Deficiencies (last 3 years)
Deficiencies (over 3 years)
30.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
658% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
91 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a physical abuse incident where Resident 2 assaulted Resident 1, resulting in injuries requiring hospitalization.
Complaint Details
The complaint investigation found substantiated physical abuse where Resident 2 hit Resident 1 multiple times in the face on 12/4/25, causing injuries that required hospital transfer. Resident 2 had a history of aggressive behavior and medication noncompliance that was not adequately managed by the facility.
Findings
The facility failed to protect Resident 1 from physical abuse by Resident 2, who had escalating aggressive behaviors and medication noncompliance. Resident 1 sustained multiple facial injuries and was hospitalized. The facility did not adequately address Resident 2's behavior or separate the residents despite known risks.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical abuse, resulting in actual harm to a resident.
Report Facts
Number of punches Resident 1 received: 25
Psychotropic medication dosage: 200
Date of incident: Dec 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed Resident 2's noncompliance with psychotropic medication and that Resident 2 was not moved to a different room. |
| Mental Health Nurse Practitioner | Mental Health Nurse Practitioner | Evaluated Resident 2 and recommended increased psychotropic medication dosage. |
| Medical Doctor | Medical Doctor | Confirmed care of both residents and acknowledged failure to follow abuse policy. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Aug 14, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including notification of the Medical Director about significant changes in resident condition, safe discharge planning, and development of elopement care plans.
Findings
The facility failed to notify the Medical Director about Resident 1's refusal to eat, take medications, and aggressive behavior, potentially delaying treatment. Additionally, the facility did not notify appropriate parties or develop a safe discharge plan when Resident 1 left against medical advice, nor was an elopement care plan created despite Resident 1's high risk for elopement.
Deficiencies (3)
Failed to notify the Medical Director of Resident 1's refusal to eat, take medications, and aggressive behavior.
Failed to ensure a safe discharge plan including notification of Ombudsman, Adult Protective Services, police, and Responsible Party when Resident 1 left against medical advice.
Failed to develop an elopement care plan for Resident 1 despite high risk and history of leaving the facility.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 2 | Licensed Nurse | Confirmed failure to notify Medical Director about Resident 1's aggressive behavior and refusal to eat or take medications. |
| Director of Nursing | Director of Nursing | Confirmed Resident 1's behavioral changes and failure to notify Medical Director; emphasized importance of notification. |
| Medical Director | Medical Director | Stated no notification received about Resident 1's condition changes and expressed desire to be informed. |
| Licensed Nurse 3 | Licensed Nurse | Performed readmission assessment; stated expectation to notify Ombudsman, APS, and complete required forms for AMA discharge. |
| Social Services Director | Social Services Director | Confirmed failure to notify Ombudsman, APS, and police regarding Resident 1's AMA discharge. |
| Administrator | Administrator | Acknowledged failure to notify APS and Ombudsman about Resident 1's AMA discharge. |
| Licensed Nurse 1 | Licensed Nurse | Performed readmission assessment; confirmed Resident 1 required elopement care plan which was not developed. |
| Minimum Data Set Nurse | MDS Nurse | Stated Resident 1's high elopement risk and need for elopement care plan. |
Inspection Report
Deficiencies: 1
Date: Jul 31, 2025
Visit Reason
The inspection was conducted to evaluate compliance with physical therapy service requirements for a resident as ordered by the physician and outlined in the plan of care.
Findings
The facility failed to provide physical therapy services as ordered for Resident 1, who was prescribed therapy five times per week starting 7/4/25. Documentation showed multiple missed therapy sessions due to staff illness and lack of a physical therapist, placing the resident at risk for decline in functional abilities and unmet care plan goals.
Deficiencies (1)
Failure to provide specialized rehabilitative services as required for a resident.
Report Facts
Therapy sessions ordered per week: 5
Therapy sessions received: 5
Therapy session dates with notes: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed Resident 1 was not seen by PT in July after 7/14/25 and discussed risks of missed therapy |
| Administrator | Administrator | Stated facility did not have a Physical Therapist at time of inspection but expected return on 8/4/25 |
| Occupational Therapist | Occupational Therapist | Interviewed and confirmed physical therapist was not in the building and Resident 1 was scheduled for 5 therapy sessions per week |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure a safe discharge plan for Resident 1 who left the facility against medical advice (AMA).
Complaint Details
The investigation was complaint-driven, focusing on Resident 1 leaving the facility AMA without a safe discharge plan. APS considered the discharge self-neglect and unsafe. The facility's failure to notify APS delayed locating Resident 1 and arranging needed services.
Findings
The facility failed to ensure Resident 1 had a safe discharge plan when he expressed wanting to leave AMA. Resident 1 left the facility without proper support, was found confused and gravely disabled 3.4 miles away, and the facility did not notify appropriate parties such as the physician, ombudsman, social services, or Adult Protective Services (APS). Documentation of alternatives to leaving AMA was lacking.
Deficiencies (4)
Failure to ensure Resident 1 had a safe discharge plan when leaving AMA.
