Citations (last 4 years)
Citations (over 4 years)
5.8 citations/year
Citations are regulatory findings recorded during state inspections.
45% worse than California average
California average: 4 citations/yearCitations per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Citations: 1
Date: Mar 6, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to promptly follow up and report x-ray results for a resident who fell, resulting in delayed treatment.
Complaint Details
The complaint investigation found that the facility did not follow up on x-ray results for Resident 1 for two days after a fall, delaying notification to the physician and treatment. The delay was substantiated and resulted in potential harm to the resident.
Findings
The facility failed to notify the physician of x-ray results for Resident 1's broken left tibia for two days, causing unnecessary severe pain and delayed treatment. The Director of Nursing confirmed the facility did not receive the x-ray report within 24 hours and did not follow up as expected.
Citations (1)
F 0684: The facility failed to provide appropriate treatment and care by not promptly reporting x-ray results for Resident 1 after a fall, resulting in delayed treatment for a broken left tibia and ongoing severe pain.
Report Facts
Date of x-ray order: Mar 2, 2025
Date x-ray results received: Mar 4, 2025
BIMS score: 8
Pain level: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Licensed Nurse | Wrote progress notes and pain evaluations related to Resident 1's fall and condition |
| Licensed Nurse D | Licensed Nurse | Wrote progress note ordering left knee x-ray for Resident 1 |
| Licensed Nurse E | Licensed Nurse | Wrote progress note documenting Resident 1's continuous pain and orders to send to hospital |
| Director of Nursing | Director of Nursing | Confirmed failure to receive and follow up on x-ray results for Resident 1 |
Inspection Report
Routine
Citations: 1
Date: Mar 6, 2025
Visit Reason
The inspection was conducted due to a fall incident involving Resident 1, focusing on the facility's follow-up and reporting of x-ray results after the fall.
Findings
The facility failed to promptly follow up and report the results of an x-ray for Resident 1 after a fall, resulting in a two-day delay in treatment for a broken left tibia, causing unnecessary severe pain and potential negative impacts on the resident's well-being.
Citations (1)
Failure to follow up and promptly report x-ray results for Resident 1 after a fall, causing delay in treatment.
Report Facts
Date of x-ray order: Mar 2, 2025
Date of x-ray result receipt delay: 2
Pain level: 8
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Licensed Nurse | Wrote progress notes and evaluations related to Resident 1's fall and pain |
| Licensed Nurse D | Licensed Nurse | Wrote progress note ordering left knee x-ray for Resident 1 |
| Licensed Nurse E | Licensed Nurse | Wrote progress note documenting Resident 1's continuous pain and orders to send to hospital |
| Director of Nursing | Director of Nursing | Confirmed delay in receiving x-ray results and failure to notify physician |
Inspection Report
Complaint Investigation
Citations: 1
Date: Jan 17, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide a written notice to a resident about a proposed room change.
Complaint Details
The complaint investigation found that Resident 1 did not receive a written notice about the room change as required by federal regulations. The Social Service Director and Director of Nursing confirmed the omission and acknowledged the requirement for written notice.
Findings
The facility failed to honor the resident's right to receive written notice before a room change, causing distress and frustration to the resident. The Social Service Director and Director of Nursing acknowledged that a written notice was required but was not provided.
Citations (1)
F 0559: The facility failed to provide Resident 1 with a written notice of a proposed room change, violating the resident's right to receive notice before a change. This failure caused Resident 1 distress and frustration due to lack of control over the move.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Interviewed regarding the room change decision and failure to provide written notice. | |
| Director of Nursing | Interviewed and confirmed the failure to provide written notice about the room change. | |
| Certified Nursing Assistant (CNA) A | Reported Resident 1 was upset about the move and requested SSD to speak with Resident 1. | |
| Personal Therapist (PT) | Observed Resident 1 upset about the move and confirmed Resident 1 did not agree to move initially. |
Inspection Report
Annual Inspection
Citations: 3
Date: Nov 21, 2024
Visit Reason
The inspection was conducted to assess the accuracy and completeness of Minimum Data Set (MDS) assessments and Preadmission Screening and Resident Review (PASRR) processes for residents at the facility.
Findings
The facility failed to ensure accurate MDS assessments for 2 of 19 sampled residents and failed to initiate or accurately complete Level I PASRR screenings for 3 residents, missing serious mental illness diagnoses and failing to complete required screenings upon readmission.
Citations (3)
Failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 residents.
