Inspection Reports for
Jacob Health Care Center
4075 54TH STREET, SAN DIEGO, CA, 92105
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
88% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 27, 2024
Visit Reason
The inspection was conducted following a report of a missing medication card containing 60 tablets of Morphine, a controlled substance, which was unaccounted for during a routine medication reorder attempt.
Complaint Details
The visit was complaint-related due to a missing controlled medication (Morphine) reported by staff. The complaint was substantiated as the medication was confirmed missing after review and interviews.
Findings
The facility failed to follow its policy regarding receipt and storage of controlled medications, resulting in the missing Morphine medication card. Interviews with nursing staff and review of delivery logs confirmed the medication was delivered but not properly accounted for in the controlled medication drawer, and reconciliation could not be verified due to missing count sheets. The medication was reported missing to pharmacy and law enforcement.
Deficiencies (1)
Failure to follow policy regarding receipt and storage of controlled medications, resulting in a missing Morphine medication card.
Report Facts
Quantity of missing medication tablets: 60
Date of medication delivery: Oct 20, 2024
Date medication was reported missing: Oct 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Signed delivery log for the missing Morphine medication on 10/20/24 |
| LN 2 | Licensed Nurse | Interviewed regarding missing Morphine medication and medication reconciliation procedures |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed about missing medication and facility procedures |
| Director of Nursing | Director of Nursing (DON) | Interviewed about notification and reporting of missing medication |
Inspection Report
Routine
Deficiencies: 13
Date: Sep 12, 2024
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations related to resident care, medication administration, infection control, staffing, and quality assurance at Jacob Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to conduct required PASARR II screenings, incomplete and inaccurate care plans, medication administration errors, insufficient staffing leading to delayed response to call lights, failure to implement non-pharmacological pain interventions prior to PRN medications, improper dialysis site care, failure to maintain a safe environment with side rails, and inadequate infection control practices. Additionally, the facility's quality assurance program did not adequately address unnecessary use of antipsychotic medications.
Deficiencies (13)
Failed to ensure PASARR II screenings were conducted for residents with mental health diagnoses.
Failed to develop a resident-centered care plan including dementia care for Resident 6.
Failed to revise care plan after discontinuation of gastrostomy tube for Resident 81.
Failed to ensure professional standards in medication administration for Residents 5, 6, and 18, including improper schizophrenia diagnoses and failure to check heart rate before administering blood pressure medications.
Failed to provide timely incontinence care and nail care for Residents 28 and 30.
Failed to install side rails as ordered for Resident 28, creating a fall risk.
Failed to implement non-pharmacological interventions prior to PRN pain medication administration for Residents 22, 99, and 312.
Failed to remove dialysis pressure dressing within 4 hours post-dialysis for Resident 71.
Failed to provide sufficient nursing staff to meet resident needs, resulting in delayed call light responses.
Failed to ensure Residents 5 and 6 were free from unnecessary antipsychotic medications without clear indications.
Failed to ensure medication error rates were below 5% when two routine medications were unavailable for Resident 72.
Failed to implement Enhanced Barrier Precautions for Resident 211 with an indwelling catheter to prevent infection transmission.
Quality Assurance and Performance Improvement (QAPI) committee failed to identify and address unnecessary use of antipsychotic medications.
Report Facts
Medication administrations: 17
Medication administrations: 7
Medication administrations: 3
Medication error rate threshold: 5
BIMS cognitive score: 3
BIMS cognitive score: 11
BIMS cognitive score: 15
BIMS cognitive score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 23 | Licensed Nurse | Observed administering medication and interviewed about medication administration and call light response |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration, staffing, infection control, and QAPI |
| MDSN | Minimum Data Set Nurse | Interviewed regarding PASARR screening deficiencies |
| RD | Registered Dietitian | Interviewed regarding Resident 81's feeding status and care plan |
| LN 32 | Licensed Nurse | Observed and interviewed regarding blood pressure medication administration and infection control PPE use |
| CNA 33 | Certified Nursing Assistant | Interviewed regarding incontinence care and nail care |
| SW 1 | Social Worker | Interviewed regarding Resident 5 and Resident 6 medication and diagnoses |
| ADM | Administrator | Interviewed regarding staffing and QAPI |
| LN 34 | Licensed Nurse | Interviewed regarding medication availability and administration |
| IPN | Infection Prevention Nurse | Interviewed regarding infection control practices |
| CNA 1 | Certified Nursing Assistant | Interviewed regarding Resident 5's medication and hallucinations |
| RP 1 | Responsible Party | Interviewed regarding Resident 5's diagnosis and medication |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 31, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the care and treatment of pressure ulcers for Resident 1, focusing on whether appropriate pressure ulcer care was provided and if nursing staff had the necessary competency to perform wound treatments.