Failure to notify physician, ombudsman, social services director, and APS when Resident 1 expressed desire to leave AMA.
Lack of documentation of alternatives offered to Resident 1 to prevent leaving AMA.
Failure to have a plan for safe transportation or discharge for Resident 1 who was a high fall risk and cognitively impaired.
Report Facts
Residents sampled: 3
Distance Resident 1 found from facility (miles): 3.4
Resident 1's apartment distance from facility (miles): 21
Falls in past three months: 1
Medications contributing to falls: 3
Evaluation hold duration (hours): 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Interviewed regarding Resident 1 leaving AMA and failure to notify appropriate parties |
| LN 2 | Licensed Nurse | Reviewed Resident 1's Electronic Health Record and noted lack of documentation |
| LN 3 | Licensed Nurse | Stated the nurse on duty should have notified the MD and documented notification |
| MD | Medical Director | Assessed Resident 1 upon admission and commented on lack of notification about AMA discharge |
| SSD | Social Services Director | Interviewed about expectations for notification and discharge planning |
| DON | Director of Nursing | Acknowledged Resident 1's cognitive impairment and lack of documentation of alternatives to AMA |
| ADM | Administrator | Acknowledged deficiencies in AMA process and need to notify APS |
| APS 1 | Adult Protective Services Employee | Stated expectation to be notified when Resident 1 left AMA and described delays caused by lack of notification |
| OMB | Ombudsman | Stated facility did not notify him when Resident 1 expressed desire to leave AMA |
| DO 1 | Deputy Officer | Reported Resident 1 left AMA and was later found confused and gravely disabled |
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 19
Date: Mar 14, 2025
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with federal regulations and ensure resident safety and quality of care.
Findings
The facility was found deficient in multiple areas including resident rights, environment, care planning, medication management, infection control, food safety, and physical environment. Specific issues included failure to maintain resident advance directives, inadequate room sizes, improper medication administration and documentation, unsafe food storage and preparation, and lapses in infection prevention practices.
Deficiencies (19)
Failure to ensure Resident 39's advance directive was available and properly documented.
Failure to maintain a clean, comfortable, and homelike environment with multiple areas of wall damage, mismatched paint, and damaged fixtures.
Failure to resubmit PASARR screening for Resident 71 within required timeframe.
Failure to develop a baseline care plan within 48 hours addressing communication needs for Resident 249.
Failure to develop and implement a care plan for anticoagulant monitoring for Resident 66.
Failure to conduct quarterly IDT care conferences for Resident 31 as scheduled.
Delay in performing STAT left hand x-ray for Resident 96 and failure to timely notify physician of delay.
Unsafe medication storage with medications at bedside, opened emergency kit without documentation, and undated multi-dose vial of Heparin.
Failure to ensure pharmaceutical services met resident needs including undocumented antibiotic doses for Resident 66 and unavailable nicotine patch for Resident 300.
Failure to ensure safe monitoring and administration of blood pressure medications for Resident 35, including use of same vital signs for multiple doses and administration of conflicting medications.
Failure to follow food safety standards including improper labeling, poor kitchen sanitation, food storage violations, and worn food preparation equipment.
Failure to provide adequate protein content in alternative meal options compared to main entrée.
Failure to provide appropriate portion sizes for pureed diets leading to potential malnutrition.
Failure to properly dispose of garbage with dumpsters left uncovered posing risk of infestation.
Failure to maintain confidentiality of resident medical records with documents of Resident 31 found in Resident 98's file.
Failure of Quality Assessment Performance Improvement (QAPI) program to address delayed background checks for newly hired staff.
Failure to implement infection prevention and control measures including improper glucometer disinfection and urinal left on bedside table.
Failure to follow Antibiotic Stewardship Program protocols including incomplete antibiotic time-out and lack of urine culture for Resident 90.
Failure to provide shared resident rooms with at least 80 square feet per resident in 33 rooms.
Report Facts
Residents affected: 91
Rooms with inadequate space: 33
Background check delay: 22
Missed antibiotic doses: 3
Missed nicotine patch doses: 6
Room measurements: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nurse Assistant | Background check completed 22 months after hire |
| CNA 2 | Certified Nurse Assistant | Background check completed 24 months after hire |
| LN 8 | Licensed Nurse | Background check completed 24 months after hire |
| LN 1 | Licensed Nurse | Observed cleaning glucometer improperly |
| LN 5 | Licensed Nurse | Involved in delayed x-ray follow-up and medication administration |
| DON | Director of Nursing | Provided multiple statements on expectations and deficiencies |
| CDM | Certified Dietary Manager | Provided statements on food preparation and kitchen sanitation |
| MATD | Maintenance Director | Provided room measurements and facility condition statements |
| IP | Infection Preventionist | Reviewed infection control and antibiotic stewardship deficiencies |
| DSD | Director of Staff Development | Reviewed employee files and background check delays |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 31, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to develop a care plan addressing alcohol withdrawal and elopement prevention for Resident 1 upon admission.
Complaint Details
The complaint investigation was substantiated, confirming that Resident 1 eloped twice from the facility due to lack of appropriate care planning and monitoring for elopement risk and alcohol withdrawal.
