Citations (last 4 years)
Citations (over 4 years)
21.3 citations/year
Citations are regulatory findings recorded during state inspections.
433% worse than California average
California average: 4 citations/yearCitations per year
40
30
20
10
0
Occupancy
Latest occupancy rate
94% occupied
Based on a October 2024 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Citations: 2
Date: Dec 10, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to maintain resident privacy and to ensure the environment was free from accident hazards, specifically concerning Resident 1's treatment and safety.
Complaint Details
The complaint investigation found substantiated issues regarding Resident 1's privacy violation and environmental safety hazards related to the arm positioning device left on the resident's arm, with potential negative effects on psychosocial well-being and safety.
Findings
The facility failed to maintain Resident 1's privacy when a licensed nurse used her personal phone to take a photograph of the resident's arm tied to the bed, violating privacy rights. Additionally, the facility failed to ensure Resident 1's environment was free from accident hazards by leaving an arm positioning device secured to the resident's bedframe beyond the appropriate time, potentially causing harm.
Citations (2)
Failure to maintain residents' personal and medical records private and confidential, including unauthorized photo taken on personal phone.
Failure to ensure nursing home area is free from accident hazards; Resident 1's arm remained in an arm positioning device secured to bedframe beyond appropriate time.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 3 | Licensed Nurse | Named in privacy violation finding for taking a photograph of Resident 1's arm on personal phone. |
| LN 1 | Licensed Nurse | Informed about arm positioning device and involved in removal and reporting process. |
| CNA 1 | Certified Nursing Assistant | Reported arm positioning device on Resident 1 and removed it during care. |
| CNA 2 | Certified Nursing Assistant | Reported arm positioning device and communicated with CNA 1 and nurses. |
| CNA 3 | Certified Nursing Assistant | Informed LN 3 about arm positioning device secured to bedframe. |
| LN 2 | Licensed Nurse | Observed arm positioning device and assisted during agitation incident. |
| LN 4 | Licensed Nurse (Outside Agency) | Requested assistance and failed to report removal of arm positioning device. |
| Administrator | Administrator | Confirmed privacy violation and potential emotional distress caused by arm positioning device. |
| Clinical Nurse Officer | Clinical Nurse Officer | Provided expert opinion on appropriate use and removal of arm positioning device. |
Inspection Report
Complaint Investigation
Citations: 1
Date: Nov 24, 2025
Visit Reason
The investigation was conducted due to concerns about the facility's failure to implement appropriate safety interventions and supervision to prevent accidents and elopement of a cognitively impaired resident.
Complaint Details
The complaint investigation found substantiated failures including lack of proper elopement risk assessment, failure to implement an elopement care plan, and failure to follow medical orders to send Resident 1 to the hospital. Resident 1 eloped on 10/4/25 and was found by a family friend in a vulnerable state. The facility did not notify the family promptly after the elopement.
Findings
The facility failed to accurately assess and reassess Resident 1 for elopement risk, did not create an elopement risk care plan timely, and did not follow a doctor's order to send Resident 1 to the hospital despite increased confusion and wandering behavior. Resident 1 eloped from the facility and was found one mile away in a vulnerable state, exposing him to potential physical and emotional harm.
Citations (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in Resident 1 eloping and being found in a dangerous situation.
Report Facts
BIMS score: 5
Date of elopement: Oct 4, 2025
Distance eloped: 1
Number of hospital admissions: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 5 | Licensed Nurse | Evening shift nurse prior to elopement who reported Resident 1's multiple elopement attempts and non-compliance |
| LN 1 | Licensed Nurse | Day shift nurse who informed the doctor of Resident 1's change in condition and did not send Resident 1 to the ER |
| LN 2 | Licensed Nurse | Night shift nurse who cared for Resident 1 and did not send him to hospital despite orders |
| Director of Nursing | Director of Nursing | Oversaw Resident 1's care, confirmed failures in elopement risk assessment and care planning |
| Assistant Director of Nursing | Assistant Director of Nursing | Attempted to place wander guard on Resident 1 and reported his refusal |
| Medical Doctor | Medical Doctor | Ordered labs and hospital transfer for Resident 1 due to increased confusion |
| Administrator | Administrator | Reviewed video footage of elopement and acknowledged staffing and supervision issues |
Inspection Report
Citations: 1
Date: Jul 15, 2025
Visit Reason
The inspection was conducted to assess compliance with nursing home regulations, specifically focusing on safe resident handling and accident prevention following an incident involving a resident injury.
