Deficiencies (last 4 years)
Deficiencies (over 4 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
250% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 10, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards, focusing on safeguarding resident-identifiable information and maintaining accurate medical records.
Findings
The facility failed to maintain accurate documentation of wound care treatments for one sampled resident, resulting in potential miscommunication among staff and inaccurate representation of care provided. Missing documentation was noted for wound treatments on two specific dates in November 2025.
Deficiencies (1)
Failure to maintain accurate documentation of wound care treatments on the resident's Treatment Administration Record (TAR) as per facility policy.
Report Facts
Residents sampled: 2
Residents affected: 1
Missing wound treatment dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse | Interviewed regarding missing wound treatment documentation and confirmed treatments were provided but not documented | |
| Director of Nursing | Stated wound treatment documentation should be accurate to confirm care was provided | |
| Administrator | Stated wound care treatment documentation should be accurate to ensure treatments were provided as ordered |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jul 23, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to care planning, treatment, and wound care for residents, specifically focusing on Resident 1's care needs following a right hip dislocation and wound abscess.
Findings
The facility failed to develop and implement a comprehensive, person-centered care plan for Resident 1, including monitoring the side effects and effectiveness of antibiotic treatments and hip dislocation precautions. Additionally, the facility did not provide appropriate wound care and treatment according to physician orders, with missing documentation and unsigned treatment records, potentially leading to worsening resident outcomes.
Deficiencies (2)
Failure to develop and implement a complete care plan that meets all the resident's needs, including monitoring antibiotic use and hip dislocation precautions for Resident 1.
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, including inadequate wound care and monitoring for Resident 1's right hip abscess.
Report Facts
Residents sampled: 3
Residents affected: 1
Dates with missing treatment signatures: 11
Dates with missing wound monitoring signatures: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Interviewed regarding lack of documentation for hip precaution interventions and wound care treatment |
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse | Interviewed regarding admission care plan initiation and missing treatment signatures |
| Physical Therapist 1 | Physical Therapist | Interviewed regarding hip dislocation care plan and interventions |
| Director of Nursing | Director of Nursing | Interviewed regarding absence of care plans and documentation for Resident 1's hip dislocation and antibiotic use |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 31, 2025
Visit Reason
The inspection was conducted due to allegations of sexual abuse and failure to report suspected abuse, as well as concerns about the functionality of the call light system in resident bathrooms and bathing areas.
Complaint Details
The complaint investigation found that the facility did not report sexual abuse allegations made by Resident 2 to the required authorities. The Director of Nursing denied awareness of such allegations, and the Administrator considered the allegations part of Resident 1's past history.
Findings
The facility failed to timely report an allegation of sexual abuse for one resident to appropriate authorities, potentially delaying investigation and risking further abuse. Additionally, the facility failed to ensure a working call light system for one resident, risking delayed response to resident requests and compromising safety.
Deficiencies (2)
Failed to timely report allegation of sexual abuse for one resident to the California Department of Public Health, Ombudsman, and local law enforcement.
Failed to ensure the call light system was functioning for one resident's bathroom and bathing area.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding awareness of sexual abuse allegations and call light system functionality. |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding importance of functioning call light system. |
| Administrator | Administrator | Interviewed regarding abuse allegations history. |
Inspection Report
Routine
Deficiencies: 10
Date: Apr 17, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, restorative nursing care documentation, feeding tube care, respiratory safety signage, psychotropic medication management, food storage practices, accurate medical record documentation, infection control practices, room size compliance, and call light accessibility.
Deficiencies (10)
Failure to provide dignity and respect to Resident 36 by taking food items and washing boots without permission.
Failure to document restorative nursing care for Resident 18, including application of knee splints and passive range of motion exercises.
Failure to check gastrostomy tube placement prior to water flush and medication administration for Resident 32.
Failure to post No Smoking/Oxygen in Use sign outside Resident 98's room despite continuous oxygen therapy.
Failure to implement gradual dose reduction and monitor efficacy and target behaviors for psychotropic medication (Lexapro) for Resident 35.
Failure to label and date opened food containers and frozen vegetables in the kitchen.
Inaccurate documentation of bowel and bladder assessment for Resident 33, indicating continence when resident was incontinent.
Failure to don full personal protective equipment including N95 respirator and eye protection when entering COVID-19 isolation rooms for Residents 9, 40, 42, and 150; and failure to properly dispose of soiled clothes and diaper for Resident 17.
