Deficiencies (last 4 years)
Deficiencies (over 4 years)
15.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
288% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
98 residents
Based on a October 2024 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 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.
Deficiencies (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
Deficiencies: 1
Date: Nov 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement appropriate safety interventions and supervision to prevent accidents, specifically concerning a resident who eloped from the facility.
Complaint Details
The complaint investigation found that Resident 1 was not properly assessed for elopement risk, was not reassessed after increased confusion and wandering, and no elopement care plan was created until after the resident eloped. A doctor's order to send Resident 1 to the hospital was not followed by staff over multiple shifts. Resident 1 eloped on 10/4/25 and was found by a family friend near a shopping center in a vulnerable state. The facility failed to notify the family or responsible party about the elopement or pending medical updates.
Findings
The facility failed to accurately assess and reassess a resident's elopement risk, did not create an elopement risk care plan in a timely manner, and failed to carry out a doctor's order to send the resident to the hospital. These failures resulted in the resident eloping and being found one mile away in a potentially dangerous condition.
Deficiencies (1)
Failure to implement appropriate safety interventions including supervision to prevent accidents and elopement.
Report Facts
BIMS score: 5
Date of elopement: Oct 4, 2025
Distance found from facility: 1
Number of hospital admissions: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 5 | Evening Shift Nurse | Named in relation to failure to send Resident 1 to hospital and supervision issues |
| LN 1 | Day Shift Nurse | Named in relation to failure to send Resident 1 to hospital and supervision issues |
| LN 2 | Night Shift Nurse | Named in relation to supervision and failure to send Resident 1 to hospital |
| Director of Nursing | Director of Nursing (DON) | Named in relation to oversight and failure to ensure proper care and hospital transfer |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Named in relation to attempts to place wander guard and supervision |
| MD | Medical Doctor | Named in relation to orders for hospital transfer and lab tests |
| ADM | Administrator | Named in relation to review of video footage and facility security |
Inspection Report
Deficiencies: 1
Date: Jul 15, 2025
Visit Reason
The inspection was conducted to assess compliance with safety regulations related to accident hazards and supervision in a nursing home setting, specifically focusing on a resident transfer incident that resulted in injury.
Findings
The facility failed to use safe lifting techniques when transferring a resident, resulting in a left distal femoral fracture. The investigation revealed improper use of a towel transfer technique instead of a mechanical lift, lack of documentation, and disputed citation by the nursing home.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in actual harm to a resident.
Report Facts
Residents Affected: 2
BIMS score: 3
Date of injury: Jul 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Nurse assigned to Resident 1 on 7/5/25 who arranged hospital transfer |
| Certified Nursing Assistant 2 | CNA | CNA in charge of Resident 1 on 7/5/25 who observed injury |
| Restorative Nursing Aide 1 | RNA | Assisted in resident transfer using towel technique and explained transfer details |
| Director of Nursing | DON | Provided statements on expected transfer practices and incident details |
| Director of Staff Development | DSD | Provided information on resident program and transfer protocols |
| Physical Therapist | PT | Provided expert opinion on transfer techniques and facility training |
Inspection Report
Complaint Investigation
Deficiencies: 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.
Deficiencies (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
Complaint Investigation
Deficiencies: 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.
Deficiencies (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
Routine
Census: 98
Deficiencies: 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.
Deficiencies (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
Deficiencies: 2
Date: Sep 27, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care following resident falls and to evaluate the infection prevention and control program related to air conditioning unit maintenance.
Findings
The facility failed to ensure post-fall documentation for three residents who sustained falls, potentially risking unassessed injuries and untreated conditions. Additionally, the facility failed to maintain infection control standards as air conditioning unit filters were caked with dust and debris, posing a risk of infection spread to residents.
Deficiencies (2)
Failure to document post-fall assessments and observations for three residents who sustained falls.
Failure to maintain and change air conditioning unit filters, resulting in dust and debris accumulation.
Report Facts
Residents affected: 3
Census: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Confirmed absence of 72-hour post-fall documentation for Residents 1, 2, and 3 |
| Licensed Nurse 1 | Licensed Nurse | Confirmed no post-fall documentation in Resident 2's chart |
| Licensed Nurse 2 | Licensed Nurse | Confirmed no 72-hour post-fall documentation in Resident 3's chart |
| Maintenance Director | Maintenance Director (MDir) | Confirmed air filters had not been changed for July, August, or September 2024 |
| Administrator | Administrator | Confirmed air filters appeared ready to be changed |
Inspection Report
Routine
Deficiencies: 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.
Deficiencies (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
Routine
Deficiencies: 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.
Deficiencies (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
Routine
Deficiencies: 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.
Deficiencies (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
Deficiencies: 3
Date: Sep 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify Resident 1's Primary Care Provider (PCP) of urinalysis and culture and sensitivity results following discharge, and issues with discharge summary completeness and medication administration.
Complaint Details
The complaint investigation revealed that the facility did not notify Resident 1's PCP or home health agency of pending and completed lab results for a urinary tract infection, and the discharge summary was incomplete. Resident 1 was hospitalized with a UTI after discharge. The facility also failed to administer a prescribed medication (Liothyronine) during the stay due to lack of follow-up on medication orders.
