Deficiencies (last 4 years)
Deficiencies (over 4 years)
22.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
458% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Routine
Deficiencies: 13
Date: Apr 28, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and administrative licensing.
Findings
The facility was found deficient in multiple areas including failure to follow advance directive policies, incomplete care plans for residents, improper medication administration and monitoring, inadequate respiratory care, bed rail safety assessments, pharmaceutical service deficiencies, psychotropic medication use without non-pharmacological attempts, food palatability and safety issues, unsanitary kitchen conditions, expired administrator license, infection control lapses, and laundry equipment maintenance.
Deficiencies (13)
Failure to ensure policy and procedure was followed for advance directives for six of eight sampled residents.
Failure to develop and implement comprehensive care plans for continuous oxygen use and significant weight loss for two residents.
Failure to ensure appropriate treatment and care according to orders and resident preferences for one resident receiving hydrocodone-acetaminophen.
Failure to provide safe and appropriate respiratory care for two residents related to oxygen therapy orders.
Failure to complete bed rail entrapment assessments, attempt alternatives, and complete care plans for bed rail use for multiple residents.
Failure to ensure effective use of medications when ferrous sulfate and calcium were administered concurrently to one resident.
Failure to ensure licensed pharmacist performed monthly medication regimen review and follow up on recommendations for two residents.
Failure to implement non-pharmacological interventions prior to administering psychotropic medications for three residents.
Failure to ensure food palatability and nutritive value; foods tasted bland and were held in heated oven for extended periods.
Failure to ensure food safety and sanitation in kitchen including unsanitary cooking equipment, improper chemical storage, accessible ice scoop, and poor hand hygiene by staff.
Failure to ensure administrator license was current; administrator worked without supervision after license expiration.
Failure to implement infection prevention and control practices including hand hygiene, glove use, oxygen equipment maintenance, face mask use, labeling of resident care supplies, and PPE receptacle availability.
Failure to keep dryer lint filters clean, creating potential fire hazard.
Report Facts
Residents affected by advance directive deficiency: 6
Residents affected by care plan deficiency: 2
Residents affected by medication administration deficiency: 1
Residents affected by respiratory care deficiency: 2
Residents affected by bed rail deficiency: 48
Residents affected by pharmaceutical service deficiency: 1
Residents affected by medication regimen review deficiency: 2
Residents affected by psychotropic medication deficiency: 3
Residents affected by food palatability deficiency: 49
Residents affected by infection control deficiency: Some
Residents affected by dryer lint filter deficiency: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse D | RN | Acknowledged oxygen use and medication order issues for Resident 27 and Resident 31. |
| Licensed Vocational Nurse F | LVN | Confirmed oxygen therapy issues and weight loss care plan deficiency. |
| Director of Nursing | DON | Confirmed multiple deficiencies including care plans, medication reviews, bed rail assessments, and infection control. |
| Pharmacy Consultant | PC | Confirmed medication regimen review failures and drug interaction concerns. |
| Cook I | Cook | Acknowledged food palatability issues and improper food holding. |
| Maintenance Director | MD | Acknowledged bed rail safety assessment failures and ice scoop placement. |
| Certified Nursing Assistant G | CNA | Observed not sanitizing hands before feeding resident. |
| Certified Nursing Assistant H | CNA | Observed improper glove use and contamination. |
| Certified Nursing Assistant A | CNA | Observed wearing face mask below nose. |
| Housekeeping/Laundry Staff E | HLS | Observed dryer lint filters not cleaned. |
Inspection Report
Routine
Deficiencies: 13
Date: Apr 28, 2025
Visit Reason
Routine inspection of Empress Care Center, LLC to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to follow advance directive policies, incomplete care plans for residents, improper medication administration, inadequate respiratory care, incomplete bed rail assessments, medication regimen review failures, improper psychotropic medication use, food palatability and safety issues, unsanitary kitchen conditions, expired administrator license, infection control lapses, and laundry safety concerns.
Deficiencies (13)
F 0578: Facility failed to ensure policy was followed for advance directives for six of eight sampled residents, risking delivery of unwanted medical services.
F 0656: Facility failed to develop and implement comprehensive care plans for two residents regarding continuous oxygen use and significant weight loss.
F 0684: Facility failed to ensure appropriate treatment and care when licensed nurses administered hydrocodone-acetaminophen for moderate pain without proper physician notification.
F 0695: Facility failed to provide safe and appropriate respiratory care by not administering oxygen therapy as ordered for two residents.