Failed to initiate a Level I Preadmission Screening and Resident Review (PASRR) for a resident with a psychiatric diagnosis prior to readmission.
Failed to accurately complete a Level I PASRR for a resident with schizophrenia, missing the diagnosis on the screening.
Report Facts
Residents sampled for MDS accuracy: 19
Residents reviewed for PASRR: 3
Residents affected by MDS deficiency: 2
Residents affected by PASRR deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding MDS accuracy and PASRR process deficiencies |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS assessment completion and accuracy |
| Administrator | Administrator | Interviewed regarding expectations for MDS and PASRR accuracy |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding PASRR screening completion and responsibilities |
| Business Office Manager | Business Office Manager (BOM) | Interviewed regarding PASRR screening process and accuracy oversight |
Inspection Report
Citations: 3
Date: Nov 21, 2024
Visit Reason
The inspection was conducted to assess the accuracy and completeness of Minimum Data Set (MDS) assessments and Preadmission Screening and Resident Review (PASRR) processes for residents at the facility.
Findings
The facility failed to ensure accurate MDS assessments for two residents and failed to properly initiate or complete PASRR screenings for three residents with psychiatric diagnoses. Deficiencies included missed or inaccurate coding of mental health conditions and lack of timely PASRR reassessments upon readmission.
Citations (3)
F0641: The facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 19 sampled residents, including missed PASRR Level II coding and inaccurate smoking status documentation.
F0644: The facility failed to initiate a Level I PASRR for a resident with a psychiatric diagnosis prior to readmission and did not complete a new PASRR after psychiatric inpatient care.
F0645: The facility failed to accurately complete a Level I PASRR for a resident with schizophrenia, omitting the diagnosis from the screening.
Report Facts
Residents sampled for MDS accuracy: 19
Residents reviewed for PASRR: 3
Residents affected by MDS deficiencies: 2
Residents affected by PASRR deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding MDS and PASRR deficiencies and expectations |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS assessment accuracy and coding errors |
| Administrator | Administrator | Interviewed regarding expectations for MDS and PASRR accuracy |
| Social Services Director | Social Services Director | Interviewed regarding PASRR completion responsibilities |
| Business Office Manager | Business Office Manager | Interviewed regarding PASRR process and hospital responsibilities |
Inspection Report
Complaint Investigation
Citations: 1
Date: Sep 30, 2024
Visit Reason
The inspection was conducted following a complaint regarding the care of Resident 1, who was admitted for comfort care and experienced neglectful treatment during a night shift, including being left in soiled clothing and bedding, lack of assistance with eating, and excessive noise in the room.
Complaint Details
The complaint investigation was substantiated with findings that Resident 1 was neglected during the night shift on 9/14/24, left in soiled clothing and bedding, not assisted with eating, and exposed to loud noise despite requests to reduce it. Family members and staff interviews confirmed these issues.
Findings
The facility failed to provide care consistent with Resident 1's preferences and professional standards, resulting in minimal harm or potential for actual harm. Resident 1 was left in a soiled brief and gown, with wet sheets and loud television noise, causing distress and discomfort. Staff failed to assist with feeding and did not respond adequately to Resident 1's requests for a bedpan and earplugs.
Citations (1)
Failure to provide appropriate treatment and care according to orders, resident's preferences, and goals, including neglect in continence care and assistance with eating.
Report Facts
Residents Affected: 1
Date of survey completed: Sep 30, 2024
Time resident was found: 645
Duration of resident stay: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in deficiency for neglecting Resident 1 during night shift on 9/14/24 |
| CNA C | Certified Nursing Assistant | Found Resident 1 in soiled condition and reported the situation |
| LVN B | Licensed Vocational Nurse | Documented Resident 1's admission and concerns about care |
| LVN F | Licensed Vocational Nurse | Assumed care of Resident 1 on 9/14/24 and provided interview details |
| ADON A | Assistant Director of Nursing | Aware of Resident 1's situation and confirmed availability of earplugs and bedpans |
| DSD E | Director of Staff Development | Spoke to CNA C and educated CNA D after the incident |
Inspection Report
Routine
Census: 54
Citations: 6
Date: Jan 27, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to update and implement fall prevention protocols, inadequate medical provider oversight of resident symptoms, insufficient monitoring of high-risk anticoagulant medication, improper medication storage conditions, unsanitary food preparation practices, and failure to maintain an effective infection prevention and control program.
Citations (6)
Failure to ensure fall protocol was updated and implemented to prevent falls for a resident with a history of falls.