Findings
The facility failed to notify Resident 1's PCP of pending and completed lab results indicating a urinary tract infection, resulting in delayed follow-up care and hospitalization. Additionally, the discharge summary lacked critical information about the UTI and medication reconciliation was incomplete, leading to Resident 1 not receiving prescribed Liothyronine medication during the stay.
Deficiencies (3)
Failure to notify Resident 1's PCP of urinalysis and culture and sensitivity results after discharge, resulting in delayed follow-up care for UTI.
Discharge summary did not include Resident 1's signs and symptoms of UTI, pending lab results, and medication reconciliation list was incomplete.
Resident 1 was not administered prescribed Liothyronine medication due to failure to enter the order into the electronic health record and follow up on medication delivery.
Report Facts
Lab colony count: 100000
Medication dosage: 25
Dates: Jul 24, 2023
Dates: 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 with >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 hospitalized with UTI and expected discharge summary and lab results | |
| Director of Nurses (DON) | Acknowledged failure to send lab results to PCP and failure to follow up on medication order | |
| Pharmacist (Pharm) 1 | Reported no communication from facility to pharmacy regarding medication order clarification |
Inspection Report
Deficiencies: 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.
Deficiencies (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
Routine
Deficiencies: 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.
Deficiencies (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
Deficiencies: 12
Date: Sep 6, 2019
Visit Reason
The inspection was conducted as a routine regulatory survey of Garden City Healthcare Center to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining assistance, incomplete notification for Medicare discontinuation, failure to notify ombudsman of resident discharges, incomplete care planning for resident injury, hazardous environment due to disabled automatic doors, expired medications on medication carts, failure to follow food preparation recipes and menus, improper food storage and sanitation issues, incomplete medical records, infection control lapses, and unsafe sliding glass doors and screens.
Deficiencies (12)
Failed to provide dignified dining assistance by feeding residents while standing instead of at eye level.
Failed to complete and provide Advance Beneficiary Notice (ABN) for discontinued Medicare part A services.
Failed to notify the Office of the State Long-Term Care Ombudsman of resident transfers and discharges.
Failed to develop and implement a complete care plan after resident twisted ankle injury.
Disabled automatic front entrance doors, creating a hazard in emergency exit.
Medication cart contained expired medications.
Failed to follow recipes and menu requirements for food preparation and serving.
Improper food storage including unrefrigerated peanut butter sandwiches and unsanitary ice machine and utensils.
Garbage improperly disposed with trash on ground around outdoor bins.
Incomplete and inaccurate medical records including missing physician notification of transfer and incomplete narcotic count sheets.
Infection control failures including lack of hand hygiene by staff and overfilled isolation room garbage can.
Sliding glass doors and screens were broken, difficult to open, and lacked proper locks, compromising safety.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 24
Residents affected: 1
Expired medication: 1
Residents affected: 42
Residents affected: 24
Residents affected: 9
Residents affected: 16
Residents affected: 92
Peanut butter sandwiches: 2
Residents affected: 3
Narcotic count sheets incomplete: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in dignified dining and infection control deficiencies |
| Director of Staff Development | Interviewed regarding dignified dining and infection control | |
| Social Services Director | Interviewed regarding Medicare discontinuation and Ombudsman notifications | |
| Case Manager 1 | Interviewed regarding Medicare discontinuation notification | |
| CNA 4 | Certified Nursing Assistant | Interviewed regarding resident injury and sliding door |
| LVN 4 | Licensed Vocational Nurse | Interviewed regarding care plan development |
| RN 1 | Registered Nurse | Interviewed regarding care plan development |
| FR 1 | Front Receptionist | Interviewed regarding disabled automatic doors |
| Administrator | Interviewed regarding disabled automatic doors | |
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding expired medication |
| Director of Nursing | Interviewed regarding expired medication and narcotic count sheets | |
| DA 1 | Dietary Aide | Observed not following recipes |
| RD | Registered Dietitian | Interviewed regarding food preparation and menu compliance |
| CDM | Certified Dietary Manager | Interviewed regarding food storage and sanitation |
| DA 2 | Dietary Aide | Observed food preparation and storage issues |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding food storage |
| Maintenance Supervisor | Interviewed regarding sliding doors and ice machine | |
| Maintenance Assistant | Interviewed regarding sliding doors | |
| CNA 6 | Certified Nursing Assistant | Interviewed regarding infection control and garbage disposal |
| Housekeeping Staff | Interviewed regarding garbage disposal | |
| Medical Records Director | Interviewed regarding incomplete medical records | |
| LVN 5 | Licensed Vocational Nurse | Interviewed regarding narcotic count sheets |
| LVN 6 | Licensed Vocational Nurse | Interviewed regarding narcotic count sheets |
| RNA | Restorative Nursing Assistant | Interviewed regarding infection control and garbage disposal |
| CNA 3 | Certified Nursing Assistant | Interviewed regarding sliding doors |
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