Deficiencies (last 3 years)
Deficiencies (over 3 years)
21.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
433% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Routine
Deficiencies: 14
Date: Apr 17, 2025
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements and to evaluate the quality of care and services provided to residents.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy during personal care, incomplete care plans addressing residents' specific needs, inadequate hygiene and pressure ulcer prevention, failure to meet nutritional intake goals, improper management of feeding tubes, respiratory care deficiencies, lack of trauma-informed care, incomplete medical records, infection control lapses, improper medication storage, and failure to post nurse staffing information accessibly. Additionally, some resident rooms did not meet minimum size requirements.
Deficiencies (14)
Failed to ensure resident privacy during personal care for Resident 19 by not drawing privacy curtains.
Failed to develop comprehensive care plans addressing Resident 42's refusal to turn and reposition and Resident 16's PTSD diagnosis.
Failed to provide good hygiene to Resident 16, including cleaning of fingernails.
Failed to provide appropriate pressure ulcer care and prevent new ulcers for Resident 42, including lack of turning schedule and offloading.
Failed to provide care and services to prevent weight loss for Resident 43 who did not meet meal intake goals.
Failed to change enteral feeding water flush bags within 24 hours for Residents 5 and 30 and Resident 41.
Failed to clarify physician's order for oral medication administration for Resident 56 who was NPO and receiving medications via G-tube.
Failed to provide respiratory care including continuous oxygen for Resident 20 and timely changing of nebulizer mask and tubing for Resident 41.
Failed to provide trauma-informed care for Resident 16 with PTSD, including lack of staff awareness and no PTSD-specific care plan.
Failed to post nurse staffing data in a prominent and accessible place for residents and visitors at North and South nursing stations.
Failed to maintain proper temperature controls in the locked medication refrigerator, with multiple out-of-range temperature readings and no corrective actions.
Failed to ensure completeness of medical records for Residents 2 and 24, including undated informed consents for psychotropic medications.
Failed to follow infection prevention and control practices including unlabeled personal toiletries in shared restrooms, expired medical supplies, staff personal belongings stored in medication storage room, delayed changing of enteral feeding water flush bags, and unsanitary environment with absorbent brief left on floor near Resident 17's bed.
Failed to ensure 15 of 22 resident rooms met minimum 80 square feet per resident in multiple resident bedrooms.
Report Facts
Room size: 147
Medication refrigerator temperature: 43.5
Medication refrigerator temperature out of range: 48
Meal intake percentage: 75
Tube feeding flush volume: 200
Tube feeding flush volume: 125
Medication doses: 75
Oxygen flow rate: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in privacy curtain deficiency for Resident 19 |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including privacy, care plans, feeding tubes, respiratory care, trauma-informed care, and medication administration |
| CNA 3 | Certified Nursing Assistant | Named in care plan and PTSD deficiencies |
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Named in care plan deficiency for Resident 42 |
| Treatment Nurse | Treatment Nurse | Named in pressure ulcer prevention deficiency for Resident 42 |
| Registered Nurse Supervisor | Registered Nurse Supervisor | Named in pressure ulcer prevention and medication storage deficiencies |
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse | Named in medication administration and medication storage deficiencies |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Named in enteral feeding water flush bag deficiency |
| Certified Nursing Assistant 4 | Certified Nursing Assistant | Named in infection control deficiency for unlabeled personal toiletries |
| Restorative Nurse Assistant | Restorative Nurse Assistant | Named in infection control deficiency for unlabeled personal toiletries |
| Licensed Vocational Nurse 3 | Licensed Vocational Nurse | Named in respiratory care deficiency for Resident 41 |
| Social Services Director | Social Services Director | Named in infection control deficiency for absorbent brief on floor |
| Activities Director | Activities Director | Named in infection control deficiency for absorbent brief on floor |
| Family Member 1 | Provided information about Resident 16's PTSD diagnosis and concerns | |
| Director of Staff Development | Director of Staff Development | Named in PTSD care deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 31, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to conduct a thorough investigation of an alleged abuse incident between Residents 1 and 2 on 1/18/2025, specifically the failure to obtain a statement from a witness, Resident 3.