F 0700: Facility failed to complete bed rail entrapment assessments for 48 residents, attempt alternatives for six residents, and complete a bed rail care plan for one resident.
F 0755: Facility failed to ensure effective medication use when one resident received ferrous sulfate and calcium simultaneously, reducing iron absorption.
F 0756: Facility failed to ensure licensed pharmacist performed monthly medication regimen review and follow-up, resulting in one resident receiving excessive vitamin D dose and another receiving prolonged medication without review.
F 0758: Facility failed to ensure residents were free from unnecessary psychotropic medications by not documenting non-pharmacological approaches before administration for three residents.
F 0804: Facility failed to ensure food palatability and nutritive value by serving bland foods and holding foods in heated ovens for extended periods.
F 0812: Facility failed to ensure food safety by using unsanitary cooking equipment, storing corrosive chemicals near utensils, improperly placing ice scoop, and kitchen staff failing hand hygiene during tray preparation.
F 0836: Facility failed to ensure the administrator's license was current while working without supervision after expiration for more than 10 days.
F 0880: Facility failed to implement infection prevention and control practices including improper hand hygiene, contaminated gloves, undated oxygen tubing, dusty oxygen concentrator filter, improper mask use, unlabeled ADL supplies, and lack of PPE receptacle in isolation room.
F 0908: Facility failed to keep essential equipment safe by not cleaning lint filters in dryers, creating fire hazard risk.
Report Facts
Residents affected: 6
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 48
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 49
Pans with discoloration: 12
Dryers with lint: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse D | RN | Acknowledged care plan and medication order issues for residents |
| Licensed Vocational Nurse F | LVN | Confirmed oxygen therapy and care plan deficiencies |
| Director of Nursing | DON | Confirmed multiple deficiencies including care plans, medication reviews, and infection control |
| Pharmacy Consultant | PC | Confirmed medication regimen review failures |
| Cook I | Cook | Acknowledged food palatability and kitchen sanitation issues |
| Maintenance Director | MD | Acknowledged bed rail safety and ice scoop placement issues |
| Certified Nursing Assistant G | CNA | Failed hand hygiene before feeding resident |
| Certified Nursing Assistant H | CNA | Used contaminated gloves improperly |
| Certified Nursing Assistant A | CNA | Wore face mask below nose |
| Housekeeping/Laundry Staff E | HLS | Failed to clean dryer lint filters |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 16, 2024
Visit Reason
The inspection was conducted due to an alleged abuse complaint involving a resident, to investigate the failure to timely report suspected abuse as required by state law.
Complaint Details
The complaint involved an alleged abuse incident reported by a Certified Nurse Aide who witnessed another CNA shove graham crackers into a resident's mouth and pull the resident's ear. The report was delayed due to intimidation. The complaint was substantiated as the facility failed to report the abuse immediately as required.
Findings
The facility failed to ensure an alleged abuse involving a resident was reported immediately to the administrator or other officials within the required timeframe. The alleged abuse involved a Certified Nurse Aide shoving graham crackers into a resident's mouth and pulling the resident's ear, and the delay in reporting was due to intimidation of the reporting staff member.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. The alleged abuse was not reported immediately as required by state law.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development | Director of Staff Development | Interviewed regarding the abuse report and facility policy. |
| Director of Nursing | Director of Nursing | Interviewed regarding the reporting of the alleged abuse. |
Inspection Report
Deficiencies: 1
Date: Oct 16, 2024
Visit Reason
The inspection was conducted to investigate the facility's compliance with timely reporting of suspected abuse, neglect, or theft and the reporting of investigation results to proper authorities.
Findings
The facility failed to ensure that an alleged abuse involving a resident was reported immediately to the administrator or other officials in accordance with State law. The delay in reporting had the potential to cause further psychosocial and/or physical harm to the resident.
Deficiencies (1)
Failure to timely report suspected abuse involving a resident as required by State law.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide A | Certified Nurse Aide | Reported alleged abuse involving Resident 1 |
| Certified Nurse Aide B | Certified Nurse Aide | Alleged abuser in the abuse report involving Resident 1 |
| Director of Staff Development | Director of Staff Development | Interviewed regarding abuse report and facility policy |
| Director of Nursing | Director of Nursing | Interviewed regarding reporting of alleged abuse |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Dec 22, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements including resident care, medication administration, infection control, and facility safety.
Findings
The facility had multiple deficiencies including failure to complete advance directives and POLST forms for residents, incomplete PASRR mental health screening, lack of comprehensive person-centered care plans, failure to notify physicians of significant weight changes, improper medication administration, unsafe use of bed rails, infection control lapses, and failure to follow pneumococcal vaccination protocols.
