Inspection Reports for
Jacob Health Care Center
4075 54TH STREET, SAN DIEGO, CA, 92105
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
12.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
220% worse than California average
California average: 4 deficiencies/year
Deficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
78% occupied
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 31
Capacity: 40
Deficiencies: 4
Date: Dec 11, 2025
Visit Reason
Licensing Program Analyst Dang Nguyen conducted an unannounced Required Annual Inspection to evaluate compliance with licensing requirements at Jacob Health Care Center.
Findings
The facility was generally clean, sanitary, and in good repair with compliant environmental conditions. However, deficiencies were found related to staff training, resident annual physicals, care conference meetings, and hospice care training.
Deficiencies (4)
HSC 1569.625(b)(2) Staff training requirement was not met as 2 of 5 sampled staff did not complete 20 hours of annual training including dementia care and hospice care topics.
CCR 87463(h)(1) Two of five sampled residents lacked documented proof of an annual routine visit with a licensed medical professional within the last 12 months.
CCR 87467(a)(3) Four of five sampled residents did not have a care meeting arranged within the last 12 months to review and revise the written record of care.
CCR 87633(b)(6)(B) The hospice agency did not provide required training to 15 staff on the current and ongoing care needs of the hospice resident before hospice care began.
Report Facts
Residents in care: 31
Total licensed capacity: 40
Deficiencies cited: 4
Technical Violations: 1
Sampled resident records reviewed: 5
Sampled staff records reviewed: 5
Hospice staff requiring training: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Cruz | Administrator | Facility Administrator involved in inspection and exit interview |
| Jacqueline Ortega | RCFE Assistant Administrator | Assistant Administrator involved in inspection and exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Simon Jacob | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Census: 36
Capacity: 40
Deficiencies: 0
Date: Jul 21, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection in response to the licensee’s self-reported deaths of two residents.
Findings
No deficiencies were observed or cited during the visit. A brief facility tour and welfare check on remaining residents found no immediate safety concerns.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Cruz | Administrator | Met with Licensing Program Analyst during the visit. |
| Jacqueline Ortega | Assistant Administrator | Met with Licensing Program Analyst during the visit and participated in exit interview. |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Simon Jacob | Licensing Program Manager | Named in the report header. |
Inspection Report
Census: 29
Capacity: 40
Deficiencies: 0
Date: Apr 2, 2025
Visit Reason
Licensing Program Analyst Sabel Martinez conducted an unannounced collateral visit to the Jacob Health Care Center to conduct interviews and request records.
Findings
The visit involved interviews and record reviews with facility staff. No specific deficiencies or violations are detailed in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Cruz | Administrator | Met during the visit and assisted the Licensing Program Analyst. |
| Jacqueline Ortega | Assistant Administrator | Met during the visit, assisted the Licensing Program Analyst, and participated in the exit interview. |
| Thelma Pajarit | Medication Technician | Present during the visit and introduced to the Licensing Program Analyst. |
Inspection Report
Original Licensing
Census: 40
Capacity: 40
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
An unannounced pre-licensing visit was conducted as part of the facility's change of ownership process and to assess readiness for licensing approval.
Findings
The facility was found to be in good condition with required furnishings, safe walkways, proper water temperatures, and secure medication storage. The facility is ready to be licensed pending management approval.
Report Facts
Hospice waiver approved capacity: 5
Bedridden resident capacity: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Cruz | Administrator | Met during inspection and involved in facility management |
| Jacqueline Ortega | Assistant Administrator | Met during inspection and involved in facility management |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced pre-licensing visit |
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
Complaint Investigation
Deficiencies: 1
Date: Nov 27, 2024
Visit Reason
The inspection was conducted following a complaint regarding a missing medication card containing 60 tablets of Morphine for a resident.
Complaint Details
The complaint was substantiated. The missing Morphine medication card was confirmed missing after staff attempted to reorder it. The facility reported the loss to pharmacy and law enforcement.