Failure to ensure 13 multi-bed resident rooms met minimum square footage requirements of 80 sq. ft. per resident.
Failure to ensure call light was within reach for Resident 23, placing resident at risk for delayed assistance.
Report Facts
Medication dose: 2.5
Frozen vegetable bags: 16
Room count: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 4 | CNA | Named in dignity and respect deficiency for taking Resident 36's food and washing boots without permission |
| Licensed Vocational Nurse 2 | LVN | Failed to check gastrostomy tube placement prior to water flush and medication administration for Resident 32 |
| Director of Nursing | DON | Provided multiple interviews regarding deficiencies including dignity, restorative care, feeding tube care, oxygen signage, psychotropic medication management, infection control, and documentation |
| Dietary Supervisor | DS | Interviewed regarding food storage labeling deficiencies |
| Infection Preventionist | IP | Interviewed regarding infection control PPE deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of sexual abuse involving one resident within the required two-hour timeframe to the State Survey Agency, ombudsman, and local law enforcement.
Complaint Details
The complaint involved an allegation of sexual abuse made by Resident 1 on 3/5/2025. The allegation was not reported within the required two-hour timeframe to the State Survey Agency, ombudsman, and local law enforcement. The allegation was substantiated by interviews and record review.
Findings
The facility failed to report an allegation of sexual abuse made by Resident 1 on 3/5/2025 within the mandated two-hour timeframe. Interviews with staff and review of policies confirmed the facility's reporting requirements, but the Administrator did not initiate an investigation or report to the State Survey Agency promptly upon learning of the allegation.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents affected: 1
Timeframe for reporting: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse | LVN | Interviewed regarding mandated reporting responsibilities |
| Director of Nursing | DON | Interviewed about facility reporting policies and procedures |
| Administrator | ADM | Interviewed about the handling and reporting of the sexual abuse allegation |
| Director of Staff Development | DSD | Interviewed regarding staff reporting requirements |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 17, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with posting accurate and complete Census and Direct Care Service Hours Per Patient Day (DHPPD) information as required by facility policy and regulations.
Findings
The facility failed to post the DHPPD form on 9/16/2024 in a prominent place accessible to residents and visitors, and the posted DHPPD forms from 9/8/2024 to 9/12/2024 were incomplete, showing only projected hours without actual direct care service hours. This failure potentially limited access to accurate nurse staffing information.
Deficiencies (2)
Facility did not post the DHPPD on 9/16/2024 in a prominent place readily accessible to residents and visitors.
Facility failed to ensure the posted DHPPD for 9/8/2024 to 9/12/2024 were complete and indicated the total number and actual hours of licensed and unlicensed nursing staff who worked and directly responsible for resident care.
Report Facts
Dates of incomplete DHPPD forms: 5
Date of missing DHPPD posting: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development | DSD | Responsible for posting DHPPD forms; stated inability to post on 9/16/2024 due to workload |
| DSD Consultant | DSDC | Verified DHPPD forms were incomplete and explained policy requirements |
| Accounts Payable and Payroll Director | APPD | Responsible for completing actual DHPPD forms; stated illness prevented completion for 9/11/2024 and other dates |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 20, 2024
Visit Reason
The inspection was conducted as part of a regulatory survey to assess compliance with care standards, focusing on resident safety and care practices.
Findings
The facility failed to ensure that the call light was within reach of one sampled resident, which posed a risk of delayed assistance and potential harm. Multiple staff interviews confirmed the call light was not accessible, and facility policies emphasize the importance of call light accessibility for resident safety.
Deficiencies (1)
Failed to ensure the call light was within reach of Resident 2, risking delayed assistance and potential harm.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant 1 | Certified Nurse Assistant | Confirmed call light was not within reach and found it behind privacy curtains. |
| LVN1 | Licensed Vocational Nurse | Stated importance of call light being within resident's reach to prevent accidents. |
| Registered Nurse | Registered Nurse | Stated it is dangerous for residents not to have call light readily available. |
| Director of Nursing | Director of Nursing | Stated residents should always have call light within reach to prevent accidents. |
| Director of Staff Development | Director of Staff Development | Stated call light must be within reach and not kept behind curtains for safety reasons. |
| Certified Nurse Assistant 2 | Certified Nurse Assistant | Stated importance of answering call light promptly and ensuring it is within reach. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 11, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a fall incident involving Resident 1 on 5/26/2024, where the facility allegedly failed to provide adequate assistance and supervision during transfer to bed.