Findings
The facility failed to create and implement a care plan for Resident 1's immediate needs related to alcohol withdrawal and elopement risk, resulting in two elopement incidents on 12/6/24 and 12/13/24. Staff acknowledged lack of elopement precaution monitoring and care planning despite documented risk.
Deficiencies (1)
Failure to develop a care plan addressing alcohol withdrawal and elopement prevention for Resident 1 upon admission.
Report Facts
Elopement incidents: 2
Volume of alcohol consumption: 750
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Acknowledged only one elopement assessment was completed and no care plan was developed for Resident 1 |
| Licensed Nurse 2 | Licensed Nurse | Acknowledged no elopement or withdrawal behavior precautions were placed on Resident 1 |
| Director of Nursing | Director of Nursing | Reported two elopement episodes and stated interventions after first elopement should have included education and monitoring |
Inspection Report
Deficiencies: 1
Date: Nov 19, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding residents' access to their medical records following a complaint or concern about delayed provision of records.
Findings
The facility failed to provide Resident 1 with a copy of his medical records within 2 days after a written request was made on 2024-11-14, delaying the resident's right to timely access to his medical records. Interviews and record reviews confirmed the delay and procedural lapses in processing the request.
Deficiencies (1)
Failure to provide a copy of medical records to Resident 1 within 2 days after a written request was made.
Report Facts
Days delayed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services (SS) | Interviewed regarding the medical records request process and communication with Resident 1. | |
| Medical Records (MR) | Interviewed about the protocol for medical record requests and delay in sending documents. | |
| Administrator (Admin) | Interviewed about expectations and oversight of the medical records request process. |
Inspection Report
Routine
Deficiencies: 1
Date: Oct 23, 2024
Visit Reason
The inspection was conducted to evaluate the facility's pharmaceutical services and compliance with medication administration requirements, specifically regarding the availability and administration of prescribed medications to residents.
Findings
The facility failed to provide pharmaceutical services to meet the needs of one sampled resident when a prescribed medication (Gabapentin) for nerve pain was not available and therefore not administered. This failure had the potential to cause increased pain for the resident.
Deficiencies (1)
Failure to provide pharmaceutical services to meet the needs of Resident 1 when Gabapentin medication was not ordered and delivered as prescribed.
Report Facts
Medication dose not given: 1
Scheduled pharmacy deliveries: 3
Scheduled pharmacy deliveries: 2
Medication reorder threshold: 6
Medication reorder threshold: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Observed medication pass and stated Gabapentin was not administered because it was not available |
| Infection Preventionist | Infection Preventionist | Interviewed regarding importance of Gabapentin and medication ordering procedures |
| Director of Staff Development | Director of Staff Development | Interviewed about medication reorder responsibilities and risks of not ordering timely |
| LN 2 | Licensed Nurse | Interviewed stating follow-up with pharmacy was needed to ensure medication availability |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 1, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide timely notification to the local Long-Term Care Ombudsman office about a resident's transfer/discharge, which potentially deprived the resident of necessary protections and support.
Complaint Details
The complaint investigation found that the Ombudsman office did not receive the required notice of Resident 1's pending discharge. The resident was discharged prior to an appeal hearing despite a directive not to discharge until after the hearing. The resident became homeless and could not be located after discharge.
Findings
The facility failed to provide the LTC Ombudsman office with a copy of the Notice of Transfer/Discharge for Resident 1 prior to the discharge. Resident 1 was discharged before an appeal hearing could be held, resulting in the resident becoming homeless and unable to be located. Interviews and document reviews confirmed the facility did not follow its own policy regarding timely notification to the Ombudsman.
Deficiencies (1)
Failure to provide timely notification to the local Long-Term Care Ombudsman office of Resident 1's transfer/discharge prior to the discharge.
Report Facts
Notification Date: Jun 21, 2024
Effective Date: Jun 27, 2024
Appeal Hearing Date: Jul 15, 2024
Date of OAHA email: Jun 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Social Service Director | Responsible for providing Discharge/Transfer Notices to residents receiving public health insurance and sending notices to the Ombudsman |
| Operations Manager | Operations Manager | Notified by OAHA not to discharge Resident 1 prior to appeal hearing; acknowledged receipt of OAHA email |
Inspection Report
Deficiencies: 1
Date: Jul 26, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards regarding resident-identifiable information and medical record documentation, specifically focusing on the timeliness of smoking safety evaluation records.
Findings
The facility failed to ensure that one of five sampled residents' smoking safety evaluation records was completed and signed in a timely manner, potentially causing inaccurate documentation and risk of injury from smoking.
Deficiencies (1)
Failure to complete and sign Resident 1's smoking safety evaluation record in a timely manner.