Complaint Details
The complaint investigation focused on the facility's failure to properly investigate an alleged abuse incident between Residents 1 and 2 on 1/18/2025. The facility did not interview Resident 3, who identified herself as a witness. The investigation was deemed incomplete by the surveyors. The complaint was substantiated with findings of deficient investigation and care planning.
Findings
The facility failed to properly investigate the alleged abuse by not interviewing Resident 3, a witness to the incident, and failed to develop and implement a timely comprehensive care plan addressing wandering behavior for Resident 2. Additionally, the facility did not accurately document close monitoring and one-to-one supervision for Resident 2, potentially compromising resident safety and care consistency.
Deficiencies (3)
Failed to conduct a thorough investigation of an allegation of abuse by not obtaining a statement from a witness (Resident 3).
Failed to develop and implement a comprehensive care plan in a timely manner to address wandering behavior for Resident 2.
Failed to accurately document in the resident's clinical record when close monitoring and one-to-one supervision was implemented for Resident 2.
Report Facts
Date of alleged abuse incident: Jan 18, 2025
Date of survey completion: Jan 31, 2025
Date of care plan for wandering: Jan 21, 2025
Date one-to-one supervision started: Jan 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor | Witnessed Resident 2 enter Resident 1's room and redirected Resident 2 | |
| Administrator | Reviewed policy and stated no need to interview Resident 3 as a witness | |
| Director of Nursing | Reviewed Resident 2's care plan and stated care plan should have been created on admission |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 9, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to protect residents from physical abuse and failure to timely report suspected abuse incidents at the facility.
Complaint Details
The complaint investigation found substantiated incidents of physical abuse involving Resident 2 and failure to timely report suspected abuse involving Resident 1.
Findings
The facility failed to protect Resident 2 from physical abuse by Resident 3, who hit Resident 2 on the chest. Additionally, the facility failed to timely report an allegation of abuse involving Resident 1 to the appropriate authorities within the required two-hour timeframe, resulting in delayed notification and potential risk of further abuse.
Deficiencies (2)
Failed to protect Resident 2 from physical abuse by Resident 3 hitting Resident 2 on the chest.
Failed to timely report an allegation of abuse involving Resident 1 to the California Department of Public Health, Ombudsman, and local law enforcement within two hours as required by facility policy.
Report Facts
Date of incident: Aug 6, 2024
Date of survey completion: Aug 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Interviewed regarding failure to report abuse allegation involving Resident 1 |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident 1's report of being hit and abuse reporting |
| Activities Assistant 1 | Activities Assistant | Interviewed about Resident 3's behavior and incident with Resident 2 |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Provided 1:1 care to Resident 3 and reported on Resident 3's aggressive behavior |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Provided 1:1 care to Resident 3 and described the incident involving Resident 3 and Resident 2 |
Inspection Report
Routine
Census: 52
Deficiencies: 1
Date: Jul 3, 2024
Visit Reason
The inspection was conducted to evaluate the facility's implementation of its infection prevention and control program, specifically focusing on hand hygiene practices among staff.
Findings
The facility failed to ensure that Certified Nursing Assistants (CNA 1 and CNA 2) performed hand hygiene in accordance with the infection prevention program, potentially exposing residents and staff to infection. Observations and interviews confirmed multiple instances of staff not washing or sanitizing hands after glove removal or before and after resident contact.
Deficiencies (1)
Failure to implement infection prevention and control program by not performing hand hygiene as required.
Report Facts
Census: 52
Date of infection prevention training: May 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Observed failing to perform hand hygiene after glove removal and resident care |
| CNA 2 | Certified Nursing Assistant | Observed failing to perform hand hygiene while delivering food trays and touching resident environment |
| Licensed Vocational Nurse 2 | LVN | Interviewed regarding hand hygiene expectations |
| Licensed Vocational Nurse 3 | LVN | Interviewed regarding hand hygiene expectations |
| CNA 3 | Certified Nursing Assistant | Interviewed regarding hand hygiene expectations |
| Director of Staff Development | DSD | Interviewed regarding hand hygiene policies |
| Infection Prevention Nurse | IPN | Interviewed regarding infection prevention program and hand hygiene |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 7, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's failure to adequately monitor and supervise Resident 8, who wandered into other residents' rooms, posing a potential risk of resident-to-resident altercation and injury.