Findings
The facility failed to use safe lifting techniques when transferring a resident who had an assisted fall, resulting in a left distal femoral fracture. The nursing home staff used a towel transfer technique instead of a mechanical lift, contrary to facility policy, and the resident sustained actual harm.
Citations (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in actual harm to a resident.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Arranged resident transfer to hospital and assessed injury |
| Director of Nursing | Director of Nursing | Provided statements on transfer practices and incident |
| Restorative Nursing Aide 1 | Restorative Nursing Aide | Assisted in resident transfer using towel technique |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Assisted in resident transfer using towel technique |
| Director of Staff Development | Director of Staff Development | Provided information on resident's therapy program |
| Licensed Nurse 3 | Licensed Nurse | Assigned nurse during morning shift; did not document incident |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Observed resident condition and alerted nurse |
| Physical Therapist | Physical Therapist | Provided information on transfer techniques and training |
Inspection Report
Complaint Investigation
Citations: 2
Date: Feb 13, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to ensure safe and clinically appropriate self-administration of medications by Resident 1 while on pass from the facility.
Complaint Details
The complaint investigation found that Resident 1 was self-administering medications while on pass without assessment or training, and no interdisciplinary team meeting was held to evaluate safety. The care plan for self-administration was not developed. The complaint was substantiated with findings of minimal harm risk.
Findings
The facility failed to assess Resident 1 for safe self-administration of medications prior to allowing him to take medications on pass, and failed to develop a comprehensive care plan addressing this. Staff administered medications to Resident 1 to take off-site without proper training or interdisciplinary team approval, posing potential harm.
Citations (2)
Failure to ensure self-administration of medication was clinically safe and appropriate for Resident 1.
Failure to develop and implement a comprehensive care plan for Resident 1's self-administration of medications.
Report Facts
Date of Medication Administration Notes: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Gave Resident 1 medications to take on pass and stated no training or policy inquiry was done. |
| LN 2 | Licensed Nurse | Observed other nurses giving medications to Resident 1 on pass and copied their process without training. |
| DON | Director of Nursing | Was unaware of Resident 1 taking medications on pass until recently and confirmed no interdisciplinary team meeting or care plan was developed. |
| ADON | Assistant Director of Nursing | Explained the purpose of the interdisciplinary team meeting for safe self-administration and medication teaching. |
Inspection Report
Routine
Citations: 2
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to assess compliance with medication self-administration policies and care planning for residents, specifically focusing on Resident 1's ability to safely self-administer medications while on pass from the facility.
Findings
The facility failed to ensure Resident 1 was properly assessed and trained for self-administration of medications while on pass, and failed to develop a comprehensive care plan addressing this need. These failures posed potential risks for unsafe medication use and adverse health consequences.
Citations (2)
F 0554: The facility failed to ensure self-administration of medication was clinically safe and appropriate for Resident 1, who was not assessed prior to being given medications to self-administer while on pass.
F 0656: The facility failed to develop and implement a comprehensive care plan for Resident 1's self-administration of medications, resulting in lack of individualized interventions and potential for improper medication use.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Gave Resident 1 medications to self-administer without prior assessment or policy confirmation. |
| Director of Nursing | DON | Confirmed lack of assessment and care plan for Resident 1's medication self-administration. |
| Assistant Director of Nursing | ADON | Explained the purpose of the interdisciplinary team meeting for medication self-administration safety. |
Inspection Report
Complaint Investigation
Citations: 2
Date: Jan 6, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate care and services after an unwitnessed fall involving Resident 1, including delayed physician notification and incomplete post-fall assessments.
Complaint Details
The complaint investigation focused on Resident 1's unwitnessed fall on 12/5/24, delayed physician notification until 7:00 a.m., and failure to perform neurological, pain, and skin assessments. Interviews with family members, nursing staff, and the Assistant Director of Nursing confirmed these issues and the risks posed to Resident 1.
Findings
The facility failed to promptly notify the physician and perform necessary neurological, pain, and skin evaluations after Resident 1's unwitnessed fall on 12/5/24. Additionally, the facility failed to provide effective pain management, administering medication intended for mild pain despite Resident 1 reporting moderate pain levels. These failures posed risks of delayed treatment, increased pain, suffering, and prolonged recovery for Resident 1.
Citations (2)
Failed to provide care and services after an unwitnessed fall, including delayed physician notification and incomplete neurological, pain, and skin evaluations.
Failed to provide comprehensive and effective pain management by administering pain medication intended for mild pain despite resident reporting moderate pain.