Report Facts
Residents sampled: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development | Director of Staff Development | Signed Resident 1's Smoking Safety Evaluation record late and provided explanation about the evaluation process |
| Medical Records Director | Medical Records Director | Reviewed Resident 1's Smoking Safety Evaluation record and explained documentation locking process |
| Director of Nursing | Director of Nursing | Acknowledged the delay in signing Resident 1's Smoking Safety Evaluation record and stated expectations for timely documentation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 29, 2024
Visit Reason
The inspection was conducted due to a complaint alleging physical abuse of Resident 1 by a Certified Nursing Assistant (CNA 1), who was reported to have grabbed and hit the resident in the face.
Complaint Details
The complaint investigation substantiated that CNA 1 struck Resident 1 in the face causing injury. Interviews with staff, family member, and clinical record reviews supported the allegation. The facility and medical director stated the incident was preventable and unacceptable.
Findings
The facility failed to protect Resident 1 from physical abuse by CNA 1, resulting in the resident sustaining a lip injury with bleeding and discoloration. Multiple interviews and clinical record reviews confirmed the incident and the facility acknowledged the behavior was unacceptable.
Deficiencies (1)
Failure to protect Resident 1 from physical abuse by facility staff, resulting in injury.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in physical abuse finding against Resident 1 |
| CNA 6 | Certified Nursing Assistant | Witnessed commotion and reported Resident 1's injury |
| LN 2 | Licensed Nurse | Interviewed regarding Resident 1's behavior and incident |
| OPM | Operations Manager | Interviewed and stated injury was preventable and behavior unacceptable |
| Admin | Facility Administrator | Interviewed and stated CNA 1's behavior was not acceptable |
| SSD | Social Services Director | Spoke with Resident 1 and family member about incident |
| DON | Director of Nursing | Stated facility was safe but CNA 1's behavior was unacceptable |
| MD | Medical Director | Stated facility was safe and incident was isolated but unacceptable |
Inspection Report
Routine
Deficiencies: 2
Date: May 20, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning and treatment standards, including review of incidents involving resident altercations and injury management.
Findings
The facility failed to develop comprehensive care plans for two residents involved in altercations and delayed informing the medical provider about a resident's cervical fracture, resulting in potential risks for inadequate care and delayed treatment.
Deficiencies (2)
Failed to develop a comprehensive care plan for two residents involved in altercations, resulting in potential unmet psychosocial needs.
Failed to provide timely treatment and inform medical provider of a cervical fracture for one resident, resulting in delayed treatment and risk of worsening injury.
Report Facts
Residents sampled: 7
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Confirmed lack of care plans for residents after altercations and stated expectations regarding discharge instructions |
| Licensed Nurse 5 | Licensed Nurse (LN) | Cared for Resident 7 on 4/8/2024 and provided discharge information to medical provider |
| Director of Staff Development | Director of Staff Development (DSD) | Reviewed discharge notes and informed medical provider about fracture on 4/26/2024 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where Resident 3 hit Resident 5 after Resident 5 shouted and cursed at Resident 3 to stop staring at her.
Complaint Details
The complaint investigation found that Resident 3 hit Resident 5 on the face and shoulder after Resident 5 shouted and cursed at him. The incident occurred on 5/3/24 near the nurse's station hallway and was witnessed by staff and another resident. Resident 5 was given medication for pain. Resident 3 had moderate cognitive impairment, while Resident 5 was cognitively intact. Staff interviews confirmed the behaviors and incident details.
Findings
The facility failed to ensure residents were free from verbal and physical abuse, resulting in physical pain for Resident 5 and potential psychosocial harm to both residents. The incident involved a physical altercation between two residents, witnessed by staff and another resident, with documented behaviors of verbal aggression by Resident 5 and physical retaliation by Resident 3.
Deficiencies (1)
Failure to protect residents from verbal and physical abuse between residents.
Report Facts
BIMS score: 10
BIMS score: 15
Date of incident: May 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse (LN 1) | Interviewed regarding Resident 5's behaviors and incident details | |
| Certified Nursing Assistant (CNA 1) | Interviewed about Resident 5's behaviors and awareness of the incident | |
| Operations Manager (OM) | Interviewed about the incident and staff observations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 12, 2024
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to ensure that Resident 1's call light was within reach, potentially compromising the resident's ability to summon help promptly.
Complaint Details
The complaint investigation found that Resident 1's call light was not within reach, staff did not inform the resident about the call light's purpose, and the resident was at risk of falls and unmet needs. The complaint was substantiated with observations and staff interviews confirming the deficiencies.
Findings
The facility failed to ensure Resident 1's call light was accessible, which posed a risk of unmet needs and potential psychosocial or physical harm. Interviews and observations confirmed the call light was not within Resident 1's reach, and staff did not adequately inform or remind the resident about its use, despite the resident's high fall risk and cognitive impairments.
Deficiencies (1)
Failure to ensure Resident 1's call light was within reach, compromising the resident's ability to call for help promptly.
Report Facts
Residents sampled: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Verified call light was not within Resident 1's reach and stated it should be near the bed |
| CNA 2 | Certified Nursing Assistant | Assigned to Resident 1, did not inform resident about call light use |
| LN 1 | Licensed Nurse | Stated Resident 1 could use call light but staff should remind resident daily |
| Assistant Director of Nursing | ADON | Stated Resident 1 was able to use call light and emphasized need for call light to be within reach |
| Operation Manager | OM | Stated call lights must be accessible to prevent safety risks and unmet needs |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 23, 2024
Visit Reason
The inspection was conducted due to an allegation of verbal abuse reported by Resident 33 involving Resident 63, which was not timely reported by licensed nurse (LN) 1 to facility administration.