Findings
The facility failed to follow its policy on receipt and storage of controlled medications, resulting in a missing Morphine medication card. Interviews and record reviews confirmed the medication was delivered but not properly accounted for, and the facility reported the loss to pharmacy and law enforcement.
Deficiencies (1)
F 0761: The facility did not ensure controlled medications were properly labeled, stored, and reconciled. A medication card containing 60 tablets of Morphine was missing and unaccounted for, violating facility policy on controlled substance management.
Report Facts
Medication quantity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Signed delivery log for Morphine medication on 10/20/24; involved in medication receipt process |
| LN 2 | Licensed Nurse | Interviewed regarding missing Morphine medication and medication reconciliation process |
| 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 missing medication and facility reporting |
Inspection Report
Original Licensing
Census: 36
Capacity: 40
Deficiencies: 0
Date: Oct 30, 2024
Visit Reason
The visit was conducted as a Component II evaluation for a Change in Ownership (CHOW) application for a Residential Care Facility for the Elderly (RCFE).
Findings
The Component II completion was successful. The applicant and administrator demonstrated understanding of licensing laws, facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Cruz | Administrator | Administrator participating in the Component II evaluation and interview. |
| Toby Tilford | Applicant | Applicant participating in the Component II evaluation and interview. |
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
Routine
Deficiencies: 13
Date: Sep 12, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with federal and state regulations for nursing home care.
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, failure to implement non-pharmacological pain interventions, inadequate dialysis site care, failure to maintain safe environment with side rails, and infection control lapses related to Enhanced Barrier Precautions.
Deficiencies (13)
F0644: Facility failed to conduct required PASARR II screenings for two residents, risking improper placement and lack of needed services.
F0656: Facility failed to develop a resident-centered care plan including dementia care for one resident, risking unmet needs.
F0657: Facility failed to revise care plan timely after gastrostomy tube discontinuation for one resident, risking miscommunication.
F0658: Facility failed to ensure professional standards in medication administration for three residents, including improper schizophrenia diagnoses and failure to check vital signs.
F0677: Facility failed to provide timely assistance with activities of daily living for two residents, including incontinence care and nail care.
F0689: Facility failed to maintain a safe environment by not installing ordered side rails for one resident, risking injury.
F0697: Facility failed to implement non-pharmacological pain interventions prior to administering PRN pain medications for three residents.
F0698: Facility failed to provide appropriate dialysis access care including timely removal of pressure dressing for one resident.
F0725: Facility failed to provide sufficient nursing staff to meet resident needs, resulting in delayed call light responses and unmet care needs.
F0758: Facility failed to ensure two residents were free from unnecessary antipsychotic medications without clear indications, risking side effects.
F0759: Facility failed to ensure medication error rate was below 5% when two routine medications were unavailable and omitted for one resident.
F0867: Facility's Quality Assurance program failed to identify and address unnecessary use of antipsychotic medications due to lack of indication review.
F0880: Facility failed to implement Enhanced Barrier Precautions for a resident with an indwelling catheter, risking infection transmission.
Report Facts
Medication administrations: 17
Medication administrations: 7
Medication administrations: 3
Medication administrations: 2
Staff call offs: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD 1 | Physician | Diagnosed Residents 5 and 6 with schizophrenia without proper documentation; unreachable for clarification. |
| John Smith | Director of Nursing | Named as DON involved in multiple interviews and findings related to medication use, care planning, and staffing. |
| Certified Nursing Assistant 1 | CNA | Interviewed regarding Resident 5's lack of hallucinations. |
| Licensed Nurse 23 | LN | Observed medication administration and interviewed about call light response issues. |
| Certified Nursing Assistant 33 | CNA | Interviewed regarding incontinence care delays and nail care issues. |
| Licensed Nurse 34 | LN | Observed medication pass and interviewed about omitted medications for Resident 72. |
| Director of Nursing | DON | Interviewed multiple times regarding deficiencies and facility policies. |
| Administrator | ADM | Interviewed regarding staffing and QAPI program. |
| Infection Prevention Nurse | IPN | Interviewed regarding infection control practices for Resident 211. |
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
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.