Complaint Details
The complaint investigation found that Resident 8 wandered into other residents' rooms frequently without adequate supervision, with staff and residents confirming the behavior. The facility did not provide 1:1 supervision despite the known risk and dementia diagnosis. The complaint was substantiated with findings of inadequate monitoring and supervision.
Findings
The facility failed to provide adequate supervision to Resident 8, who had dementia and a history of wandering into other residents' rooms without a 1:1 sitter. Staff and residents confirmed Resident 8's wandering behavior, and the facility lacked a specific monitoring schedule for Resident 8 despite awareness of the risk. The facility's policy required adequate supervision to prevent accidents, but this was not effectively implemented for Resident 8.
Deficiencies (1)
Failure to monitor and supervise Resident 8 to prevent wandering into other residents' rooms.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) 1 | Interviewed regarding Resident 8's wandering behavior and lack of 1:1 supervision. | |
| Certified Nurse Assistant (CNA) 1 | Interviewed about Resident 8's wandering and need for redirection. | |
| Licensed Vocational Nurse (LVN) 2 | Interviewed about Resident 8's wandering and interactions with other residents. | |
| Business Office Manager (BOM) | Observed Resident 8 wandering and standing in front of other residents' doors. | |
| Director of Staff Development (DSD) | Discussed staff awareness of Resident 8's wandering and lack of specific supervision schedule. | |
| Resident 12 | Reported Resident 8 wandering into their room and bathroom. | |
| Resident 5 | Reported Resident 8 wandering into their room and others'. | |
| Social Services Director (SSD) | Reported Resident 8's confusion and wandering, and staff's responsibility to redirect. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 22, 2024
Visit Reason
The inspection was conducted due to complaints and incidents involving physical abuse by Resident 3 towards Residents 1 and 2, focusing on failure to provide appropriate supervision and treatment for Resident 3 with behavioral problems.
Complaint Details
The investigation was complaint-driven, focusing on substantiated incidents of physical abuse by Resident 3 against Residents 1 and 2, confirmed by interviews, progress notes, and care plans indicating suspected abuse.
Findings
The facility failed to ensure Resident 3 received 1:1 supervision as required by the care plan, resulting in Resident 3 physically abusing Residents 1 and 2. Resident 3 had severe cognitive impairment and behavioral issues, but the facility did not provide adequate supervision or appropriate treatment to prevent abuse incidents.
Deficiencies (2)
Failure to protect residents from physical abuse by not providing 1:1 supervision to Resident 3 as required by the care plan.
Failure to provide appropriate treatment and services to Resident 3 diagnosed with dementia to maintain highest practicable well-being.
Report Facts
Date of survey completion: May 22, 2024
Number of residents sampled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding Resident 3's behavior and supervision failures |
| CNA 1 | Certified Nursing Assistant | Provided 1:1 supervision to Resident 3 after abuse incidents |
| CNA 3 | Certified Nursing Assistant | Worked night shift on 5/16/24, assigned to Resident 3 but not as 1:1 supervision |
| Occupational Therapy Assistant | Occupational Therapy Assistant (OTA) | Interviewed about Resident 3's confusion, agitation, and impulsive tendencies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 1, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to readmit Resident 1 after hospitalization and failure to perform neurological checks after a change in condition.
Complaint Details
The complaint investigation focused on Resident 1 who was transferred to a hospital and the facility's refusal to readmit the resident despite the hospital's request. The facility also failed to perform required neurological checks after Resident 1 sustained a head injury. Interviews with hospital case managers and facility administrators confirmed the refusal to readmit and acknowledged the failure to perform neuro checks.
Findings
The facility failed to readmit Resident 1 from the hospital as required by policy and violated the resident's right to return. Additionally, the facility failed to perform neurological checks on Resident 1 after a head injury, potentially placing the resident at risk for undetected neurological issues.