Complaint Details
The complaint investigation found that Resident 1 fell on 5/26/2024 while attempting to transfer to bed without staff assistance, resulting in a facial laceration. The fall risk assessment was found to be inaccurate, and the facility failed to provide required assistance despite the resident's documented need.
Findings
The facility failed to prevent a fall for Resident 1 who required partial/moderate assistance with transfers and mobility. Certified Nurse Assistant 1 was present but did not assist Resident 1 during transfer, resulting in a fall and laceration to the resident's left eyebrow. The facility's care plan lacked intervention for transfer assistance, and the post-fall risk assessment was inaccurately completed, underestimating the resident's fall risk.
Deficiencies (1)
Failure to prevent a fall due to inadequate supervision and assistance during transfer to bed for Resident 1.
Report Facts
Fall Risk Assessment Score: 7
Residents Sampled: 3
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant 1 | Certified Nurse Assistant | Present in the room during Resident 1's fall but did not assist with transfer. |
| Director of Nursing | Director of Nursing | Provided statements regarding the fall incident, fall risk assessment inaccuracies, and staff assistance failures. |
| MDS Consultant | MDS Consultant | Provided assessment details on Resident 1's need for assistance and commented on the fall incident. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 31, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to readmit a resident (Resident 1) back to the nursing home after hospitalization, exceeding the bed-hold policy.
Complaint Details
The complaint investigation found that Resident 1 was not readmitted after hospitalization on 5/22/2024 despite available beds. The facility required hospice care consent before readmission and later rescinded acceptance. The resident's right to resume residency was violated.
Findings
The facility failed to readmit Resident 1 on 5/22/2024 after hospitalization despite having available beds, citing the need for hospice care before readmission. Interviews and record reviews confirmed the resident's right to return was violated, potentially causing psychosocial harm.
Deficiencies (1)
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Report Facts
Available beds: 3
Available beds: 3
Available beds: 4
Resident room changes: 3
Bed hold period: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Stated Resident 1 would need to be on hospice before readmission and facility was full | |
| Business Office Manager | Explained bed assignment policies and no gender restrictions on empty rooms | |
| Administrator | Provided information on room assignments and hospice recommendations | |
| GACH Case Manager | Provided bed for Resident 1's readmission and reported facility rescinded acceptance | |
| GACH Social Worker | Noted facility required hospice consents before readmission |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 30, 2024
Visit Reason
The inspection was conducted due to a complaint alleging that Social Services staff insulted Resident 1, and the facility failed to timely report and properly investigate the alleged abuse as required by policy.
Complaint Details
The complaint involved Resident 1 alleging that Social Services staff screamed, yelled, and made hurtful and insulting statements to him. The facility failed to report the alleged abuse within two hours, failed to suspend the accused staff member, and did not submit the required 5-day follow-up investigation report to CDPH. The administrator did not consider the incident abuse and refused to suspend the staff or send the report.
Findings
The facility failed to report the alleged abuse within two hours to the appropriate authorities, failed to suspend the accused staff member pending investigation, and did not submit the required 5-day follow-up investigation report to the California Department of Public Health. The administrator refused to suspend the staff or send the investigation report, contrary to facility policy.
Deficiencies (2)
Failure to timely report suspected abuse to proper authorities.
Failure to respond appropriately to alleged violations by not suspending accused staff and not submitting required follow-up investigation report.
Report Facts
Residents Affected: 1
Days for follow-up report: 5
Timeframe for abuse reporting: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services | Staff | Accused of making insulting statements to Resident 1 |
| Director of Staff Development | Received complaint from Resident 1 and did not report to Administrator as required | |
| Administrator | Refused to suspend Social Services staff and refused to send investigation report to CDPH |
Inspection Report
Routine
Deficiencies: 16
Date: May 5, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, infection control, facility safety, and staff training at Foothill Heights Care Center.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consents for psychotropic medications, call lights not within reach for some residents, failure to notify physician of change in condition after a fall, failure to submit discharge tracking forms timely, lack of baseline and comprehensive care plans, improper nephrostomy bag positioning, failure to act on pharmacist recommendations, unsafe medication handling, expired food in refrigerator, issues with binding arbitration agreements, inadequate infection control practices, incomplete vaccination documentation and monitoring, insufficient room sizes for multiple resident rooms, and incomplete staff training documentation.