Report Facts
Pain rating: 5
Pain rating: 6
Pain rating: 8
BIMS score: 9
Date of fall: Dec 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Named in delayed physician notification and incomplete post-fall assessments for Resident 1 |
| ADON | Assistant Director of Nursing | Provided interview confirming facility expectations and deficiencies related to Resident 1's fall and pain management |
| MD 1 | Medical Doctor | Medical director who examined Resident 1 and stated expectations for nurse notification and pain management |
| CNA 1 | Certified Nurse Assistant | Reported Resident 1's pain and fall circumstances |
| LN 2 | Licensed Nurse | Provided interview on fall protocol and physician notification |
| LN 3 | Licensed Nurse | Reviewed medication administration and pain assessment for Resident 1 |
Inspection Report
Complaint Investigation
Citations: 14
Date: Oct 24, 2024
Visit Reason
The inspection was conducted due to complaints and allegations regarding resident rights violations, abuse, neglect, medication management, infection control, and other regulatory compliance issues at the facility.
Complaint Details
The investigation was complaint-driven, focusing on allegations of resident rights violations, sexual abuse, neglect, verbal abuse, medication errors, infection control breaches, and failure to report and investigate incidents. The Immediate Jeopardy was related to failure to assess capacity and protect residents from sexual abuse.
Findings
The facility was found deficient in multiple areas including failure to protect residents' rights and dignity, inadequate call light accessibility, failure to prevent and investigate sexual abuse and neglect, failure to timely report and investigate verbal abuse and altercations, inaccurate PASARR screening, incomplete neurological assessments post-fall, failure to communicate with residents in their preferred language, unsafe medication storage and administration practices, inadequate infection prevention and control, and failure to monitor antibiotic use effectively.
Citations (14)
F0550: The facility failed to ensure a resident's right to a dignified existence when Resident 49 was exposed to hearing her roommate engage in sexual activity without intervention, causing humiliation and psychosocial harm.
F0558: The facility failed to ensure Resident 37 had her call light within reach, resulting in inability to summon staff and potential injury.
F0600: The facility failed to protect residents from sexual abuse by not assessing capacity to consent for sexual activity between Residents 32 and 38 and not notifying responsible parties or physicians.
F0609: The facility failed to timely report allegations of abuse involving Residents 32, 38, 25, and 311 to the state survey agency, delaying investigation and risking resident safety.
F0610: The facility failed to investigate allegations of verbal abuse and threats between Residents 311 and 25 and did not implement safeguards to prevent further abuse.
F0645: The facility failed to complete an accurate PASARR Level 1 screening for Resident 20, potentially limiting access to needed mental health services.
F0656: The facility failed to ensure neurological assessments were completed as ordered for Resident 96 following a fall, risking delayed identification of neurological changes.
F0689: The facility failed to ensure safe medication storage practices including hazardous drug labeling, proper storage of IV medications, and control of outdated or unlabeled medications in multiple medication carts and refrigerators.
F0755: The facility failed to ensure safe use and storage of Emergency kits for IV medications and refrigerated medications, including controlled substances, with no documentation of use or replacement.
F0757: The facility failed to monitor high-risk medications properly, including failure to hold blood pressure medication per order for Resident 70 and lack of blood sugar monitoring parameters for Resident 306 on insulin therapy.
F0761: The facility failed to label hazardous medications properly and store medications securely, including failure to segregate controlled drugs and maintain medication expiration and beyond use dates.
F0812: The facility failed to maintain a clean commercial can opener free from metal shavings, risking foodborne illness for residents.
F0880: The facility failed to follow infection prevention and control practices including failure to wear gowns during high contact care, improper aseptic technique when reconstituting IV antibiotics, and placing dirty cups with clean cups on the coffee cart.
F0881: The facility failed to implement an effective Antibiotic Stewardship Program by not tracking antibiotic duration, culture results, or outcomes, risking inappropriate antibiotic use and resistance.
Report Facts
Resident sample size: 21
Resident census: 98
Fall risk score: 18
BIMS score: 10
BIMS score: 12
Medication administration errors: 7
Urine cultures: 22
Blood cultures: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RP 2 | Responsible Party | Named in relation to Resident 32's sexual consent and relationship |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including sexual abuse, medication, and infection control |
| Licensed Nurse 1 | Licensed Nurse | Observed not following infection control and medication administration procedures |
| Activities Assistant | Activities Assistant | Interviewed about awareness of sexual activity between residents |
| Social Services Director | Social Services Director | Involved in care planning and resident relationship discussions |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Interviewed about call light accessibility and resident communication |
| Licensed Nurse 7 | Licensed Nurse | Interviewed about medication administration and storage |
| Infection Preventionist | Infection Preventionist | Interviewed about infection control practices and antibiotic stewardship |
Inspection Report
Routine
Census: 98
Citations: 14
Date: Oct 24, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident rights, safety, medication management, infection control, and care planning.