Failure to ensure resident's symptoms and distress were addressed timely when treatment was ineffective.
Failure to monitor high-risk anticoagulant medication daily for possible adverse effects.
Failure to store house supply medications at controlled room temperature in Central Supply Storage room.
Failure to ensure food was prepared in a clean sanitary manner, including use of trash cans without foot controls and unclean gas valve area.
Failure to establish and maintain an infection prevention and control program, including unclean shared pill cutters, improper glove use by nursing staff, unsanitized shared glucometer, lack of accessible hand sanitizers, and insufficient PPE availability.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 54
Residents affected: 54
Residents affected: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Named in symptom management deficiency related to ineffective medication and skin condition |
| Licensed Vocational Nurse 4 | Licensed Vocational Nurse | Named in infection control deficiency for failure to follow glove and hand hygiene protocols |
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse | Named in infection control deficiency related to glucometer sanitization |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including fall protocol, medication monitoring, infection control, and medication storage |
| Medical Doctor 1 | Medical Doctor | Named in symptom management deficiency for lack of timely progress notes and treatment adjustments |
| Dietary Services Manager | Dietary Services Manager | Named in food preparation deficiency regarding trash can and kitchen cleanliness |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Named in infection control deficiency regarding PPE availability and hand sanitizer placement |
Inspection Report
Complaint Investigation
Census: 54
Citations: 6
Date: Jan 27, 2022
Visit Reason
The inspection was conducted to investigate complaints related to resident care, medication management, infection control, and facility safety.
Complaint Details
The visit was complaint-related, investigating multiple issues including fall prevention, medication management, infection control, and food safety. The complaints were substantiated based on observations, interviews, and record reviews.
Findings
The facility was found deficient in multiple areas including failure to update and implement fall prevention protocols, inadequate medical provider oversight of resident symptoms, insufficient monitoring of high-risk anticoagulant medication, improper medication storage conditions, unsanitary food preparation practices, and failure to maintain an effective infection prevention and control program.
Citations (6)
F 0689: The facility failed to ensure fall protocol updates and interventions were completed for Resident 4 after falls on 9/1/21 and 11/30/21, including missing interdisciplinary team notes after the first fall.
F 0711: The facility failed to ensure Resident 52's symptoms and distress from itching were addressed timely when Benadryl was ineffective, and medical provider progress notes were not updated.
F 0757: The facility failed to monitor Resident 28's high-risk anticoagulant medication (rivaroxaban) daily for side effects as required by the care plan.
F 0761: The facility failed to store house supply medications in the Central Supply Storage room at controlled room temperature, and did not monitor room temperature.
F 0812: The facility failed to ensure food was prepared in a clean sanitary manner, including use of a trash can without foot controls and dust/spider webs near the stove.
F 0880: The facility failed to maintain an infection prevention and control program, including unclean shared pill cutters, improper glove use by nursing staff in isolation rooms, unsanitized shared glucometer, lack of accessible hand sanitizers, and insufficient PPE availability.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 54
Medication administration frequency: 3
Medication order date: Aug 14, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Noted ineffectiveness of Benadryl and recommended alternative treatment for Resident 52 |
| LVN 4 | Licensed Vocational Nurse | Observed not following infection control practices in multiple resident rooms |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including fall protocol, medication monitoring, infection control, and storage issues |
| Medical Doctor 1 | Physician | Interviewed regarding Resident 52's care and progress notes |
| Dietary Services Manager | Dietary Services Manager | Interviewed regarding food preparation deficiencies |
| Infection Preventionist Nurse | Infection Preventionist (IP) Nurse | Interviewed regarding infection control program deficiencies |
Inspection Report
Citations: 1
Date: Jun 13, 2019
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety standards, specifically regarding the presence of an air gap in kitchen sink drain lines to prevent contamination.
Findings
The facility failed to have an air gap in its four kitchen sink drain lines, which could allow sewage to back up into sinks used for cleaning dishes and fresh produce, posing a risk of food contamination. Observations and interviews confirmed the absence of a proper air gap.
Citations (1)
Facility failed to have an air gap in four kitchen sink drain lines to prevent backflow of sewage.
Report Facts
Number of kitchen sink drain lines without air gap: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Services Supervisor | Dietary Services Supervisor | Interviewed regarding the absence of air gaps in kitchen sink drain lines. |
| Environmental Services Supervisor | Environmental Services Supervisor | Acknowledged the absence of air gaps in kitchen sink drain lines during observation and interview. |
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