Deficiencies (16)
Failure to obtain informed consents for psychotropic medications for two residents.
Call lights were not within sight and reach for four residents while in bed.
Failure to ensure responsible party was informed about advance directives for one resident.
Failure to notify physician of change in condition after a fall for one resident.
Failure to submit Minimum Data Set Discharge Tracking Forms to CMS within required timeframe for two residents.
Failure to develop a baseline care plan within 48 hours of admission for one resident.
Failure to develop and implement a care plan to address behavior of getting up unassisted from wheelchair for one resident.
Nephrostomy bag was improperly positioned at kidney level instead of below kidney level for one resident.
Failure to act upon pharmacist's recommendation for A1C blood test for one resident with diabetes.
Medications were left unattended during medication administration observation for one resident.
Expired ground beef was found in the refrigerator past the use-by date.
Failure to comply with binding arbitration agreement requirements for three residents.
Failure to sanitize blood pressure cuff between residents' use for two residents.
Failure to document influenza and pneumococcal vaccine administration and monitor resident for side effects for one resident.
Multiple resident rooms did not meet minimum square footage requirements.
Failure to maintain an effective training program with proper documentation for staff.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Rooms: 13
In-service logs: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 2 | LVN | Named in medication administration and call light findings |
| Licensed Vocational Nurse 3 | LVN | Named in nephrostomy bag and fall notification findings |
| Director of Nursing | DON | Named in fall notification, nephrostomy bag, medication safety, and vaccination findings |
| Infection Preventionist | IP | Named in informed consent, infection control, and vaccination findings |
| Certified Nurse Assistant 4 | CNA | Named in fall risk behavior findings |
| Licensed Vocational Nurse 4 | LVN | Named in fall notification findings |
| Registered Nurse 1 | RN | Named in vaccination monitoring findings |
| Accounts Payable/Admissions | AA | Named in binding arbitration agreement findings |
| Dietary Supervisor | DS | Named in expired food findings |
| Licensed Vocational Nurse 1 | LVN | Named in medication administration and fall notification findings |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 5, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify the physician of a change in condition for Resident 22 after a fall on 4/24/2024 and failure to develop and implement a care plan addressing the resident's behavior of getting up unassisted from the wheelchair.
Complaint Details
The complaint investigation focused on Resident 22's fall on 4/24/2024, failure to notify the physician timely, and lack of a care plan to prevent falls related to the resident's behavior of getting up unassisted from the wheelchair. The investigation included interviews with nursing staff, the Director of Nursing, the Medical Director, dialysis nurse, and review of medical records and facility policies.
Findings
The facility failed to notify the physician promptly after Resident 22's fall resulting in a head injury and laceration, and failed to develop and implement a care plan to address Resident 22's behavior of getting up unassisted from the wheelchair, increasing the risk of falls and injury.
Deficiencies (2)
Failed to notify the physician of a change in condition for Resident 22 after a fall on 4/24/2024.
Failed to develop and implement a care plan to address Resident 22's behavior of getting up out of the wheelchair unassisted.
Report Facts
Residents sampled: 14
Date of fall: Apr 24, 2024
Date of survey completion: May 5, 2024
Date of admission: Resident 22 readmitted on undisclosed date
Date of History and Physical: Jan 24, 2024
Date of Minimum Data Set: Mar 31, 2024
Date of Fall Risk Assessment: Apr 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Licensed Vocational Nurse | Left message and sent text to MD after Resident 22's fall; did not continue attempts to contact MD |
| LVN 4 | Licensed Vocational Nurse | Interviewed regarding emergency procedures and communication with MD |
| DN | Dialysis Nurse | Reported Resident 22's injuries and pain during dialysis and communication with Physician Assistant |
| DON | Director of Nursing | Stated that LVN 3 should have called 911 and sent Resident 22 for evaluation when MD did not respond |
| MD | Medical Doctor | Provided standard practice instructions for unwitnessed falls with head injury and communication expectations |
| LVN 1 | Licensed Vocational Nurse | Interviewed about assessment and notification procedures after head injury fall |
| CNA 4 | Certified Nurse Assistant | Reported on Resident 22's behavior and supervision practices |
| IPN | Infection Preventionist Nurse | Interviewed regarding absence of care plan for Resident 22's behavior |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 8, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically to assess whether a comprehensive, resident-centered care plan was developed and implemented for sampled residents.