Findings
The facility was found deficient in multiple areas including failure to protect residents' rights to dignity and freedom from abuse, inadequate call light accessibility, failure to assess capacity for sexual consent, failure to timely report and investigate abuse allegations, inaccurate PASARR screening, incomplete neurological assessments post-fall, failure to provide communication in resident's preferred language, unsafe medication storage and handling, failure to follow infection control precautions, and inadequate antibiotic stewardship.
Citations (14)
Failure to ensure resident's right to a dignified existence and to protect from exposure to roommate's sexual activity.
Failure to ensure call light was within reach for a resident with physical limitations.
Failure to protect residents from sexual abuse and failure to assess capacity for sexual consent for two residents engaged in sexual activity.
Failure to timely report allegations of abuse involving sexual activity and verbal altercation to the state survey agency.
Failure to complete accurate PASARR screening for a resident with serious mental illness.
Failure to complete neurological assessments following a fall as per care plan and facility policy.
Failure to provide daily communication in resident's preferred language (Greek) and failure to utilize interpreter services.
Failure to ensure environment free of accident hazards when cigarettes and lighter were left accessible to other residents outdoors.
Failure to ensure safe use and storage of emergency medication kits and IV medications including controlled substances.
Failure to follow hold parameters for blood pressure medication and failure to monitor blood sugar appropriately for insulin use.
Failure to ensure hazardous medications were labeled and handled safely and failure to maintain accountability of IV medications and supplies.
Failure to clean commercial can opener blade leading to potential foodborne illness risk.
Failure to follow infection prevention and control measures including enhanced barrier precautions, aseptic technique, and separation of clean and dirty items.
Failure to implement an antibiotic stewardship program that adequately tracks and assesses antibiotic use.
Report Facts
Resident census: 98
Florinef doses given despite hold parameters: 7
Urine cultures: 22
Blood cultures: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Observed failure to wipe medication vial rubber stopper and failure to wear gown during PICC line access |
| LN 3 | Licensed Nurse | Observed open and unsealed emergency kits and unaccounted IV medication bags |
| LN 7 | Licensed Nurse | Observed unsafe medication storage and failure to follow medication hold parameters |
| DON | Director of Nursing | Acknowledged multiple policy and procedure failures including medication management, infection control, and PASARR screening |
| IP | Infection Preventionist | Described failure to follow enhanced barrier precautions and infection control policies |
| CM 1 | Case Manager | Involved in resident room change and verbal altercation investigation |
| AA | Activity Assistant | Reported awareness of residents' sexual activity and lack of policy guidance |
| RP 2 | Responsible Party | Reported concerns about resident's sexual consent capacity |
Inspection Report
Routine
Census: 99
Citations: 2
Date: Sep 27, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care related to post-fall documentation and infection prevention and control practices in the facility.
Findings
The facility failed to ensure post-fall assessments and documentation were completed for three residents who sustained falls, risking unassessed injuries. Additionally, the facility failed to maintain infection control standards as air conditioning unit filters were caked with dust and debris, potentially exposing 99 residents to airborne infections.
Citations (2)
F 0684: The facility failed to provide appropriate post-fall treatment and care for three residents by not documenting 72-hour post-fall assessments, risking unassessed injuries and untreated conditions.
F 0880: The facility failed to maintain infection prevention standards for a census of 99 residents due to air conditioning unit filters being caked with dust and debris, increasing infection risk.
Report Facts
Resident census: 99
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses (DON) | Confirmed absence of 72-hour post-fall documentation for three residents | |
| Licensed Nurse (LN) 1 | Confirmed no post-fall documentation in Resident 2's chart | |
| Licensed Nurse (LN) 2 | Confirmed no 72-hour post-fall documentation in Resident 3's chart | |
| Maintenance Director (MDir) | Confirmed air filters had not been changed for several months | |
| Administrator | Confirmed air filters appeared overdue for changing |
Inspection Report
Routine
Citations: 3
Date: Mar 21, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to resident transfers, medication administration, and accident prevention in the nursing facility.