Deficiencies (13)
F 0578: Facility failed to complete advance directive and POLST forms for 11 of 15 sampled residents, risking delivery of inappropriate medical services.
F 0645: Facility failed to accurately complete PASRR mental health screening for one resident, potentially limiting access to specialized mental health services.
F 0656: Facility failed to develop comprehensive, person-centered care plans for four residents, including lack of care plan for hearing aid use for one resident.
F 0684: Facility failed to notify physicians and perform alert charting for significant weight changes in residents, improperly managed blood pressure medication orders, used alcohol wipes incorrectly after blood draws, and failed to manage diabetes care appropriately.
F 0700: Facility failed to obtain informed consent, conduct assessments, and properly document use of bed rails for six residents, risking resident safety.
F 0758: Facility failed to limit PRN psychotropic medication orders to 14 days for one resident, risking unnecessary medication administration.
F 0759: Facility had a medication error rate of 7.41% with two medication errors involving wrong aspirin formulation and administering another resident's eye drops.
F 0761: Facility failed to label lubricant eye drop bottles with resident identification, resulting in medication administration errors.
F 0806: Facility failed to accommodate food preferences for two residents by serving disliked foods, risking decreased meal intake and negative health effects.
F 0812: Facility failed to maintain safe and sanitary food service operations including storing dented cans, lack of air gap in two-compartment sink, and staff not following hand hygiene and glove use protocols.
F 0880: Facility failed to implement infection control practices including hand hygiene lapses, improper PPE use, staff mask misuse, and urine drainage bag placement on floor.
F 0883: Facility failed to follow pneumococcal vaccination protocols for four residents, missing recommended vaccine doses and timing.
F 0909: Facility failed to ensure proper fitting and inspection of bed rails for three residents, resulting in loose and unsafe bed rails.
Report Facts
Medication error rate: 7.41
Weight loss: 12.6
Weight gain: 7.8
Weight loss: 9.4
BIMS score: 3
MDS assessment date: Nov 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in medication error findings and care plan interviews |
| LVN E | Licensed Vocational Nurse | Named in medication administration and infection control findings |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including bed rails, infection control, and care plans |
| SSD | Social Service Director | Interviewed regarding advance directives and infection control mask use |
| MS | Maintenance Supervisor | Interviewed regarding bed rail fitting and kitchen sanitation |
| CP | Consultant Pharmacist | Interviewed regarding medication administration errors |
| RN F | Licensed Vocational Nurse | Named in medication administration error with eye drops |
| RN C | Registered Nurse | Named in infection control PPE misuse |
| CNA G | Certified Nursing Assistant | Named in infection control and catheter care findings |
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Dec 22, 2023
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements including resident rights, care planning, infection control, medication administration, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to complete advance directives and POLST forms for sampled residents, incomplete PASRR mental health screening, inadequate comprehensive care plans, failure to notify physicians and document weight changes, improper medication administration, unsafe use and documentation of bed side rails, infection control lapses, improper food service practices, and failure to follow pneumococcal vaccination protocols.
Deficiencies (16)
Failure to complete advance directives and POLST forms for 11 of 15 sampled residents.
Failure to ensure accurate PASRR mental health screening for one of two residents.
Failure to develop and implement comprehensive, person-centered care plans for four of fifteen sampled residents.
Failure to notify physician and document alert charting for significant weight changes in residents.
Failure to follow proper procedures during blood glucose testing including use of alcohol wipes to wipe blood.
Physician orders for blood pressure medications lacked holding parameters.
Failure to follow diabetes management protocols including diet and blood glucose monitoring.
Failure to obtain informed consent, conduct assessments, and properly document use of bed side rails for six sampled residents.
Physician order for PRN psychotropic medication lacked a 14-day limit.
Medication errors including administering wrong formulation of aspirin and wrong eye drops to residents.
Failure to properly label eye drop bottles leading to medication errors.
Failure to accommodate food preferences for two residents resulting in serving disliked foods.
Unsafe and unsanitary food service practices including dented cans, lack of air gap in sink, and improper hand hygiene by maintenance staff.
Multiple infection control failures including improper hand hygiene, improper PPE use, and urine drainage bag on floor.
Failure to follow pneumococcal vaccination protocols for four sampled residents.
Failure to ensure bed side rails were properly fitted and secured for three sampled residents.