Deficiencies (2)
Failed to readmit Resident 1 back to the facility from the hospital as indicated in the facility's policy and procedure titled, readmission to Facility.
Failed to perform neurological checks as indicated in the facility's policy and procedure titled, Head Injury, for Resident 1 after a change in condition.
Report Facts
Date of readmission: Mar 19, 2024
Date of transfer to hospital: Apr 28, 2024
Date of neuro check failure: Mar 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Stated neuro checks were needed for Resident 1 after change in condition. |
| Director of Case Management | Director of Case Management | Interviewed regarding Resident 1's transfer and readmission refusal. |
| Director of Business Development | Director of Business Development | Confirmed facility decision not to readmit Resident 1. |
| Administrator | Administrator | Stated it was not safe to accept/readmit Resident 1 back to the facility. |
| Director of Nursing | Director of Nursing | Acknowledged neuro checks should have been done for Resident 1. |
Inspection Report
Routine
Deficiencies: 16
Date: Apr 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including medication self-administration, PASRR screening, care planning, activities, medication administration, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to assess resident ability to self-administer medications, incomplete PASRR follow-up, inadequate care planning and care plan revisions, failure to provide preferred activities, medication administration errors including expired medication use and crushing non-crushable meds, infection control lapses including improper use of PPE and sanitation, failure to ensure hearing aids availability, improper catheter care, expired medication storage, and inadequate resident room size.
Deficiencies (16)
Failure to conduct assessment for resident self-administration of medication (Resident 53).
Failure to follow up with Department of Health Care Services for PASRR Level II evaluation (Resident 24).
Failure to develop a comprehensive care plan for weight loss (Resident 22).
Failure to revise care plans for range of motion decline and hearing aid use (Residents 47 and 19).
Failure to provide preferred activities such as music for Resident 20.
Failure to provide dentures and follow up on dental treatment authorization (Resident 19).
Failure to change peripheral IV Heplock in accordance with policy (Resident 41).
Failure to ensure hearing aids were made available daily (Resident 19).
Failure to provide appropriate indwelling urinary catheter care and infection control practices (Resident 12).
Failure to monitor and act upon significant weight loss (Resident 5).
Medication errors including crushing non-crushable Metformin ER and administering expired Diltiazem (Residents 4 and 10).
Expired medications stored in medication storage room.
Failure to ensure resident and/or responsible party understood Binding Arbitration Agreement (Residents 53, 12, and 24).
Failure to implement Enhanced Barrier Precautions timely and lapses in infection control practices (Residents 12, 159, 3, 15, and 57).
Failure to ensure food safety including expired milk and improper sanitizing solution concentration in kitchen.
Resident rooms did not meet minimum 80 square feet per resident in multiple occupancy rooms (15 of 22 rooms).
Report Facts
Medication error rate: 11.11
Weight loss percentage: 8.77
Sanitizer concentration: 200
Resident room size: 147
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 3 | LVN | Interviewed regarding Resident 53's medication self-administration assessment |
| Director of Nursing | DON | Provided multiple interviews regarding policies, care plans, and infection control |
| Admissions Assistant 1 | AA 1 | Responsible for explaining Binding Arbitration Agreement |
| Certified Nurse Assistant 5 | CNA 5 | Interviewed regarding Resident 19's hearing aids |
| Treatment Nurse 1 | TXN 1 | Observed providing urinary catheter care and interviewed about infection control |
| Licensed Vocational Nurse 5 | LVN 5 | Observed medication administration errors and infection control lapses |
| Dietary Services Director 2 | DSD 2 | Interviewed regarding kitchen sanitation and food storage |
| Infection Preventionist Nurse | IPN | Provided infection control policy and practice information |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 21, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure a safe discharge for Resident 1, who was at risk for elopement and was discharged to an inappropriate facility, resulting in the resident leaving unsupervised and being reported missing.
Complaint Details
The complaint involved Resident 1 being discharged to an Independent Living Facility despite being at risk for elopement. The resident left the facility unsupervised, leading to a missing person report filed by family. The investigation found the discharge was inappropriate and lacked proper preparation and orientation.