Findings
The facility was found deficient in documenting resident transfers accurately, ensuring medication availability and physician notification, and providing adequate supervision to prevent resident falls. These deficiencies posed minimal harm or potential for actual harm to residents.
Citations (3)
Failed to ensure accurate and complete documentation for a resident transfer to an acute care hospital, including date, time, destination, transport method, and disposition of personal effects and medications.
Failed to ensure professional standards of practice by not administering prescribed medication to a resident and not informing the physician of the medication unavailability.
Failed to provide a safe environment and adequate supervision, resulting in a resident falling from bed and sustaining lacerations, a nosebleed, and a hematoma.
Report Facts
Dates medication unavailable: 5
Date of resident fall: Resident 2 fell on 2/10/24 at 10:21 PM.
Date of resident transfer notes: Resident 2 transfer noted on 2/11/24 and 2/12/24.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Confirmed lack of transfer documentation and physician notification regarding medication unavailability; provided statements on findings. |
| LN 1 | Licensed Nurse | Noted missing medication during medication pass and described protocol for medication unavailability. |
| CNA 1 | Certified Nurse Assistant | Described circumstances of resident fall while changing fitted sheet. |
Inspection Report
Complaint Investigation
Citations: 3
Date: Mar 21, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to properly document resident transfers, medication administration errors, and ensuring resident safety to prevent accidents.
Complaint Details
The investigation was complaint-driven, focusing on issues related to resident transfer documentation, medication administration, and fall prevention. The deficiencies were substantiated with evidence from interviews, record reviews, and policy assessments.
Findings
The facility failed to document the transfer details of a resident sent to the hospital, did not administer prescribed medication to a resident and failed to notify the physician, and did not provide adequate supervision to prevent a resident's fall resulting in injuries.
Citations (3)
F 0622: The facility failed to document the date, time, destination, transportation method, and disposition of personal effects and medications for a resident transferred to an acute care hospital.
F 0658: The facility failed to ensure a resident received prescribed medication and did not inform the physician that the medication was unavailable for administration.
F 0689: The facility failed to provide adequate supervision to prevent a resident from falling out of bed, resulting in lacerations, a nosebleed, and a hematoma.
Report Facts
Medication unavailable days: 5
Date of resident fall: Resident 2 fell on 2/10/24 at 10:21 PM.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Confirmed lack of transfer documentation and medication notification to physician. |
| CNA 1 | Certified Nurse Assistant | Witnessed resident fall while changing fitted sheet. |
| Licensed Nurse 1 | Licensed Nurse | Noted missing medication during medication pass and described pharmacy notification process. |
Inspection Report
Routine
Citations: 2
Date: Jan 18, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with respiratory care standards following observations, interviews, and record reviews related to Resident 1's respiratory treatment and equipment maintenance.
Findings
The facility failed to provide timely as-needed breathing treatment to Resident 1 and did not maintain the oxygen concentrator filter properly, resulting in delayed treatment and potential malfunction of the oxygen delivery system.
Citations (2)
Resident 1's as needed breathing treatment was not provided in a timely manner.
Resident 1's oxygen concentrator filter was covered in dust/debris and not cleaned as required.
Report Facts
Time delay for breathing treatment: 1
Medication administration time: 8.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant 1 | CNA | Reported Resident 1 requested breathing treatment around 6:45 a.m. |
| Licensed Nurse 2 | LN | Informed about Resident 1's request and stated the Infection Preventionist provided the treatment |
| Infection Preventionist | IP | Administered the breathing treatment to Resident 1 around 8 to 8:30 a.m. |
| Director of Nursing | DON | Stated as needed medications should be administered as soon as possible and confirmed oxygen concentrator filter cleaning schedule |
Inspection Report
Citations: 1
Date: Jan 18, 2024
Visit Reason
The inspection was conducted to evaluate compliance with respiratory care standards for residents, specifically addressing the timeliness and adequacy of respiratory treatments and equipment maintenance.
Findings
The facility failed to provide timely as-needed breathing treatment to Resident 1 and did not maintain the oxygen concentrator filter in a clean condition, potentially compromising respiratory care.
Citations (1)
F 0695: The facility failed to provide Resident 1's as-needed breathing treatment in a timely manner, resulting in a delay of over an hour. The oxygen concentrator filter for Resident 1 was found to be covered in dust and debris, indicating inadequate cleaning.