Report Facts
Medication error rate: 7.41
Weight loss: 12.6
Weight gain: 7.8
Weight loss: 9.4
Hearing aid refusal: 3
Medication doses: 81
Medication doses: 0.5
Medication opportunities: 27
Medication errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Verified lack of comprehensive care plans and medication administration errors. |
| DON | Director of Nursing | Verified multiple deficiencies including care plans, infection control, medication errors, and bed rail safety. |
| SSD | Social Service Director | Verified missing advance directives and improper mask use. |
| LVN E | Licensed Vocational Nurse | Administered wrong aspirin formulation and failed hand hygiene after medication administration. |
| LVN F | Licensed Vocational Nurse | Administered wrong eye drops and failed to label medication bottles. |
| MS | Maintenance Supervisor | Acknowledged lack of air gap in kitchen sink and improper hand hygiene. |
| RN C | Registered Nurse | Wore N95 mask over surgical mask improperly. |
| CNA G | Certified Nursing Assistant | Acknowledged improper placement of urine drainage bag. |
| IP | Infection Preventionist | Confirmed infection control lapses and vaccination deficiencies. |
| CP | Consultant Pharmacist | Confirmed medication administration errors and labeling issues. |
| DS | Dietary Supervisor | Confirmed food service deficiencies including serving disliked foods and dented cans. |
| RN | Registered Nurse | Observed failing to perform hand hygiene between glove changes. |
Inspection Report
Routine
Deficiencies: 16
Date: Sep 2, 2022
Visit Reason
Routine inspection of Empress Care Center, LLC to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to notify physicians upon resident discharge, incomplete significant change assessments, failure to transmit Minimum Data Set assessments, incomplete care plans, inadequate skin assessments and treatments, failure to follow fall prevention orders, improper oxygen therapy, unacted pharmacist medication recommendations, unnecessary medications, medication administration errors, menu deviations, unsafe food storage and preparation practices, infection control lapses, and maintenance issues affecting resident safety and comfort.
Deficiencies (16)
F0622: The facility failed to notify the physician upon discharge of Resident 49 and did not complete a discharge summary or obtain a physician's order for discharge.
F0637: The facility failed to complete a significant change in status assessment for Resident 48 after weight loss and decline in activities of daily living.
F0640: The facility failed to transmit Minimum Data Set quarterly assessments electronically to CMS for Resident 44.
F0656: The facility failed to develop comprehensive person-centered care plans for Residents 21, 26, and 30 addressing anxiety, hearing difficulty, bleeding precautions, and antipsychotic medication use.
F0684: The facility failed to monitor and document skin condition changes for Resident 22, resulting in progression of skin blisters and risk of infection.
F0686: The facility failed to ensure prescribed pressure ulcer treatments were followed for Residents 43 and 44, including use of correct solutions and irrigation.
F0689: The facility failed to implement a fall prevention order for Resident 20 by not placing a pad alarm on the bed.
F0695: The facility failed to administer oxygen therapy properly for Resident 3, with an unclean and empty humidifier bottle.
F0756: The facility failed to act on consultant pharmacist medication regimen review recommendations for Residents 7, 37, and 44, resulting in unnecessary medications and lack of monitoring.
F0757: Resident 7 received long-term diuretic and levothyroxine without routine electrolyte and thyroid function monitoring, risking serious medical conditions.
F0759: The facility had a medication error rate of 10.71% with errors including improper phenytoin administration, and insulin given too early before meals for Residents 30 and 37.
F0803: The facility failed to follow the planned menu when roast beef was served instead of Swedish meatballs for 11 residents on mechanical soft diet.
F0812: The facility failed to ensure food was stored and prepared under safe and sanitary conditions including thawing meatballs at room temperature, improper storage of sanitizing supplies, broken oven door, unclean can opener, crumbs under microwave, personal items in food areas, and incomplete ice scooper cleaning logs.
F0813: The facility failed to properly store, label, and date food brought from outside for Resident 6, risking foodborne illness.
F0880: The facility failed to implement infection control practices including failure to change oxygen tubing weekly for Residents 4 and 43, hand hygiene lapses by staff, and failure to disinfect medication trays between residents.
F0921: Resident 21's bathroom sink was clogged and toilet bowl leaked water onto the floor, creating an unsafe and unsanitary environment; maintenance was unaware and preventive maintenance was not performed.