Findings
The facility failed to ensure a safe discharge for Resident 1 by discharging him to an Independent Living Facility that was not secured, despite his elopement risk. There was no documented evidence of sufficient preparation or orientation prior to discharge. Resident 1 left the facility unsupervised, walked 1.4 miles to a hospital, and was reported missing by family. Interviews revealed miscommunication and misunderstanding about the level of care and security at the receiving facility.
Deficiencies (1)
Failure to ensure a safe discharge for Resident 1 at risk for elopement by transferring to an unsecured Independent Living Facility without sufficient preparation or orientation.
Report Facts
Residents affected: 3
Distance walked by Resident 1: 7392
Date of discharge: Mar 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding Resident 1's discharge and facility security |
| Social Services Director | Social Services Director | Interviewed regarding discharge planning and knowledge of receiving facility services |
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Interviewed about Resident 1's condition and risk for elopement |
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse | Interviewed about Resident 1's mobility |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Interviewed about Resident 1's behavior and attempts to leave |
| Family Member 1 | Provided information about Resident 1's discharge and missing person report | |
| Owner/Manager of ILF 1 | Owner/Manager | Interviewed about the nature of the Independent Living Facility and Resident 1's departure |
| Administrator | Administrator | Interviewed regarding expectations for safe discharge |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 10, 2024
Visit Reason
The inspection was conducted following a complaint related to the elopement of Resident 1 from the facility on 1/4/2024, to investigate the facility's compliance with care planning and supervision policies.
Complaint Details
The complaint investigation focused on Resident 1's elopement on 1/4/2024. The resident was found by police the next day with minor injury. The investigation found failures in care planning and supervision. The complaint was substantiated based on these findings.
Findings
The facility failed to develop and implement an individualized, person-centered care plan for Resident 1's elopement risk and did not ensure adequate supervision to prevent elopement. Resident 1 eloped by exiting through a bathroom window, and the interdisciplinary team did not evaluate or address the unique factors contributing to the resident's high elopement risk prior to the incident.
Deficiencies (2)
Failed to develop and implement an individualized care plan for elopement risk for Resident 1.
Failed to ensure adequate supervision and follow policy for elopement and wandering residents, increasing Resident 1's risk for elopement.
Report Facts
Date of Resident 1 admission: Nov 2, 2023
Date of elopement incident: Jan 4, 2024
Bathroom window distance from floor (inches): 56.75
Bathroom window maximum opening width (inches): 15.25
Bathroom window height (inches): 22
Height of rubber brown high stool (inches): 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | CNA | Assigned CNA for Resident 1, observed resident before elopement and took lunch break |
| Certified Nursing Assistant 2 | CNA | Monitored Resident 1 and exit doors, last saw Resident 1 walking before elopement |
| Licensed Vocational Nurse 1 | LVN | Observed Resident 1 before elopement, noted bathroom window screen pushed out |
| Director of Nursing | DON | Reviewed care plans and policies, stated no prior IDT meeting or person-centered care plan for elopement risk |
| Registered Nurse 1 | RN | Provided information on Resident 1's behavior and elopement protocol initiation |
Inspection Report
Deficiencies: 1
Date: Oct 24, 2023
Visit Reason
The inspection was conducted to evaluate compliance with facility policies and procedures related to pre-employment screening, specifically ensuring background checks were completed prior to employees providing care to residents.
Findings
The facility failed to ensure that one of seven sampled employees (Licensed Vocational Nurse 1) had a complete background check done prior to providing care, which posed a potential risk to resident safety. The background check was completed after the employee started working, contrary to the facility's policy.
Deficiencies (1)
Failure to ensure one of seven sampled employees had a complete background check prior to providing care as required by facility policy.
Report Facts
Employees sampled: 7
Dates related to employee background check: LVN 1 left facility on 2021-09-01, rehired on 2022-03-09, background check completed on 2022-04-04
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | Charge Nurse | Named in deficiency for incomplete background check prior to providing care |
| Director of Staff Development | Provided interview and record review regarding background check process and findings |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 3, 2023
Visit Reason
The inspection was conducted due to an allegation of sexual abuse reported by Resident 1 against two male nurses during the night shift. The investigation focused on the facility's failure to timely report the suspected abuse to the State Survey Agency, Ombudsman, and local law enforcement.