Report Facts
Residents affected: 1
Date of survey: Jan 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) 1 | Reported Resident 1's request for breathing treatment | |
| Licensed Nurse (LN) 2 | Administered breathing treatment and commented on delay risk | |
| Infection Preventionist (IP) | Administered breathing treatment to Resident 1 | |
| Director of Nursing (DON) | Provided statements on medication administration timing and filter cleaning |
Inspection Report
Routine
Citations: 16
Date: Sep 14, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to medication administration, resident care plans, call light functionality, notification of transfers, PASARR screening, respiratory care, restorative nursing services, medication storage, pharmaceutical services, food safety, binding arbitration agreements, and infection control practices.
Findings
The facility was found deficient in multiple areas including unsafe medication administration practices, failure to develop comprehensive care plans, inadequate call light accommodations, failure to notify the Ombudsman of resident transfers, inaccurate PASARR screening, lack of oxygen orders, medication errors, improper medication storage, incomplete restorative nursing services, failure to properly explain binding arbitration agreements, and inadequate infection control during glucometer use.
Citations (16)
Allow residents to self-administer drugs if determined clinically appropriate; failure to ensure self-administration was clinically safe for one resident.
Reasonably accommodate the needs and preferences of each resident; failure to provide appropriate call light for one resident.
Provide timely notification to the resident, representative, and ombudsman before transfer or discharge; failure to notify Ombudsman for two residents.
PASARR screening for mental disorders or intellectual disabilities was inaccurate for one resident.
Develop and implement a complete care plan that meets all resident needs; failure to develop care plans for indwelling catheter, oxygen, and dental care for three residents.
Ensure services provided meet professional standards of quality; failures related to PICC line dressing changes, inaccurate bipolar diagnosis, and medication administration.
Provide appropriate care to maintain or improve range of motion; failure to provide restorative nursing assistant services as ordered for three residents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder; failure to provide appropriate catheter care and monitoring for one resident.
Provide safe and appropriate respiratory care; failure to have oxygen order for one resident, failure to monitor nebulizer treatment and undated nebulizer mask for another resident.
Provide pharmaceutical services to meet resident needs; failure to ensure accountability of medication delivery documents with unsigned packing slips.
Implement gradual dose reductions and non-pharmacological interventions for psychotropic medications; failure to clarify duration and reassessment of PRN lorazepam use for two residents.
Ensure medication error rates are not 5 percent or greater; medication error rate of 8.7% observed including improper medication administration via G-tube and documentation errors.
Ensure drugs and biologicals are labeled and stored properly; undated and expired medications found in medication cart and refrigerator.
Procure food from approved sources and maintain food safety standards; dietary aide observed preparing food without wearing beard restraint.
Inform resident or representatives of binding arbitration agreement rights; failure to clearly explain arbitration terms, optional nature, right to rescind, and litigation rights to five residents.
Provide and implement infection prevention and control program; failure to properly clean and disinfect shared glucometers between resident use.
Report Facts
Medication error rate: 8.7
Medication administration observations: 46
Residents affected: 91
RNA sessions completed: 6
RNA sessions completed: 2
RNA sessions completed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 5 | Licensed Nurse | Named in medication administration and glucometer cleaning deficiencies. |
| LN 7 | Licensed Nurse | Named in medication administration errors related to G-tube medications. |
| LN 12 | Licensed Nurse | Named in medication storage deficiencies. |
| Director of Nursing | Director of Nursing | Named in multiple interviews related to deficiencies and facility policies. |
| AC | Admissions Coordinator | Named in binding arbitration agreement explanation deficiencies. |
| DOA | Director of Admissions | Named in binding arbitration agreement explanation deficiencies. |
| RNA 1 | Restorative Nursing Assistant | Named in restorative nursing services deficiencies. |
| DON | Director of Nursing | Named in multiple interviews related to deficiencies and facility policies. |
Inspection Report
Complaint Investigation
Citations: 3
Date: Sep 8, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to ensure professional standards of practice, including proper notification of laboratory results to the primary care provider and home health agency, completeness of discharge summaries, and medication administration accuracy.
Complaint Details
The complaint investigation focused on Resident 1's care related to notification of lab results, discharge summary completeness, and medication administration. The complaint was substantiated as the facility failed to notify the PCP and home health agency of lab results, did not provide a complete discharge summary, and did not administer a prescribed medication.
Findings
The facility failed to notify Resident 1's primary care provider of urinalysis and culture results after discharge, resulting in delayed treatment of a urinary tract infection. The discharge summary lacked critical information for continuity of care, and the medication reconciliation list was incomplete. Additionally, the facility did not administer a prescribed medication (Liothyronine) during the resident's stay due to failure to follow up on the medication order.