Complaint Details
The complaint investigation focused on Resident 1's pressure ulcer care. It was substantiated that the facility failed to provide appropriate care and that a licensed nurse lacked competency in wound treatment, leading to potential harm.
Findings
The facility failed to ensure proper pressure ulcer care for Resident 1, including failure to maintain infection control, follow treatment orders, and document treatments. Additionally, one licensed nurse (LN 1) lacked competency in performing pressure ulcer treatments, which posed a risk for wound deterioration and infection.
Deficiencies (2)
Failure to provide care/treatment to prevent worsening of pressure ulcers, including removal of dressings by CNA, lack of wound coverage, failure to re-cleanse wounds after contact with bedding, and incomplete treatment documentation.
Failure to ensure licensed nurse had competency to perform pressure ulcer treatments, including not following treatment orders, improper wound care techniques, and lack of documented competency evaluation.
Report Facts
Pressure ulcer measurements: 5.7
Pressure ulcer measurements: 5.9
Pressure ulcer measurements: 4.3
Pressure ulcer measurements: 2.9
Treatment duration: 21
Treatment dates with blank entries: 7
Observation date: Jan 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Named in findings related to inadequate wound care and lack of competency in pressure ulcer treatment |
| CNA 1 | Certified Nursing Assistant | Removed Resident 1's wound dressings improperly |
| CNA 2 | Certified Nursing Assistant | Assisted with repositioning Resident 1 during wound treatment observation |
| Director of Staff Development | Interviewed regarding staff competency and wound care procedures | |
| Director of Nursing | Interviewed regarding wound care expectations and competency requirements |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 26, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Jacob Healthcare Center.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Nov 8, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Jacob Healthcare Center, summarizing the findings of a regulatory survey completed on November 8, 2023.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 12, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to obtain informed consent for psychotropic medication administration and failure to provide requested medical records to a resident's family member.
Complaint Details
The complaint investigation found substantiated issues regarding lack of informed consent for medication and delays in providing medical records to the family member.
Findings
The facility failed to ensure informed consent was signed before administering psychotropic medication to one resident, and failed to provide requested medical records to the resident's family member in a timely manner, resulting in delays.
Deficiencies (2)
Failure to ensure informed consent was signed for psychotropic medication before administration.
Failure to provide copies of medical records requested by resident's family member in a timely manner.
Report Facts
Medication dosage: 100
Dates of medical record requests: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding informed consent and medical record requests |
| Medical Record Director | Medical Record Director | Interviewed regarding processing of medical record requests |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jun 11, 2021
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory standards for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to dress a resident in a dignified manner, failure to protect resident medical information, inadequate cleaning of ceiling vents, failure to provide requested grooming services, failure to follow CDC pneumococcal vaccination guidelines, and lapses in infection prevention and control practices.
Deficiencies (7)
Failed to dress one sampled resident in a dignified manner during a meal.
Failed to ensure resident's medical information was secured and protected, exposing it to unauthorized people.
Did not ensure all ceiling vents were clean, increasing risk of poor air quality.
Did not provide requested grooming services resulting in unwanted facial hair for a resident.
Failed to identify and follow current CDC recommendations for pneumococcal vaccination, not offering PCV13 vaccine to residents.
Did not ensure staff wore appropriate PPE when entering isolation rooms and failed to ensure proper glove use in kitchen food preparation.