Complaint Details
The complaint involved an allegation by Resident 1 that she was touched inappropriately by two male nurses during the night shift. The allegation was made between 7/21/2023 and 7/24/2023, but the facility did not report it until 7/24/2023. The Director of Nursing and Administrator acknowledged the failure to report timely. Staff interviews revealed confusion and inconsistent reporting. The allegation was substantiated by the facility's investigation leading to suspension of the involved staff.
Findings
The facility failed to report the allegation of sexual abuse within the required timeframe, potentially risking further harm to Resident 1 or others. Resident 1 exhibited confusion and made accusations against staff, but the incident was not reported until several days later. The Director of Nursing suspended the involved staff upon learning of the allegations. The facility's policy requires immediate reporting within two hours of an allegation.
Deficiencies (1)
Failure to timely report suspected abuse of Resident 1 to proper authorities.
Report Facts
Date of Resident 1 admission: Feb 2, 2023
Date of History and Physical: Feb 6, 2023
Date of Minimum Data Set: May 5, 2023
Date of SBAR Communication Forms: Jul 21, 2023
Date of SBAR Communication Forms: Jul 24, 2023
Date of Report of Suspected Abuse: Jul 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Documented Resident 1's altered mental status and was accused by Resident 1 of inappropriate touching |
| Director of Nursing | Director of Nursing | First made aware of the alleged abuse on 7/24/2023 and suspended involved staff |
| Certified Nursing Assistant 4 | Certified Nursing Assistant | Witnessed Resident 1's behavior on 7/22/2023 |
| Activity Staff 2 | Activity Staff | Witnessed Resident 1's behavior and reported the incident to DON |
| Administrator | Administrator | Interviewed regarding facility's response to abuse allegations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 5, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's emergency contacts about a black-and-blue discoloration under the resident's right eye.
Complaint Details
The complaint investigation found that the facility did not notify Resident 1's Conservator and/or friend about the discoloration under Resident 1's right eye, despite Resident 1 lacking decision-making capacity. Licensed Vocational Nurse 1 documented the resident as self-responsible and did not make follow-up calls or notify the next shift. The Director of Nursing confirmed the failure and stated the discoloration was considered a change in condition requiring notification.
Findings
The facility failed to inform Resident 1's Conservator and/or friend about the discoloration under Resident 1's right eye despite the resident lacking capacity to make decisions. Licensed Vocational Nurse 1 documented the resident as self-responsible and did not notify the Conservator or friend, contrary to facility policy. This failure had the potential to prevent the Conservator and friend from being aware of any new treatment recommendations.
Deficiencies (2)
Facility failed to inform Resident 1's emergency contacts about a black-and-blue discoloration under Resident 1's right eye.
Facility failed to ensure Resident 1's clinical record contained accurate information regarding notification of emergency contacts about the discoloration.
Report Facts
Residents sampled: 5
Date of resident admission: Mar 3, 2021
Date of History and Physical: Mar 22, 2023
Date of Minimum Data Set: Jun 7, 2023
Date of Change of Condition Evaluation: Jun 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Notified physician about discoloration but failed to notify Conservator or friend |
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse | Reviewed COC and stated standard procedure is to notify Conservator/friend of injury |
| Director of Nursing | Director of Nursing | Confirmed failure to notify Conservator and stated discoloration was a change in condition |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Noticed discoloration and notified charge nurse |
Inspection Report
Routine
Deficiencies: 14
Date: Apr 21, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements including resident rights, care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate response to call lights, improper feeding assistance, privacy violations, failure to follow notification of changes policy, inaccurate resident assessments, incomplete care plans, inadequate pain management, improper medication monitoring, food service deficiencies, and infection control lapses.
Deficiencies (14)
Failure to maintain the dignity of residents by not responding promptly to call lights, improper feeding assistance, and lack of privacy during care.
