call lights being accessible and promptly answered.

The complaint investigation found that the facility did not report the resident-to-resident abuse incident within 2 hours as required by policy. The incident occurred on 4/23/2024 at 4:00 A.M., but notification to the State Survey Agency, Ombudsman, and law enforcement was delayed until 9:30 A.M. to 10:03 A.M. The facility staff acknowledged the failure to report timely during interviews on 5/7/2024.

The facility failed to report the resident-to-resident abuse incident to the State Survey Agency, Ombudsman, and local law enforcement within the required 2-hour timeframe, delaying investigation and potentially placing the resident at risk. Interviews and record reviews confirmed the delay in reporting and noncompliance with the facility's Abuse and Crime Reporting policy effective 9/11/2023.

The facility failed to provide adequate storage and inventory for residents' personal belongings, resulting in lost items and a non-homelike environment for Resident 38. Additionally, the facility failed to prepare and store food safely, including improper use of hairnets, lack of hand hygiene and apron changes during dishwashing, and improper food storage at bedside, potentially exposing residents to foodborne illness.

The facility was found deficient in multiple areas including failure to provide adequate storage and inventory of resident belongings, inadequate bed size for a resident, failure to ensure call lights were within reach or functioning, unsafe environmental hazards, improper feeding tube management, inadequate pain management, unsafe food handling and storage practices, insufficient room size per resident, and failure to maintain a working call system in resident bathrooms.

The facility failed to provide functioning call lights for two of five selected residents, which could delay staff response to residents' needs and potentially lead to falls or accidents. Observations and interviews confirmed that call lights were not working properly, and staff acknowledged the risks associated with malfunctioning call systems.

The investigation was triggered by a complaint alleging physical abuse and misappropriation of Resident 1's Electronic Benefit Transfer (EBT) card funds. The complaint was substantiated by findings that the facility delayed reporting the incident to the Department of Public Health and failed to ensure safe transfer practices, resulting in injury to Resident 1.

The facility failed to report alleged abuse related to missing funds within the required 2-hour timeframe, delaying an onsite inspection and potentially placing 77 residents at risk. Additionally, the facility failed to provide adequate supervision and safe transfer for Resident 1, resulting in a fall and a 7-centimeter laceration requiring hospital treatment.

The complaint investigation involved Resident 1 who reported abuse and neglect, including failure to provide proper care and disrespect by staff, leading to the resident calling the police on 12/14/2023. The facility failed to report the abuse allegation to the Department of Public Health, Ombudsman, and local law enforcement within five working days as required. The investigation found failures in reporting, documentation, and follow-up with the resident.

The facility failed to provide showers as preferred by Resident 1, failed to timely report and investigate allegations of abuse for Resident 1, and failed to provide timely incontinence care to Resident 2, potentially leading to discomfort, risk of infection, and delayed abuse prevention.

The visit was complaint-related, initiated as a 10-day complaint investigation. The gas leak allegation was substantiated by observations of gas smell and maintenance staff statements. Trash bins and window screen issues were also noted as violations.

The inspection found multiple deficiencies including a gas leak near the memory care unit, uncovered trash bins attracting insects, and damaged window screens posing risks to residents. Maintenance records were requested, and the facility was cited for violations related to maintenance and operation.

The visit was complaint-related, initiated as a 10-day complaint investigation. The complaint was substantiated by observations of gas leak and maintenance issues.

The inspection found uncovered trash bins attracting flies, insects, and mosquitoes, damaged window screens in need of repair, and a persistent gas leak near the memory care unit posing potential health and safety risks to residents. Maintenance records were requested and the licensee was cited for violations under CCR 87303(a-e) and 87303(f)(1-2).

The visit was complaint-related, focusing on substantiation of failure to monitor residents on antipsychotic medications and lack of nonpharmacological interventions prior to medication dose increases. The complaint was substantiated with findings of inadequate monitoring and documentation.

The facility failed to monitor two sampled residents for target behaviors related to antipsychotic medication use and did not document nonpharmacological interventions prior to increasing medication doses. Documentation gaps were noted in nursing progress notes and medication administration records, and staff interviews confirmed lack of documentation and inconsistent observation of behaviors. The facility's policy requires non-drug interventions before medication use, which was not followed.

The complaint involved failure to report an unusual occurrence of maggots found in Resident 1's wound, failure to implement a comprehensive care plan, and failure to maintain a pest-free environment. The complaint was substantiated as the facility failed to report the incident timely and failed to provide adequate care, resulting in harm to Resident 1.

The facility failed to report an unusual occurrence of maggots found in Resident 1's left heel wound to the State Survey Agency within 24 hours, failed to develop and implement a comprehensive person-centered care plan including blood sugar monitoring, failed to follow up on a vascular consult recommendation, failed to conduct an interdisciplinary care conference, failed to provide appropriate wound care and nutrition, and failed to maintain a pest-free environment. These deficiencies resulted in Resident 1's wound worsening, transfer to a hospital, and below the knee amputation.

The complaint investigation found that Residents 4 and 5 exhibited uncontrollable screaming episodes which staff failed to attend to. The complaint was substantiated by observations on 2/27/2023 and interviews with staff including CNA 3 and the Interim Director of Nursing.

The facility failed to provide necessary behavioral health care and services in accordance with residents' care plans, as staff did not attend to Residents 4 and 5 during episodes of uncontrollable screaming in the hallway. Observations and interviews confirmed staff neglect in responding to these behavioral health needs.

The complaint alleged that staff did not treat resident #1 with dignity or respect, citing inappropriate comments by staff #1 calling the resident 'entitled.' Another allegation was that staff did not meet the needs of resident #1, including failure to honor a room accommodation request and inconsistent staff assignment for showers. The dignity and respect allegation was substantiated; the care needs allegation was unsubstantiated.

The allegation that staff did not treat resident #1 with dignity or respect was substantiated based on staff comments and corroborating evidence. The allegation that staff did not meet the needs of resident #1 was found to be unsubstantiated due to insufficient evidence.

The complaint alleged that staff did not treat resident #1 with dignity or respect, citing inappropriate comments by staff member #1 calling the resident 'entitled.' It also alleged staff did not meet resident #1's care needs, including honoring a room accommodation request and consistent staffing for showers. The dignity allegation was substantiated; the care needs allegation was unsubstantiated.

The allegation that staff did not treat resident #1 with dignity or respect was substantiated based on staff comments and corroborating evidence. The allegation that staff did not meet the needs of resident #1 was unsubstantiated due to insufficient evidence, with other residents reporting their needs were met.

The facility was found deficient in multiple areas including failure to maintain resident dignity with urinary catheter privacy bags, call light accessibility, advance directive documentation, care plan implementation, pressure ulcer prevention, accident hazard prevention, catheter care, feeding tube syringe changes, peripheral IV catheter documentation, oxygen therapy administration and labeling, medication dating and storage security, food safety and preparation, and infection prevention practices.