Report Facts
Medication error rate: 10.71
Residents affected by deficiencies: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Licensed Vocational Nurse | Named in findings related to skin care treatment lapses and infection control failures |
| RN K | Registered Nurse | Interviewed regarding Minimum Data Set assessments and medication administration |
| NS | Nursing Supervisor | Observed and interviewed regarding medication administration errors and care plans |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication regimen reviews and infection control |
| CNA I | Certified Nursing Assistant | Observed not performing hand hygiene before feeding Resident 13 |
| CNA L | Certified Nursing Assistant | Observed not performing hand hygiene between residents |
| KS | Kitchen Supervisor | Interviewed regarding food safety and sanitation deficiencies |
| DM | Dietary Manager | Interviewed regarding food safety and menu compliance |
| RD | Registered Dietitian | Interviewed regarding menu compliance and food safety |
| CP | Consultant Pharmacist | Interviewed regarding medication regimen review recommendations |
| MS | Maintenance Supervisor | Interviewed regarding maintenance issues and preventive maintenance |
| IP | Infection Preventionist | Interviewed regarding infection control practices |
Inspection Report
Routine
Deficiencies: 16
Date: Sep 2, 2022
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements for nursing home care, including resident care, medication management, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to notify physicians upon resident discharge, incomplete significant change assessments, failure to transmit Minimum Data Set assessments timely, incomplete care plans, inadequate skin assessment and treatment, failure to follow fall prevention orders, improper oxygen therapy, unacted pharmacist medication recommendations, unnecessary medications, medication administration errors, failure to follow menus, unsafe food storage and preparation, improper infection control practices, and unsafe environmental conditions such as leaking toilets and clogged sinks.
Deficiencies (16)
Failed to notify the physician upon discharge of Resident 49.
Failed to complete a significant change in status assessment for Resident 48.
Failed to transmit Minimum Data Set quarterly assessments to CMS for Resident 44.
Failed to develop and implement comprehensive person-centered care plans for Residents 21, 26, and 30.
Failed to assess and monitor skin condition of Resident 22, resulting in progression of skin blisters.
Failed to ensure prescribed treatment for pressure ulcers was followed for Residents 43 and 44.
Failed to follow fall prevention order for Resident 20 when pad alarm was not placed in bed.
Failed to administer oxygen therapy according to standards for Resident 3; humidifier bottle was empty and unclean.
Failed to act on consultant pharmacist medication regimen review recommendations for Residents 7, 37, and 44.
Failed to ensure Residents 36 and 44 were free from unnecessary psychotropic medications and required monitoring tests were not done.
Medication administration errors for Residents 30, 37, and 40 including improper shaking of phenytoin, insulin given too early before meals.
Failed to follow planned menu; roast beef served instead of Swedish meatballs for mechanical soft diet residents.
Failed to ensure food was stored and prepared under safe and sanitary conditions including thawing meatballs at room temperature, broken oven door, unsanitary can opener, crumbs under microwave, personal items in food prep area, and incomplete cleaning logs.
Failed to properly store and label food brought from outside for Resident 6.
Failed to implement infection control practices including failure to change oxygen tubing weekly, hand hygiene lapses by staff, and failure to disinfect medication trays between residents.
Failed to maintain a safe and functional environment; Resident 21's bathroom sink was clogged and toilet bowl leaked with water on floor.
Report Facts
Medication error rate: 10.71
Resident sample size: 15
Resident sample size: 12
Residents affected: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse K | Registered Nurse | Reviewed clinical records and confirmed failure to transmit MDS assessments and incomplete significant change assessment. |
| Director of Nursing | Director of Nursing | Confirmed multiple deficiencies including failure to notify physician, medication regimen review follow-up, and infection control lapses. |
| Licensed Vocational Nurse D | Licensed Vocational Nurse | Observed failing to follow wound care protocols and infection control practices. |
| Nurse Supervisor | Nurse Supervisor | Observed medication administration errors and infection control lapses. |
| Consultant Pharmacist | Consultant Pharmacist | Made medication regimen review recommendations that were not acted upon. |
| Kitchen Supervisor | Kitchen Supervisor | Acknowledged unsafe food handling and storage practices. |
| Dietary Manager | Dietary Manager | Confirmed food safety and menu compliance issues. |
| Registered Dietitian | Registered Dietitian | Confirmed menu and food safety deficiencies. |
| Certified Nursing Assistant B | Certified Nursing Assistant | Unaware of fall prevention pad alarm order. |
| Certified Nursing Assistant I | Certified Nursing Assistant | Failed to perform hand hygiene before feeding resident. |
| Maintenance Supervisor | Maintenance Supervisor | Unaware of leaking toilet and clogged sink; acknowledged lack of preventive maintenance. |
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