Failure to follow policy on notification of changes resulting in untreated skin breakdown and delayed treatment.
Failure to ensure accuracy of resident assessments including nutritional and bowel/bladder assessments.
Failure to develop and implement comprehensive care plans addressing all resident needs including medication monitoring, catheter care, and bowel/bladder incontinence.
Failure to provide adequate pain management and assessment for resident receiving restorative nursing program services.
Failure to maintain resident mobility and follow physical therapy discharge recommendations resulting in significant decline in ambulation.
Failure to provide adequate hydration and nutrition for resident with gastrostomy tube, resulting in dehydration and hospitalization.
Failure to follow mechanical soft diet menu and recipes resulting in residents receiving less protein and overcooked food.
Failure to accommodate resident food preferences resulting in unmet nutritional needs.
Failure to ensure safe and sanitary food storage including unlabeled opened food and personal food stored in kitchen freezer.
Failure to ensure Director of Nursing had an active and valid RN license upon hire.
Failure to provide appropriate infection prevention practices including hand hygiene before catheter care.
Failure to ensure medication regimen review was completed and maintained in resident's medical record.
Failure to implement gradual dose reductions and monitor side effects of psychotropic medications resulting in over sedation and lethargy.
Report Facts
Open wounds: 2
Braden Scale score: 15
Weight loss: 5
Blood sugar level: 293
Blood sugar level: 700
Room size: 216
Walking distance: 200
Walking distance: 20
Medication doses: 10
Medication doses: 100
Medication doses: 50
Medication doses: 650
Medication doses: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 4 | Certified Nursing Assistant | Named in findings related to feeding assistance and call light response. |
| DON | Director of Nursing | Provided multiple interviews regarding facility policies and deficiencies. |
| RNA 1 | Restorative Nursing Aide | Observed providing range of motion exercises and reporting resident pain. |
| LVN 3 | Licensed Vocational Nurse | Monitored medication side effects and provided care. |
| WPA | Wound Physician Assistant | Evaluated and treated skin breakdown. |
| MDS 1 | Minimum Data Set Nurse | Provided assessment and interview regarding resident care. |
| RNA 2 | Restorative Nursing Aide | Provided ambulation assistance to Resident 43. |
| PTA 1 | Physical Therapy Assistant | Provided therapy and ambulation training to Resident 43. |
| DS | Dietary Supervisor | Interviewed regarding food service and menu compliance. |
| CNA 8 | Certified Nursing Assistant | Provided care and reported on resident skin and feeding. |
| DON 2 | Director of Nursing | Employed without active RN license. |
| TN | Treatment Nurse | Observed and interviewed regarding wound care and pain management. |
Inspection Report
Deficiencies: 2
Date: Mar 8, 2023
Visit Reason
The inspection was conducted to evaluate compliance with admission documentation requirements and infection prevention and control practices at Pomona Vista Care Center.
Findings
The facility failed to obtain signatures for all admission documents for one sampled resident, resulting in potential lack of informed consent. Additionally, the facility failed to maintain proper infection control practices when staff entered the room of a COVID-19 infected resident without proper personal protective equipment (PPE).
Deficiencies (2)
Failed to explain and obtain signatures for all admission documents for one sampled resident; admission agreement was not completed prior to or within 24 hours as required.
Failed to maintain infection control practices when staff entered the room of a resident infected with COVID-19 without wearing proper PPE.
Report Facts
Residents Affected: 1
Dates of interviews: Jan 23, 2023
Dates of interviews: Jan 26, 2023
Dates of interviews: Feb 16, 2023
Dates of in-service training: Nov 30, 2022
Dates of in-service training: Dec 27, 2022
Date of admission record review: Dec 10, 2022
Date of History and Physical: Dec 7, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Named in infection control deficiency for entering resident's room without proper PPE |
| Director of Nursing | Director of Nursing | Provided information regarding infection control incident and staff training |
| Admission Coordinator | Admission Coordinator | Provided information regarding admission paperwork delay and signature issues |
| Infection Preventionist | Infection Preventionist | Provided information on PPE training and infection control policies |
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