Complaint Details
The investigation was complaint-driven, focusing on Resident 1's pressure ulcer care. The complaint was substantiated with findings of deficient care and lack of competency by nursing staff.
Findings
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident 1. Licensed nurse and CNA staff did not follow treatment orders, failed to maintain infection control, and lacked competency in wound care, resulting in potential worsening or infection of pressure ulcers.
Deficiencies (2)
F 0686: The facility failed to provide care/treatment to prevent worsening of pressure ulcers for Resident 1, including failure to cover wounds, maintain infection control, and follow treatment orders. Treatment administration records had blank entries, making verification impossible.
F 0726: The facility failed to ensure licensed nurse competency in performing pressure ulcer treatments for Resident 1, resulting in improper wound care and potential for wound deterioration or infection.
Report Facts
Treatment record blank entries: 7
Pressure ulcer measurements: 5.7
Pressure ulcer measurements: 5.9
Pressure ulcer measurements: 4.3
Pressure ulcer measurements: 2.9
Wound slough percentage: 80
Wound slough percentage: 30
Wound depth: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Observed performing wound care improperly and admitted lack of competency and failure to follow treatment orders. |
| CNA 1 | Certified Nursing Assistant | Removed Resident 1's wound dressings improperly and acknowledged the error. |
| CNA 2 | Certified Nursing Assistant | Assisted with repositioning Resident 1 during wound care observation. |
| DSD | Director of Staff Development | Provided statements on competency requirements and deficiencies in wound care training. |
| DON | Director of Nursing | Provided statements on expected nursing care standards and deficiencies observed. |
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
Annual Inspection
Deficiencies: 0
Date: Jan 26, 2024
Visit Reason
Annual survey inspection of Jacob Healthcare Center to assess compliance with health and safety regulations.
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
Annual Inspection
Deficiencies: 0
Date: Nov 8, 2023
Visit Reason
Annual survey inspection of Jacob Healthcare Center to assess compliance with health and safety regulations.
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
Complaint Investigation
Deficiencies: 2
Date: Jul 12, 2023
Visit Reason
The inspection was conducted following 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 psychotropic medication and delayed provision of medical records to the resident's family member.
Findings
The facility failed to ensure informed consent was obtained before administering psychotropic medication to one resident and failed to provide requested medical records to the resident's family member in a timely manner, causing delays in access to records.
Deficiencies (2)
F 0552: The facility failed to ensure informed consent was signed for one resident before administering psychotropic medication. The resident received quetiapine without documented family member approval.
F 0573: The facility failed to provide copies of medical records requested by a resident's family member, resulting in a delay in reviewing the resident's medical record.
Report Facts
Medication dosage: 100
Dates of medical record requests: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding informed consent and medical record requests | |
| 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
Annual Inspection
Deficiencies: 7
Date: Jun 11, 2021
Visit Reason
The inspection was conducted as a recertification annual survey to assess compliance with federal regulations and facility policies.
Findings
The facility was found deficient in multiple areas including resident dignity during meals, confidentiality of medical records, environmental cleanliness, grooming services, infection prevention and control practices, and pneumococcal vaccination policies. Deficiencies were generally of minimal harm but affected several residents and had potential risks for resident well-being and safety.
Deficiencies (7)
F 0550: The facility failed to dress one resident in a dignified manner during a meal, exposing the resident's back due to an untied hospital gown.
F 0583: The facility failed to secure and protect one resident's medical information, exposing it on a medication cart accessible to unauthorized persons.
F 0584: The facility did not ensure ceiling vents were clean in resident rooms, increasing the risk of poor air quality.
F 0677: The facility did not provide requested grooming services, resulting in one resident having unwanted facial hair.