Complaint Details
The complaint involved an allegation of verbal abuse by Resident 63 towards Resident 33, which was not reported by LN 1 to the Administrator or other authorities, delaying investigation. The complaint was substantiated based on interviews and record review.
Findings
The facility failed to ensure the allegation of verbal abuse was reported, resulting in a delay of investigation and potential psychological harm to Resident 33. Interviews and record reviews confirmed the incident and the failure to report it to the Administrator and other authorities.
Deficiencies (1)
Failure to timely report suspected verbal abuse involving Resident 33 and Resident 63.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Named in failure to report allegation of verbal abuse. |
| Director of Nursing | Director of Nursing (DON) | Stated the incident should have been reported to the Administrator. |
| Administrator | Administrator (ADM) | Stated the incident should have been reported to her. |
| Operations Manager | Operations Manager | Stated he had not been informed of the allegation. |
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 19
Date: Feb 23, 2024
Visit Reason
The inspection was conducted as part of the annual recertification survey and complaint investigations to assess compliance with federal regulations for nursing home operations and resident care.
Findings
The facility had multiple deficiencies including failure to accurately document resident preferences for life-sustaining treatment, failure to provide timely Medicare non-coverage notices, failure to report alleged verbal abuse, inadequate coordination with PASARR program, incomplete care plans, medication errors including duplicate psychotropic medications, inadequate pharmaceutical services, food safety and sanitation issues, failure to inform residents about binding arbitration agreements, lack of hospice service agreements, infection control lapses, and insufficient resident room space.
Deficiencies (19)
Resident preferences regarding life sustaining treatment were not accurately reflected in the electronic health record for 1 of 21 sampled residents.
Failed to provide timely and specific notification of Medicare non-coverage to 2 of 3 sampled residents.
Failed to report an allegation of verbal abuse for 1 of 21 sampled residents.
Failed to coordinate assessments with PASARR program for 3 of 21 sampled residents.
Failed to develop and implement resident specific care plans for dialysis and hospice services for 2 of 21 sampled residents.
Failed to consistently complete quarterly interdisciplinary team care plan conferences for 2 of 21 sampled residents.
Resident 18 received duplicate psychotropic medications without diagnosis for seizures and no gradual dose reduction attempts.
Facility failed to clarify midodrine order parameters and failed to reconcile controlled drugs to prevent diversion.
Consultant pharmacist failed to identify and report medication irregularities including unnecessary psychotropic medications and therapy duplications for Residents 18 and 41.
Medication error rate exceeded 5% with 4 errors in 25 observed medication passes including missed nicotine patch and magnesium/folic acid administration.
Medications were not properly labeled or discarded after expiration or discontinuation in multiple medication carts and treatment areas.
Facility failed to employ a full-time Registered Dietitian or Certified Dietary Supervisor resulting in inadequate dietary supervision.
Pureed food was prepared with water instead of warm milk, potentially decreasing nutritive value.
Food storage and service standards were not met including open freezer door, unlabeled dry foods and spices, uncovered salads, unwashed fruits, and incomplete dishwasher and sanitizer logs.
Facility dumpster lids were left open and one dumpster was overfilled, risking pest attraction.
Residents and/or representatives were not adequately informed about binding arbitration agreements and their right to refuse or rescind.
Facility failed to ensure hospice services were coordinated with a written agreement and proper documentation of hospice visits for Resident 197.
Facility failed to implement water management program since August 2023 and failed to disinfect shared glucometers according to manufacturer instructions.
Shared resident bedrooms did not meet minimum space requirements of 80 square feet per resident in 33 rooms.
