Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Oct 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including the accuracy of PASARR screening for mental disorders and adequacy of resident room sizes.
Findings
The facility failed to ensure the accuracy of a Level I PASARR screening for one resident with a mental illness diagnosis and failed to ensure that residents' rooms met minimum size requirements in 8 rooms. Interviews with staff confirmed expectations for accurate PASARR screening and room size compliance.
Deficiencies (2)
Failed to ensure accuracy of Level I PASARR screening for mental disorders for Resident #74.
Failed to ensure residents' rooms measured at least 80 square feet per resident in 8 rooms.
Report Facts
Residents' rooms below minimum size: 8
Residents' rooms measured: 13
Room sizes measured: 70
Room sizes measured: 78.75
Room sizes measured: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Responsible for checking PASARR accuracy; stated Resident #74 had mental illness diagnosis that should have been indicated. | |
| Director of Nursing | DON | Stated expectation that PASARR screening was completed and accurate; confirmed Resident #74 had mental illness diagnosis. |
| Administrator | Stated expectation that PASARR was completed timely and accurately; aware of room size requirements. | |
| Certified Nursing Assistant #1 | CNA | Stated no problems providing care due to resident room size. |
| Certified Nursing Assistant #2 | CNA | Stated no issues providing care due to resident room size. |
| Licensed Vocational Nurse #3 | LVN | Stated never had issue providing care due to resident room size. |
Inspection Report
Deficiencies: 1
Date: Mar 27, 2024
Visit Reason
The inspection was conducted to evaluate the nursing facility's compliance with professional standards of quality, specifically regarding the care and treatment of residents, including wound care and documentation of physician's orders.
Findings
The facility failed to provide services meeting professional standards for one resident, as nursing staff did not consistently document carrying out physician's orders related to wound care. This failure contributed to the formation and worsening of a sacrococcyx wound, progressing from Stage 1 to Stage 4 pressure injury with unstageable wounds noted. Numerous treatment administration records showed multiple instances where ordered treatments were not carried out or documented.
Deficiencies (1)
Failure to document and carry out physician's orders for wound care, including cleansing, application of barrier cream, use of air mattress, and dressing changes for Resident 1's sacrococcyx pressure injury.
Report Facts
Dates with missed treatment documentation: 40
Braden Scale score: 9
Wound size increase percentages: 133
Wound length increase percentage: 24
Wound width increase percentage: 37
Wound depth increase percentage: 100
Longest tunnel increase percentage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed on 5/17/24 confirming the deficiency related to lack of documentation of wound care treatments |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Oct 21, 2021
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations regarding resident care, medication management, infection control, food service, and facility safety.
Findings
The facility was found deficient in multiple areas including timely completion of resident assessments, medication errors, inaccurate medical records, infection control lapses, unsafe medication storage, poor food quality, and inadequate resident room space. Deficiencies were generally of minimal harm but had potential risks for residents.
Deficiencies (13)
Failed to complete Comprehensive Minimum Data Set (MDS) assessments within required timeframes for multiple residents.
Failed to provide care meeting professional standards when a resident was cleaned with Chlorox bleach wipes after incontinence.
Provided oxygen therapy to residents without doctor's orders.
Failed to perform complete assessments and maintain dialysis communication records for residents receiving dialysis.
Pharmacist medication regimen reviews were not promptly acted upon for some residents.
Failed to ensure residents were free from unnecessary psychotropic medications without gradual dose reductions or clinical rationale.
Medication error rate of 11.43% observed, including missed doses and medications given incorrectly.
Failed to ensure safe medication storage; presence of unlabeled, discontinued medications and mixed storage of different medication types.
Food served was dry, overcooked, and unpalatable, potentially affecting resident nutrition.
Used unpasteurized eggs and failed to follow proper hand hygiene and glove use in food preparation.
Resident medical record contained another resident's confidential information, compromising record accuracy and confidentiality.
Failed to follow infection control practices including hand hygiene, glove changes, and proper specimen storage.
Multiple resident rooms did not provide at least 80 square feet per resident as required.
Report Facts
Medication error rate: 11.43
Medication errors observed: 4
Residents affected by room size deficiency: 22
Loose tablets found: 37
Unlabeled JP drain fluid volume: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Interviewed regarding medication regimen reviews, dialysis care, and medication errors |
| Licensed Vocational Nurse 3 | LVN 3 | Confirmed lack of doctor's orders for oxygen therapy for residents |
| Occupational Therapy Assistant | OTA | Involved in cleaning resident with disinfectant wipes |
| Licensed Vocational Nurse 7 | LVN 7 | Assessed resident after cleaning with disinfectant wipes |
| Consultant Pharmacist | CP | Provided medication regimen review recommendations |
| Dietary Manager Assistant | DMA | Interviewed about food quality issues |
| Regional Clinical Consultant | RCC | Interviewed about medical record accuracy issue |
| Director of Nursing | DON | Interviewed about medication room specimen storage |
| Director of Staff Development | DSD | Interviewed about specimen storage and staff responsibilities |
Inspection Report
Routine
Deficiencies: 2
Date: Nov 21, 2019
Visit Reason
The inspection was conducted to assess compliance with food storage and room size regulations at the facility.
Findings
The facility failed to ensure food was stored under sanitary conditions with undated and expired items in dry storage, posing a potential risk for foodborne illness. Additionally, seven resident rooms with multiple beds provided less than the required 80 square feet per resident, though observations found sufficient space for care and no negative consequences, leading to a recommendation for a room size waiver.
Deficiencies (2)
Food was stored under unsanitary conditions with an undated bottle of sesame oil and an expired bottle of cooking wine beyond the discard date.
Seven resident rooms with multiple beds provided less than 80 square feet per resident, below regulatory requirements.
Report Facts
Room square footage per bed: 71.88
Room square footage per bed: 70.8
Room square footage per bed: 70.8
Room square footage per bed: 71.88
Room square footage per bed: 71.88
Room square footage per bed: 71.31
Room square footage per bed: 75.93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding food storage deficiencies | |
| Licensed Vocational Nurse 1 | Interviewed regarding room size and care provision | |
| Certified Nursing Assistant 1 | Interviewed regarding room size and care provision | |
| Licensed Resource Nurse 1 | Interviewed regarding room size and care provision |
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