Failed to develop and implement policies and procedures for flu and pneumonia vaccinations in accordance with CDC guidelines.
Report Facts
Residents affected: 124
Residents affected: 24
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 10 | Certified Nursing Assistant | Acknowledged dressing failure of Resident 31 |
| CNA 11 | Certified Nursing Assistant | Acknowledged dressing failure of Resident 31 |
| DON | Director of Nursing | Acknowledged dressing failure and infection control deficiencies |
| LN 12 | Licensed Nurse | Acknowledged exposure of resident medical information |
| LN 2 | Licensed Nurse | Acknowledged exposure of resident medical information and PPE failure |
| CNA 1 | Certified Nursing Assistant | Failed to shave Resident 44 as requested |
| MR 1 | Medical Records Staff | Provided shower documentation for Resident 44 |
| ICP | Infection Control Preventionist | Interviewed regarding infection control and vaccination deficiencies |
| LN 14 | Licensed Nurse | Interviewed regarding pneumococcal vaccination practices |
| QA nurse | Quality Assurance Nurse | Interviewed regarding vaccination practices |
| PC | Pharmacy Consultant | Interviewed regarding vaccination practices and guidelines |
| MD | Medical Director | Interviewed regarding vaccination practices |
| DA 1 | Dietary Aide | Observed and interviewed regarding improper glove use |
| DM | Dietary Manager | Interviewed regarding dietary staff glove use |
| Dietitian 1 | Dietitian | Interviewed regarding dietary staff glove use |
| UM | Unit Manager | Interviewed regarding PPE use in isolation rooms |
| LN 2 | Licensed Nurse | Failed to wear gown when entering isolation room |
Inspection Report
Routine
Deficiencies: 5
Date: Sep 19, 2019
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, medical record accuracy, infection control, and care planning at Jacob Healthcare Center.
Findings
The facility was found deficient in multiple areas including inaccurate MDS assessments, failure to develop comprehensive care plans for residents performing self-care (especially respiratory and urinary catheter care), failure to provide routine fingernail care, inaccurate and incomplete medical record documentation, and lapses in infection control practices such as improper handling of suction catheters and soiled linen. These deficiencies posed risks of inaccurate health information, inadequate care, and potential infection.
Deficiencies (5)
Failed to accurately record an MDS assessment for one of 24 residents reviewed, causing inaccurate information transmission to CMS.
Failed to develop and implement comprehensive care plans for residents performing self suctioning and urinary catheter care.
Failed to provide routine fingernail care to a resident, resulting in long nails that posed a risk of skin injury and infection.
Failed to ensure medical records were accurate and complete for residents, including inconsistent dialysis access monitoring and incorrect urinary catheter care documentation.
Failed to maintain infection control practices related to self suctioning respiratory care and improper handling of soiled linen in resident rooms.
Report Facts
Residents reviewed for MDS accuracy: 24
Residents reviewed for respiratory care: 14
Residents reviewed for urinary catheter care: 3
Length of yankauer suction catheter debris: 250
Resident 5's nail length: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 11 | Charge Nurse | Discussed nail care procedures and expectations for communication about nail trimming |
| DON | Director of Nursing | Acknowledged deficiencies in care planning, infection control, and documentation |
| RT 1 | Respiratory Therapist | Provided instruction on suction catheter care and acknowledged infection control issues |
| LRT | Licensed Respiratory Therapist | Interviewed regarding self suctioning care plans and infection control |
| CNA 12 | Certified Nursing Assistant | Reported on nail care responsibilities and communication |
| CNA 16 | Certified Nursing Assistant | Interviewed about Resident 67's catheter self-care |
| CNA 17 | Certified Nursing Assistant | Interviewed about Resident 6 and 67's catheter self-care |
| LN 16 | Licensed Nurse | Discussed documentation and care provision for catheter care |
| LN 17 | Licensed Nurse | Discussed dialysis access monitoring and infection control |
| ICN | Infection Control Nurse | Interviewed regarding infection control practices and concerns |
Report
December 11, 2025
Report
July 21, 2025
Report
April 2, 2025
Report
December 17, 2024
Report
October 30, 2024
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