Report Facts
Medication error rate: 16
Resident rooms below space requirement: 33
Residents affected by food safety issues: 90
Residents affected by medication duplication: 1
Residents affected by medication errors: 2
Residents affected by arbitration agreement issue: 2
Residents affected by hospice coordination issue: 1
Residents affected by infection control lapses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 20 | Licensed Nurse | Named in medication administration errors and glucometer disinfection lapses |
| LN 24 | Licensed Nurse | Named in medication administration errors and glucometer disinfection lapses |
| LN 26 | Licensed Nurse | Named in medication errors, care plan issues, and psychotropic medication findings |
| LN 28 | Licensed Nurse | Named in glucometer disinfection lapses |
| Director of Nursing | Director of Nursing | Named in multiple findings including medication and care plan issues |
| Director of Staff Development | Director of Staff Development | Named in dietary supervision and medication administration findings |
| Registered Dietitian | Registered Dietitian | Named in dietary supervision and food preparation findings |
| Certified Dietary Supervisor | Certified Dietary Supervisor | Named in dietary supervision and food preparation findings |
| Director of Business Development and Admissions | Director of Business Development and Admissions | Named in binding arbitration agreement findings |
| Administrator | Administrator | Named in hospice coordination and binding arbitration agreement findings |
| Assistant Business Office Manager | Assistant Business Office Manager | Named in Medicare non-coverage notification findings |
| Consultant Pharmacist | Consultant Pharmacist | Named in medication review and psychotropic medication findings |
| Director of Maintenance | Director of Maintenance | Named in room measurement and water management program findings |
| Social Service Director | Social Service Director | Named in PASARR and psychotropic medication findings |
| Operations Manager | Operations Manager | Named in verbal abuse reporting findings |
| Licensed Nurse 1 | Licensed Nurse | Named in hospice coordination findings |
| Licensed Nurse 24 | Licensed Nurse | Named in hospice and medication administration findings |
| Licensed Nurse 18 | Licensed Nurse | Named in psychotropic medication findings |
| Dietary Aide 1 | Dietary Aide | Named in food preparation and food safety findings |
| Dietary Aide 2 | Dietary Aide | Named in dishwasher and sanitizer log findings |
| Housekeeper 1 | Housekeeper | Named in room size findings |
| Certified Nurse Assistant 1 | Certified Nurse Assistant | Named in room size findings |
Inspection Report
Life Safety
Census: 94
Deficiencies: 2
Date: Jan 23, 2024
Visit Reason
The inspection was conducted due to a failure of the facility's emergency electrical power system during a power outage on 2024-01-10, including failure of the generator to automatically start and lack of documented generator safety checks.
Findings
The facility failed to provide emergency electrical power for 15-20 minutes during a power outage and did not complete or document required weekly and monthly generator safety checks as per facility policy, placing residents at risk, especially those dependent on electrically powered medical equipment.
Deficiencies (2)
Failure to provide emergency electrical power during a power outage on 1/10/24 due to generator failure to automatically start.
Failure to complete and document weekly and monthly generator safety checks as required by facility policy.
Report Facts
Residents affected: 94
Duration of power outage: 15
Duration of power outage: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director | Interviewed regarding generator failure and maintenance logs |
| Administrator | Administrator | Interviewed regarding power outage and generator failure |
| Licensed Nurse 1 | Licensed Nurse | Interviewed regarding power outage and resident risk |
| Licensed Nurse 2 | Licensed Nurse | Interviewed regarding power outage and resident risk |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding expectations for generator checks |
| Director of Nursing | Director of Nursing | Acknowledged policy non-compliance |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 6, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement its policy and procedure on abuse prevention, specifically concerning missing background checks for staff.
Complaint Details
The complaint investigation found that the facility did not have a background check on file for Staff 1, who had been employed since 4/21/21. The Administrator confirmed the missing documentation during an interview on 11/2/23.
Findings
The facility failed to maintain a complete employee file for one of three sampled staff members, as Staff 1's background check was not located. This exposed residents to potential risk by allowing a staff member to work without documented criminal history screening.
Deficiencies (1)
Failure to implement policies and procedures to prevent abuse, neglect, and theft due to missing background check in Staff 1's employee file.
Report Facts
Staff members sampled: 3
Employment start date: Apr 21, 2021
Inspection Report
Routine
Census: 9
Deficiencies: 3
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with providing a safe, clean, comfortable, and homelike environment for residents, focusing on the condition of resident rooms and maintenance of the environment.
Findings
The facility failed to maintain a clean and homelike environment in three sampled rooms (Rooms A, B, and C), with multiple broken items, soiled curtains, stained floors, and inadequate maintenance follow-up, posing potential risks to residents' physical and psychosocial wellbeing.
Deficiencies (3)
Room A had a broken light fixture, broken footboard, broken bedside cabinet, broken closet door handle, broken bathroom window screen, soiled divider curtains, red stains on floor and glass door, dusty ceiling vent with spider webs, and dried brown stains on bed frame.
Room B had three soiled divider curtains and black grime on the floor behind bathroom and entry doors.
Room C had two broken closet storage drawer handles and broken tiles under bed 3.
Report Facts
Residents affected: 9
Maintenance work order entries: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HSK 1 | Housekeeper | Interviewed about cleaning routines and awareness of broken items in Room A. |
| LN 1 | Licensed Nurse | Interviewed about the condition and safety of Room A. |
| CNA 1 | Certified Nurse Assistant | Interviewed about awareness and reporting of broken items in Room A. |
| DSD | Director of Staff Development | Interviewed about maintenance staffing and reporting systems. |
| ADON | Assistant Director of Nurses | Interviewed about expectations for room cleanliness and repair priorities. |
| TS | Transportation Staff | Interviewed about maintenance repairs and reporting procedures. |
| CNA 2 | Certified Nurse Assistant | Interviewed about broken drawer handles and reporting training. |
| LS 1 | Laundry Staff | Interviewed about curtain cleaning schedules. |
| LN 2 | Licensed Nurse | Interviewed about reporting broken items to DON or maintenance. |
| LN 3 | Licensed Nurse | Interviewed about reporting broken items to maintenance or administrator. |
| ADM | Administrator | Interviewed about housekeeping responsibilities, maintenance reporting system, and follow-up. |
Inspection Report
Routine
Census: 91
Deficiencies: 3
Date: Sep 23, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically related to COVID-19 precautions and practices.