Findings
The facility failed to develop a comprehensive care plan for one of three sampled residents, resulting in potential harm due to lack of specific interventions to prevent decline in functional ability. The care plan for osteoporosis included inappropriate interventions and omitted necessary medication supplementation.
Deficiencies (1)
Failed to develop and implement a complete care plan that meets all the resident's needs, with timetables and measurable actions for Resident 1.
Report Facts
Residents sampled: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding Resident 1's diagnosis and care plan | |
| Administrator | Interviewed regarding Resident 1's diagnosis and care plan | |
| Minimum Data Set Nurse | Interviewed regarding care plan interventions for Resident 1 |
Inspection Report
Routine
Deficiencies: 1
Date: Dec 27, 2023
Visit Reason
The inspection was conducted to assess whether the facility ensured that Licensed Vocational Nurses (LVNs) completed and had their annual competency skills checked according to the facility's policy and procedure.
Findings
The facility failed to maintain a licensed competency skills log for licensed nurses, and some LVNs had not completed or signed competency skills forms. The Director of Nursing and Director of Staff Development acknowledged the lack of a specific tracking method and incomplete documentation of annual competencies.
Deficiencies (1)
Failure to ensure Licensed Vocational Nurses annual competency skills were checked and completed based on facility policy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development | Director of Staff Development | Interviewed regarding lack of licensed competency skills log and incomplete competency documentation. |
| Director of Nursing | Director of Nursing | Interviewed regarding annual competency process and policy review. |
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Interviewed and stated not having signed or seen competency skills forms. |
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse | Interviewed and stated not having completed licensed nurse competency skills. |
Inspection Report
Deficiencies: 2
Date: Nov 7, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with respiratory care standards, specifically regarding oxygen therapy and respiratory care services for residents.
Findings
The facility failed to provide safe and appropriate respiratory care for one sampled resident by not maintaining the oxygen humidifier with sterile water, which could cause nasal dryness and discomfort, and by improper monitoring of oxygen delivery devices. Several staff interviews confirmed lapses in monitoring and changing the humidifier as required by facility policy.
Deficiencies (2)
Resident 1's oxygen humidifier bottle was empty and did not have sterile water, risking nasal dryness and serious complications.
Resident 1's nasal cannula was not properly monitored, placing the resident at risk for shortness of breath and/or hypoxia.
Report Facts
Oxygen flow rate: 2
Oxygen saturation: 95
Date of Order Summary Report: Aug 21, 2023
Date of MDS assessment: Oct 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 (LVN 1) | Interviewed regarding oxygen use and humidifier monitoring | |
| Licensed Vocational Nurse 2 (LVN 2) | Confirmed oxygen humidifier was empty during observation | |
| Infection Preventionist Nurse (IP Nurse) | Provided information on oxygen saturation and humidifier monitoring | |
| Director of Nursing (DON) | Interviewed about resident condition and facility monitoring policies |
Inspection Report
Deficiencies: 2
Date: Nov 7, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with respiratory care standards, specifically regarding oxygen therapy and respiratory care services for residents.
Findings
The facility failed to provide safe and appropriate respiratory care for one resident by not maintaining the oxygen humidifier with sterile water, which could cause nasal dryness and discomfort, and by improper monitoring of the resident's oxygen delivery device, placing the resident at risk for hypoxia and other complications.
Deficiencies (2)
Resident 1's oxygen humidifier bottle was empty and did not have sterile water, risking nasal dryness and serious complications.
Resident 1's nasal cannula was not properly monitored and was found hanging off the bed, risking shortness of breath and hypoxia.
Report Facts
Oxygen flow rate: 2
Oxygen saturation: 95
Date of Order Summary Report: Aug 21, 2023
Date of MDS assessment: Oct 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Interviewed regarding oxygen therapy monitoring and humidifier maintenance |
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse | Confirmed oxygen humidifier was empty during observation |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Provided information on oxygen saturation and humidifier monitoring |
| Director of Nursing | Director of Nursing | Interviewed regarding resident's respiratory condition and facility monitoring procedures |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 2, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure proper care and supervision of Resident 1 during activities of daily living, specifically toilet use, which resulted in a fall and injury.