F 0867: The Quality Assurance committee failed to identify and implement current CDC pneumococcal vaccination recommendations, affecting all residents.
F 0880: The facility failed to ensure staff wore appropriate PPE when entering isolation rooms and did not ensure proper glove use in the kitchen, risking infection spread and foodborne illness.
F 0883: The facility failed to offer pneumococcal vaccines according to CDC guidelines to residents and did not document vaccine discussions or administration.
Report Facts
Residents affected: 124
Residents observed: 24
Residents observed waiting for lunch: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 10 | Certified Nursing Assistant | Acknowledged dressing resident improperly during meal |
| CNA 11 | Certified Nursing Assistant | Acknowledged putting hospital gown on resident exposing back |
| DON | Director of Nursing | Interviewed regarding resident dignity and PPE use |
| LN 12 | Licensed Nurse | Acknowledged exposure of resident medical information |
| LN 2 | Licensed Nurse | Acknowledged exposure of resident medical information and PPE noncompliance |
| CNA 1 | Certified Nursing Assistant | Failed to shave resident as requested |
| ICP | Infection Control Preventionist | Interviewed about infection control and vaccination deficiencies |
| QA nurse | Quality Assurance Nurse | Interviewed about vaccination practices |
| PC | Pharmacy Consultant | Interviewed about pneumococcal vaccination guidelines |
| MD | Medical Director | Interviewed about vaccination policies and QAPI meetings |
| 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 and training needs |
| LN 14 | Licensed Nurse | Interviewed about vaccination practices |
| LN 2 | Licensed Nurse | Failed to wear gown when entering isolation room |
| UM | Unit Manager | Interviewed about PPE donning procedures |
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 |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Sep 19, 2019
Visit Reason
The inspection was conducted to investigate complaints related to inaccurate resident assessments, incomplete care plans for respiratory and urinary catheter care, inadequate fingernail care, inaccurate medical record documentation, and infection control issues.
Complaint Details
The investigation was complaint-driven, focusing on issues such as inaccurate MDS coding, lack of care plans for self suctioning and catheter care, inadequate fingernail care, inaccurate medical record documentation, and infection control breaches.
Findings
The facility failed to accurately record MDS assessments, develop comprehensive care plans for residents performing self suctioning and urinary catheter care, provide routine fingernail care, maintain accurate medical records, and ensure proper infection control practices including handling of suction catheters and soiled linen.
Deficiencies (5)
F0640: The facility failed to accurately record an MDS assessment for one of 24 residents reviewed, causing inaccurate information transmission to CMS.
F0656: The facility failed to develop and implement comprehensive care plans for eight residents reviewed for respiratory care and two for urinary catheter care, risking inappropriate care.
F0677: The facility failed to provide routine fingernail care to one resident, placing the resident at risk of skin injury and infection due to long fingernails.
F0842: The facility failed to maintain accurate medical records for three residents, including incomplete dialysis access monitoring and incorrect urinary catheter care documentation.
F0880: The facility failed to implement an effective infection prevention and control program, including improper handling of suction catheters by residents and leaving 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
Volume of oral secretions: 250
Resident BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Nurse (MDSN 6) | Interviewed regarding inaccurate MDS assessment for Resident 75 | |
| Licensed Nurse (LN 11) | Interviewed about fingernail care and catheter care documentation | |
| Director of Nursing (DON) | Acknowledged failures in care planning, infection control, and documentation | |
| Respiratory Therapist (RT 1) | Interviewed about suction catheter care and infection control | |
| Licensed Nurse (LN 16) | Interviewed about catheter care documentation discrepancies | |
| Infection Control Nurse (ICN) | Interviewed about infection control practices and concerns | |
| Certified Nursing Assistant (CNA 12) | Interviewed about fingernail care procedures | |
| Certified Nursing Assistant (CNA 13) | Interviewed about catheter care for Resident 90 |
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