Findings
The facility failed to ensure adequate infection prevention and control measures for COVID-19, including lack of isolation precaution signs outside COVID positive residents' rooms, staff not consistently wearing N95 masks in the Alzheimer's Care Unit, failure to change facemasks when moving between units, and staff not being fit tested for N95 masks. These failures posed a risk of COVID-19 transmission among residents, staff, and visitors.
Deficiencies (3)
Isolation precautions signs were not posted outside COVID positive residents' rooms and isolation precautions were not taken for all COVID positive residents.
A staff member did not wear an N95 mask in the Alzheimer's Care Unit where COVID positive residents were present, and staff did not change facemasks after exiting the ACU unit before entering non-COVID units.
Staff were not fit tested for N95 masks as required.
Report Facts
Census: 91
Active COVID positive residents: 12
N95 fit testing date: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | CNA | Mentioned in relation to COVID positive resident care and PPE use |
| Certified Nursing Assistant 2 | CNA | Mentioned in relation to COVID positive resident care and PPE use, and fit testing |
| Licensed Nurse 1 | LN | Mentioned in relation to COVID positive resident care and fit testing |
| Director of Staff Development | DSD | Provided information on COVID positive residents and PPE requirements |
| Infection Preventionist | IP | Provided information on infection control practices and PPE requirements |
| Administrator | ADM | Provided statements on isolation precaution signage and PPE use |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 2, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of physical abuse by Resident 1 against two other residents.
Complaint Details
The complaint investigation found substantiated physical abuse incidents involving Resident 1 hitting Resident 2 and Resident 3. The residents were immediately separated and no injuries were found upon assessment.
Findings
The facility failed to ensure two residents were free from physical abuse by another resident, resulting in one resident being slapped in the face and another being hit on the arm. Interviews and record reviews confirmed the incidents and the facility's policy on abuse was referenced.
Deficiencies (1)
Failure to protect residents from physical abuse by another resident, resulting in slapping and hitting incidents.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding physical abuse of a resident by another resident.
Complaint Details
The complaint investigation found substantiated physical abuse where Resident 1 was hit in the face by Resident 2, causing injury.
Findings
The facility failed to ensure one resident was free from physical abuse when he was struck by another resident, resulting in a bruised left eye. Interviews and record reviews confirmed the incident and the facility's abuse policy was referenced.
Deficiencies (1)
Failure to protect a resident from physical abuse by another resident, resulting in a bruised left eye.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant 1 | Certified Nurse Assistant | Witnessed Resident 2 punching Resident 1 in the face. |
Inspection Report
Deficiencies: 1
Date: May 31, 2023
Visit Reason
The inspection was conducted to assess compliance with safety regulations after a resident sustained a burn injury from spilling hot coffee served in an uncovered styrofoam cup.
Findings
The facility failed to ensure safe serving of hot liquids to one resident, who spilled coffee on herself causing a first-degree burn. The resident had not been assessed for ability to handle hot liquids at the time, and the facility policy requires use of mugs with lids for safety.
Deficiencies (1)
Failure to ensure one resident was served hot liquids safely, resulting in a first-degree burn from spilling coffee served in an uncovered styrofoam cup.
Report Facts
Burn size: 4
Burn size: 5
Burn size: 3
Burn size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Wrote SBAR communication form documenting the burn injury |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Provided coffee in uncovered styrofoam cup leading to spill |
| Director of Nursing | Director of Nursing | Interviewed resident and confirmed failure to assess resident's ability to handle hot liquids |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 1, 2023
Visit Reason
The inspection was conducted due to a complaint alleging verbal abuse by a Certified Nursing Assistant (CNA 1) towards a resident during care.
Complaint Details
The complaint was substantiated. Resident 1 reported verbal abuse by CNA 1. The facility's investigation confirmed the allegation, and CNA 1 was terminated due to two allegations during the investigation.
Findings
The facility substantiated the complaint that CNA 1 verbally abused Resident 1 by telling her to 'Get off your butt and use the commode' while providing care, which caused emotional distress to the resident. CNA 1 was terminated following the investigation.
Deficiencies (1)
Failure to ensure one of three sampled residents was treated with dignity and respect when CNA 1 verbally abused Resident 1 by telling her to 'Get off your butt and use the commode' while providing care.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in verbal abuse finding and subsequent termination. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 27, 2023
Visit Reason
The inspection was conducted due to a complaint alleging verbal abuse by a Certified Nursing Assistant (CNA) towards Resident 1, specifically that the CNA called the resident an offensive name during care.
Complaint Details
The complaint was substantiated. Resident 1 reported verbal abuse by CNA 1 on 2/4/23. CNA 1 denied the allegation but the facility investigation confirmed the incident and CNA 1 was terminated.
Findings
The facility substantiated the allegation that CNA 1 verbally abused Resident 1 by calling her an 'ass' during a brief change. The CNA denied the accusation but was terminated following the investigation. Resident 1 reported feeling disrespected and hurt by the incident.