Citations (3)
F 0658: The facility failed to notify Resident 1's primary care provider of urinalysis and culture results after discharge, resulting in delayed follow-up care for a urinary tract infection.
F 0661: The discharge summary for Resident 1 did not include signs and symptoms of a urinary tract infection, pending lab results, and the medication reconciliation list was incomplete, affecting continuity of care.
F 0760: The facility failed to administer Liothyronine to Resident 1 from the time it was ordered until discharge due to lack of follow-up on the medication order.
Report Facts
Colony count: 100000
Medication order date: Jul 24, 2023
Discharge date: Jul 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Doctor (MD) 1 | Stated protocol to fax lab results to PCP or home health after discharge | |
| Nurse Practitioner (NP) | Confirmed urine culture >100,000 bacteria treated as infection and lab results should have been faxed | |
| Home Health Licensed Nurse (HHLN) | Reported not receiving lab results from facility | |
| Primary Care Provider (PCP) | Reported Resident 1 was hospitalized with UTI and expected discharge summary and lab results | |
| Director of Nurses (DON) | Acknowledged failure to send lab results and follow up on medication order | |
| Pharmacist (Pharm) 1 | Reported no communication from facility to pharmacy regarding Liothyronine order clarification |
Inspection Report
Citations: 1
Date: Mar 8, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically regarding the development and implementation of a resident-centered care plan for Resident 3 who was prescribed Lorazepam.
Findings
The facility failed to develop and implement a care plan for Resident 3 after the resident was ordered Lorazepam, resulting in a lack of monitoring for behaviors and side effects related to the medication. This failure placed the resident at risk of not receiving appropriate care to maintain their highest practicable physical, mental, and psychosocial well-being.
Citations (1)
Failure to develop and implement a complete care plan for Resident 3 related to Lorazepam medication, including monitoring for behaviors and side effects.
Report Facts
Medication doses administered: 2
Lorazepam dosage: 1
Lorazepam dosage: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set Coordinator | Interviewed regarding absence of Lorazepam care plan | |
| Assistant Director of Nursing | Interviewed about expectations for care plan creation and importance | |
| LVN 2 | Interviewed regarding care plan responsibilities and medication monitoring |
Inspection Report
Complaint Investigation
Citations: 1
Date: Mar 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to develop and implement a resident-centered care plan for a resident prescribed Lorazepam.
Complaint Details
The complaint investigation focused on the failure to create a care plan for Lorazepam for Resident 3 and the lack of monitoring for side effects and behaviors. The complaint was substantiated as the facility did not meet regulatory requirements.
Findings
The facility failed to develop and implement a care plan for Resident 3 after Lorazepam was ordered, and the resident was not monitored for behaviors or side effects related to the medication. This failure placed the resident at risk of not receiving appropriate care to maintain their physical, mental, and psychosocial well-being.
Citations (1)
F 0656: The facility failed to develop and implement a complete care plan for Resident 3 after Lorazepam was ordered. Resident 3 was not monitored for behaviors or side effects related to the medication.
Report Facts
Medication doses: 2
Medication order duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set Coordinator | Interviewed regarding care plan requirements for Resident 3. | |
| Assistant Director of Nursing | Interviewed regarding expectations for care plan creation and revision. | |
| LVN 2 | Interviewed regarding Resident 3's care plan and medication monitoring. |
Inspection Report
Complaint Investigation
Citations: 1
Date: Mar 6, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to maintain a sanitary environment, specifically related to improper disposal of hazardous waste near a resident's room.
Complaint Details
The investigation was complaint-driven, focusing on hazardous waste disposal practices. The complaint was substantiated with findings of improper handling and storage of infectious waste near Resident 1's room.
Findings
The facility failed to provide a sanitary environment for one resident by leaving two red plastic trash bags marked hazardous near the resident's patio instead of in the proper disposal container. This posed potential harm by exposing the resident to hazardous materials and possible disease transmission.
Citations (1)
F 0921: The facility failed to ensure hazardous waste was properly disposed of, as two red plastic trash bags marked hazardous were found outside Resident 1's room instead of in a secured garbage disposal container. This posed a potential risk of exposure to hazardous materials and disease transmission.
Report Facts
Residents Affected: 1
Inspection Report
Routine
Citations: 1
Date: Mar 6, 2023
Visit Reason
The inspection was conducted to assess the sanitary environment and infection control practices at the facility, specifically related to the handling and disposal of hazardous waste near Resident 1's room.
