Deficiencies (last 3 years)
Deficiencies (over 3 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
225% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Oct 10, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including PASARR screening accuracy and resident room size standards.
Findings
The facility failed to ensure the accuracy of a Level I PASARR screening for one sampled resident with mental illness diagnosis. Additionally, the facility failed to provide resident rooms meeting minimum size requirements in 8 of 13 rooms measured.
Deficiencies (2)
F 0645 PASARR screening for Mental disorders or Intellectual Disabilities was inaccurate for Resident #74, who had a mental illness diagnosis but was not properly identified on the Level I screening.
F 0912 The facility failed to provide rooms with at least 80 square feet per resident in 8 of 13 residents' rooms measured on one unit.
Report Facts
Rooms below minimum size: 8
Residents' rooms measured: 13
Residents affected by PASARR deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding responsibility for PASARR screening accuracy and confirmed Resident #74's mental illness diagnosis should have been indicated | |
| Director of Nursing | Director of Nursing | Interviewed about expectations for PASARR screening completion and accuracy |
| Administrator | Administrator | Interviewed about expectations for PASARR screening completion and room size requirements |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding care provision related to room size |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding care provision related to room size |
| Licensed Vocational Nurse #3 | Licensed Vocational Nurse | Interviewed regarding care provision related to room size |
| Maintenance Director | Maintenance Director | Measured resident room sizes during inspection |
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
Complaint Investigation
Deficiencies: 1
Date: Mar 27, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide professional standard services, specifically the failure of nursing staff to document that physician's orders for wound care were carried out for Resident 1.
Complaint Details
The complaint investigation found that Resident 1's Treatment Administration Records from February through June 2023 had numerous dates with no licensed staff initials to demonstrate wound treatment orders were administered. The Director of Nursing confirmed this was a deficiency.
Findings
The facility failed to properly document and carry out physician-ordered treatments for Resident 1's sacrococcyx pressure injury, contributing to the formation and worsening of the wound from Stage 1 to Stage 4. Numerous treatment administration records showed multiple missed or undocumented treatments over several months.
Deficiencies (1)
F 0658: The facility failed to ensure nursing staff documented and carried out physician's orders for wound care on Resident 1, leading to worsening of a sacrococcyx pressure injury from Stage 1 to Stage 4.
Report Facts
Residents Affected: 1
Braden Scale score: 9
Wound size increase percentages: 133
Wound length increase percentage: 24
Wound width increase percentage: 37
Wound depth increase percentage: 100
Wound tunnel length increase percentage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed the deficiency regarding failure to document wound treatment administration. |
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
Routine
Deficiencies: 16
Date: Oct 21, 2021
Visit Reason
Routine inspection survey conducted to assess compliance with federal regulations for nursing home care.
Findings
The facility had multiple deficiencies including late or inaccurate Minimum Data Set (MDS) assessments, medication errors, improper dialysis care, unsafe medication storage, poor food quality, infection control lapses, inaccurate medical records, and inadequate resident room space.
Deficiencies (16)
F0636: The facility failed to complete the Comprehensive Minimum Data Set (MDS) within 14 days of admission for two residents, delaying care planning.
F0638: The facility failed to complete Quarterly MDS assessments on time for three residents, risking inadequate care based on current health status.
F0641: The facility inaccurately assessed one resident's hospice status on the MDS, risking inappropriate care.
F0684: One resident was cleaned with Chlorox bleach wipes after fecal incontinence, risking pain and chemical burns.
F0695: Two residents received oxygen therapy without doctor's orders, risking inadequate monitoring and complications.
F0698: The facility failed to provide complete dialysis assessments and communication records for three residents, risking inaccurate care.
F0756: The pharmacist's medication regimen review was not promptly acted upon for two residents, risking delayed treatment and side effects.
F0758: One resident received unnecessary psychotropic medications without gradual dose reductions or clinical rationale.
F0759: The facility had an 11.43% medication error rate with four errors observed, risking ineffective treatment for multiple residents.
F0760: One resident was not free from significant medication errors when Eliquis was not administered as prescribed, increasing stroke risk.
F0761: The facility failed to ensure safe medication storage; multiple unlabeled, discontinued medications and mixed storage of different medication types were found.
F0804: The facility failed to ensure food was palatable and attractive; observed food was dry, tough, mushy, and residents reported poor taste.
F0812: The facility used unpasteurized eggs and failed to follow proper hand hygiene and glove use during food preparation, risking foodborne illness.
F0842: Resident-identifiable information was not safeguarded; one resident's medical record contained another resident's confidential documents.
F0880: The facility failed to follow infection control practices; staff did not wash hands between residents, did not change gloves or sanitize equipment, and stored urine specimens improperly.
F0912: The facility failed to provide at least 80 square feet per resident in multiple resident rooms for 22 residents, risking insufficient personal space.
Report Facts
Medication error rate: 11.43
Medication errors observed: 4
Residents affected by room size deficiency: 22
Residents sampled: 20
Residents affected by MDS late assessments: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding MDS assessments, medication regimen reviews, and dialysis care. |
| Regional MDS Coordinator | Regional MDS Coordinator | Interviewed regarding late MDS assessments. |
| Occupational Therapy Assistant | Occupational Therapy Assistant | Interviewed regarding improper use of Chlorox wipes on resident. |
| Licensed Vocational Nurse 7 | Licensed Vocational Nurse | Interviewed regarding incident of disinfectant wipes used on resident. |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed regarding medication regimen review delays. |
| Dietary Manager Assistant | Dietary Manager Assistant | Interviewed regarding food quality issues and unawareness of unpasteurized eggs. |
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Observed and interviewed regarding hand hygiene and infection control lapses. |
| Director of Nursing | Director of Nursing | Interviewed regarding medication room specimen storage and infection control. |
| Director of Staff Development | Director of Staff Development | Interviewed regarding JP drain fluid storage and staff responsibilities. |
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
Deficiencies: 2
Date: Nov 21, 2019
Visit Reason
The inspection was conducted to assess compliance with food storage and room size regulations at the nursing home.
Findings
The facility failed to ensure food was stored under sanitary conditions with undated and expired items in dry storage. Additionally, seven resident rooms with multiple beds provided less than the required 80 square feet per resident, though no negative consequences were observed and a room size waiver was recommended.
Deficiencies (2)
F 0812: The facility failed to ensure food was stored under sanitary conditions when food in dry storage was undated and beyond the discard date, posing a potential risk for food borne illness.
F 0912: Seven resident rooms with multiple beds provided less than 80 square feet per resident, which could result in inadequate space for care delivery or storage of belongings.
Report Facts
Room square footage per bed: 70.8
Room square footage per bed: 71.88
Room square footage per bed: 71.31
Room square footage per bed: 75.93
Room total square footage: 303.75
Room total square footage: 215.66
Room total square footage: 212.4
Room total square footage: 213.93
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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