Complaint Details
The complaint investigation found that Resident 1 was left alone during toilet use despite requiring extensive assistance, leading to a fall and head injury. The complaint was substantiated based on interviews with CNA 1, LVN 1, MDS nurse, and review of medical records and facility policies.
Findings
The facility failed to provide adequate assistance and supervision to Resident 1 during toilet use, leading to an unwitnessed fall causing a head abrasion. Interviews and record reviews confirmed that Resident 1 required extensive assistance and should not have been left alone. The facility's policies and staff training on fall prevention and ADL support were reviewed.
Deficiencies (2)
Failure to ensure certified nurse assistant provided care and services for Resident 1 with activities of daily living for toilet use, resulting in a fall and injury.
Failure to ensure nursing home area is free from accident hazards and provides adequate supervision to prevent accidents for Resident 1 during toilet use.
Report Facts
Date of fall incident: Jul 27, 2023
Head abrasion size: 1
Tylenol dosage: 325
Physical therapy frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in deficiency for leaving Resident 1 alone during toilet use |
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding Resident 1's need for close monitoring during toilet use |
| MDS nurse | Provided assessment details on Resident 1's need for assistance during ADLs |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 8, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide requested medical records within the required timeframe to a resident's representative.
Complaint Details
The complaint was substantiated as the facility did not provide the requested medical records within the required timeframe, delaying access for the resident's representative.
Findings
The facility failed to provide copies of the requested medical records within two working days as required by policy, resulting in a delay for the resident's representative to obtain the records. Interviews confirmed that only some records were sent and the rest were still under review at the time of inspection.
Deficiencies (1)
Failure to provide copies of requested medical records within two working days as required by facility policy.
Report Facts
Request forms: 3
Timeframe for providing records: 72
Advance notice: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Records (MR) | Interviewed regarding delays in providing medical records | |
| Director of Nursing (DON) | Interviewed regarding facility policy and delays in providing medical records |
Inspection Report
Routine
Deficiencies: 6
Date: Nov 5, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, food safety, infection control, and facility environment at Foothill Heights Care Center.
Findings
The facility was found deficient in multiple areas including failure to update a resident's care plan after a fall, medication errors involving crushing and mixing medications, mislabeled controlled substance medication, improper food storage practices, inadequate use of personal protective equipment for infection control, and resident rooms not meeting minimum square footage requirements.
Deficiencies (6)
Failed to review and revise Resident 27's care plan after a fall on 10/30/2021.
Medication error rate of 10.71% due to crushing and mixing three medications together for Resident 37.
Pharmacy mislabeled Resident 41's hydrocodone bubble pack by not indicating it was an as needed (PRN) medication.
Food stored, prepared, served, and distributed improperly, including unlabeled opened sausage box, undated sandwiches and soup, and storage of dry supplies in refrigerator.
Failed to ensure proper use of personal protective equipment (PPE) for Resident 92 who was a person under investigation for Covid-19.
Eleven resident rooms did not meet the minimum requirement of 80 square feet per resident in multiple bed rooms.
Report Facts
Medication error rate: 10.71
Morse Fall Scale score: 35
Medication count: 28
Resident rooms below minimum square footage: 11
Square footage: 137.61
Square footage: 142.5
Square footage: 158.33
Square footage: 283.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development | Director of Staff Development (DSD) | Stated Resident 27's care plan should be updated after a fall |
| Registered Nurse 1 | Registered Nurse 1 (RN 1) | Stated care plans should be updated every three months or after change of condition; also stated licensed nurses should never crush and mix medications |
| Licensed Vocational Nurse 3 | Licensed Vocational Nurse 3 (LVN 3) | Observed crushing and mixing medications for Resident 37 |
| Director of Nursing | Director of Nursing (DON) | Stated mixing medications can be dangerous and will ensure proper medication administration training |
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse 1 (LVN 1) | Noted hydrocodone bubble pack mislabeled and stated licensed nurse should check physician orders against pharmacy labels |
| Dietary Supervisor 1 | Dietary Supervisor 1 (DS 1) | Observed food storage issues and explained refrigerator use and food origin |
| Certified Nursing Assistant 2 | Certified Nursing Assistant 2 (CNA 2) | Observed not wearing gown or gloves when entering Resident 92's room |
| Infection Preventive Nurse | Infection Preventive Nurse (IPN) | Stated facility staff must use PPE including gown, goggles, N95 mask, and gloves for Resident 92 |
Viewing
Loading inspection reports...