Findings
The facility failed to provide a sanitary environment by leaving two red plastic trash bags marked hazardous near Resident 1's patio instead of in a proper garbage disposal container, posing potential harm from exposure to hazardous materials and disease transmission.
Citations (1)
Failure to properly dispose of hazardous waste by leaving red plastic trash bags outside Resident 1's room instead of in a secured container.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Provided information about Resident 1's isolation and waste handling practices. |
| Director of Nursing | Director of Nursing | Stated that leaving infectious trash outside unattended was not acceptable and described proper disposal procedures. |
| Environmental Supervisor/Housekeeping Supervisor | Environmental Supervisor/Housekeeping Supervisor | Observed hazardous trash bags outside Resident 1's room and acknowledged improper disposal. |
| Infection Preventionist | Infection Preventionist | Confirmed oversight of sanitary environment and safe disposal of trash. |
Inspection Report
Routine
Citations: 13
Date: Sep 6, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, food and nutrition services, medical record keeping, and facility maintenance at Garden City Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining assistance, incomplete medical records, improper medication storage, failure to follow dietary menus and recipes, inadequate infection control practices, unsafe sliding glass doors, and failure to maintain a hazard-free environment. Several residents were affected by these deficiencies, which posed risks of harm, discomfort, or potential infection.
Citations (13)
F 0550: The facility failed to provide three residents with dignified dining assistance by feeding them while standing instead of at eye level, contrary to policy.
F 0582: The facility failed to provide the Advance Beneficiary Notice (ABN) with appeal contact information prior to discontinuing Medicare Part A services for one resident.
F 0623: The facility failed to notify the State Long-Term Care Ombudsman of 24 residents' transfers or discharges, limiting advocacy opportunities.
F 0656: The facility failed to develop and implement a care plan for one resident after an ankle injury, risking inadequate care.
F 0689: The facility disabled the automatic opening of the front main entrance doors, creating a hazard in emergencies.
F 0761: The facility stored expired medications in a medication cart, risking ineffective treatment.
F 0802: Dietary staff failed to follow recipes and portion sizes, including using fewer cheese slices and incorrect seasoning amounts.
F 0803: The facility failed to follow menus for 92 residents, serving incorrect portions and wrong diet entrées.
F 0812: The facility failed to maintain food safety, including dirty ice machine components, unclean utensils, incomplete cooling logs, and storing peanut butter sandwiches improperly.
F 0814: The facility failed to properly dispose of garbage, leaving trash around outdoor bins, risking pest attraction.
F 0842: The facility failed to maintain complete medical records for one resident and failed to properly label narcotic count sheets for two residents.
F 0880: The facility failed to maintain an effective infection prevention program when a CNA did not perform hand hygiene between residents and isolation room garbage was overfilled.
F 0921: The facility failed to maintain seven sliding glass doors and screens in a safe, functional manner, with broken locks, difficult operation, and damaged screens.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 24
Residents affected: 1
Medication carts: 1
Residents affected: 92
Residents affected: 42
Residents affected: 24
Residents affected: 9
Residents affected: 16
Narcotic count sheets: 3
Narcotic count sheets: 2
Sliding glass doors: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in dignified dining and infection control deficiencies |
| LVN 4 | Licensed Vocational Nurse | Named in care plan deficiency for Resident 70 |
| LVN 5 | Licensed Vocational Nurse | Named in narcotic count sheet documentation deficiency |
| LVN 6 | Licensed Vocational Nurse | Named in narcotic count sheet documentation deficiency |
| FR 1 | Front Receptionist | Named in front door automatic opening deficiency |
| DA 1 | Dietary Aide | Named in food preparation and recipe adherence deficiency |
| RD | Registered Dietitian | Named in food service and menu adherence deficiencies |
| CDM | Certified Dietary Manager | Named in food safety and storage deficiencies |
| SSD | Social Services Director | Named in Ombudsman notification deficiency |
| DON | Director of Nursing | Named in multiple deficiencies including narcotic documentation and Ombudsman notification |
| MA | Maintenance Assistant | Named in sliding door maintenance deficiency |
| MS | Maintenance Supervisor | Named in sliding door maintenance deficiency |
| CNA 6 | Certified Nursing Assistant | Named in infection control deficiency |
| RNA | Restorative Nursing Assistant | Named in infection control deficiency |
| HK 1 | Housekeeping Staff | Named in garbage disposal deficiency |
| HK 2 | Housekeeping Staff | Named in garbage disposal deficiency |
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