Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
188% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
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
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: 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
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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