Deficiencies (1)
Failure to ensure Resident 1 was treated with dignity and respect when CNA 1 called Resident 1 an ass.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in verbal abuse finding and subsequent termination. |
| Administrator | Interviewed during investigation and confirmed substantiation of allegation. | |
| Director of Nurses | DON | Interviewed during investigation and confirmed substantiation of allegation. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 9, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with fall prevention measures following an incident where a resident fell due to lack of a fall mat at the bedside.
Findings
The facility failed to ensure fall prevention measures were implemented as Resident 1 did not have a fall mat placed next to the bed, despite being identified as at risk for falls. This failure had the potential to cause injury to the resident.
Deficiencies (1)
Failure to ensure fall prevention measures were implemented when a fall mat was not placed on the floor next to the bed for Resident 1.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse (LN) 1 | Confirmed Resident 1 did not have a fall mat placed at her bedside and confirmed care plan interventions | |
| Licensed Nurse (LN) 2 | Confirmed Resident 1 did not have a fall mat in place on either side of her bed | |
| Occupational Therapist (OT) | Stated fall mats are usually recommended when someone is unsafe |
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 18
Date: Jan 13, 2023
Visit Reason
Annual recertification survey of Noble Care Center to assess compliance with health and safety regulations, resident rights, care quality, and facility environment.
Findings
The facility had multiple deficiencies including failure to treat residents with dignity during meals, inadequate accommodation of resident needs, inconsistent documentation and management of advance directives and code status, failure to notify physicians of elevated blood sugar, unsafe medication handling and storage, inadequate infection control practices, insufficient dietary management and food safety, and inadequate room space per resident in shared rooms.
Deficiencies (18)
Staff stood over residents while feeding, failing to treat them with dignity during meals.
Failure to provide reasonable accommodations such as wheelchairs, tray tables, and accessible call lights to residents.
Discrepancies and lack of documentation regarding residents' advance directives and code status orders.
Failure to provide beneficiary notification forms to residents' responsible parties regarding Medicare non-coverage.
Grievance forms were not available for residents to file grievances.
Failure to complete quarterly care conferences for a resident.
Mental health diagnosis inaccurately reflected in medical records, risking unsafe medication use.
Failure to report elevated blood sugar levels to physician in a timely manner.
Inappropriate care and management of feeding tubes including expired feeding containers and failure to follow physician orders.
Respiratory care deficiencies including lack of oxygen use signage, incorrect oxygen flow rates, undated oxygen tubing, and failure to change nebulizer tubing per policy.
Discrepancies between controlled drug records and medication administration records, hazardous medications not properly labeled, unsecured medication disposal, and unsigned drug delivery records.
Failure to carry out blood thinner orders and notify physician of missed antibiotic doses, risking severe complications from blood clots.
Failure to ensure appropriate antibiotic use and monitoring, including lack of culture and sensitivity testing and inappropriate antibiotic prescribing.
Failure to maintain food safety including contaminated refrigeration, dirty cooking equipment and utensils, unclean ovens, lack of air gaps in sinks and dishwasher, dirty kitchen floors, and incomplete temperature logs.
Failure to maintain infection prevention and control including improper laundry storage, urinary catheter bag on floor, and PICC line dressing not changed weekly.
Failure to ensure accurate food portioning for residents on specialized diets, risking inadequate nutrition.
Dietary services manager not qualified and dietary staff not supervised by a qualified dietitian.
Shared resident bedrooms did not meet minimum space requirements of 80 square feet per resident in 33 rooms.
Report Facts
Residents affected: 35
Residents affected: 96
Weight gain: 31
Blood sugar readings above 300 mg/dL: 28
Blood sugar readings above 300 mg/dL: 11
Room measurements: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 5 | Licensed Nurse | Administered valproic acid without gloves; confirmed hazardous medication label not noted in MAR |
| DON | Director of Nursing | Acknowledged multiple deficiencies including medication handling, infection control, and urinary catheter bag placement |
| DSM | Dietary Services Manager | Not certified, acknowledged measuring food portions by sight, confirmed kitchen sanitation issues |
| DC | Dietary Consultant | Counseled dietary staff, confirmed kitchen sanitation issues, and portioning problems |
| HS | Housekeeping/Laundry Supervisor | Confirmed clean and soiled linens stored together and dirty ceiling vent in laundry area |
| MS | Maintenance Supervisor | Confirmed dirty ceiling vent in laundry area and need for cleaning |
| IP 1 | Infection Preventionist Nurse | Confirmed expired and unlabeled treatment cart supplies |
| LN 1 | Licensed Nurse | Confirmed urinary catheter bag on floor |
| LN 4 | Licensed Nurse | Confirmed PICC line dressing should be changed weekly and documented |
| LN 3 | Licensed Nurse | Confirmed feeding tube label deficiencies and failure to follow feeding orders |
| CP | Consultant Pharmacist | Acknowledged hazardous medication handling issues and lack of antibiotic stewardship program involvement |
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