Inspection Reports for
San Joaquin Nursing and Rehabilitation Center

The complaint investigation found that Resident 1 did not have a scheduled follow-up appointment with the surgeon as required. The Social Services Director acknowledged the oversight and delay in care. Resident 1 confirmed no follow-up appointment was scheduled since admission.

The facility failed to follow its policy and procedure for scheduling follow-up appointments, resulting in a delay in care for Resident 1 who required a post-surgical follow-up with a surgeon. Interviews and record reviews confirmed no follow-up appointment was scheduled despite clear documentation indicating the need.

The facility failed to ensure that Resident 1's fingernails were kept clean and trimmed, which posed a risk of infection and skin injury due to scratching. The care plan was not followed, and the resident had multiple scratches and open skin areas.

The facility was found deficient in providing appropriate care for residents with urinary catheters, including failure to monitor catheter placement and document urine output, which posed a risk for urinary tract infections. Additionally, infection prevention protocols were not consistently followed, including improper use of personal protective equipment and inadequate hand hygiene during catheter care.

The facility failed to provide appropriate wound care and pressure injury treatment for Resident 1, resulting in delayed wound care and worsening of wounds. Additionally, the facility failed to maintain a safe and sanitary environment for Resident 2, including improper installation of a low air loss mattress and an unsanitary wheelchair.

The facility failed to complete background checks prior to employment for one Licensed Vocational Nurse, potentially exposing residents to staff with criminal backgrounds. Additionally, the facility failed to ensure wound treatments were completed as ordered and weekly wound assessments were performed for sampled residents, risking delayed wound healing and worsening of wounds.

The facility was found deficient in multiple areas including failure to ensure proper self-medication administration, advance directive documentation, timely notification of transfers, accurate resident assessments, adherence to physician orders, discharge summary completeness, foot care, nurse competency, performance evaluations, medication error rates, medication storage and destruction, food preference accommodations, medical record accuracy, binding arbitration agreement documentation, quality assurance program effectiveness, and infection prevention practices.

The facility failed to develop a care plan for Resident 1's pressure injury to the right buttock upon re-admission, despite orders for wound treatment. Interviews with the Director of Nurses and Treatment Nurse confirmed no care plan was developed or updated as required.

The facility failed to ensure appropriate pain management for Resident 1, who had moderate pain upon admission. Documentation showed missed administration of Lidocaine patch and incomplete pain management follow-up, with the Director of Nursing confirming the nurse should have contacted the physician for additional pain medication orders.

The facility failed to ensure baseline care plans were completed within 48 hours of admission for three sampled residents, with delays ranging from 3 to 21 days after admission. The Director of Nursing confirmed the baseline care plan should be completed within 48 hours, consistent with facility policy.

The facility failed to ensure behavioral health services were provided for Resident 1, who exhibited behavioral symptoms including refusal of care, yelling, pushing, and grabbing. Documentation and referrals for behavioral health services were lacking.

Complaint investigation triggered by a complaint from Complainant 1 regarding denial of telephone access to Resident 1. The complaint was substantiated based on interviews and observations.

The facility failed to ensure Resident 1's right to receive telephone calls was honored, as staff did not allow the resident to receive a call from Complainant 1. Interviews and observations confirmed the telephone was not accessible to Resident 1, and staff cited privacy concerns as the reason for not transferring the call.

The facility failed to ensure one of three sampled residents received necessary services for pressure injuries to promote healing, specifically due to lack of a non-compliance care plan for Resident 1 who was non-compliant with turning and repositioning protocols.

The facility failed to develop an individualized care plan for one resident who frequently pulled out his Gastrostomy Tube (G-Tube), resulting in multiple emergency room visits. The Director of Nursing confirmed the absence of a care plan and interdisciplinary team meeting to address this issue. The facility's policy requires a comprehensive, person-centered care plan developed within seven days of assessment, which was not met.

Resident 1 alleged neglect due to delayed medication and lack of care, called the police, but the facility did not investigate or report to CDPH. The Social Services Designee was unaware of the allegation and did not provide psychosocial follow-up.

The facility failed to investigate and report the allegation of neglect to the California Department of Public Health, delayed medication administration by over 10 hours, and failed to provide psychosocial follow-up after the neglect allegation, potentially causing continued neglect and psychosocial distress to Resident 1.

The facility failed to provide advance notice to one of three sampled residents (Resident 1) about a room change during a three-day hospital transfer, resulting in the resident being unaware of returning to a different room.

The complaint was substantiated based on observations, interviews, and record reviews indicating Resident 1 was moved without consent after hospitalization and was upset about not being able to return to his previous room.

The facility failed to allow Resident 1 to return to his prior room after a hospital stay, moving him without consent to a different room. Resident 1 expressed distress over the move, and the facility admitted other residents to his previous room during his absence.

The visit was complaint-related, focusing on medication administration failures for Resident 1. The deficiency was substantiated with findings of missing medication administration documentation and unavailability of medication without notifying the medical doctor.

The facility failed to ensure that physician-ordered medications, specifically Budesonide and Amiodarone, were administered to one of five sampled residents (Resident 1). Documentation was missing for medication administration, and the Director of Nursing noted that if medications were unavailable, the medical doctor should be notified.

The facility failed to provide oxygen as ordered by the physician for one resident and failed to provide humidified oxygen for two residents on continuous oxygen. These deficiencies had the potential to negatively impact the residents' medical condition.

The facility was found to have multiple deficiencies including failure to follow call light procedures, missing advance directives, delayed notification to ombudsman on resident transfer, incomplete resident assessments, lack of comprehensive care plans, medication errors including unavailable ordered medications, food safety violations, failure to ensure hand hygiene before meals, and failure to order necessary lab tests.

The complaint investigation found that the CNA moved Resident 1 from the floor to a wheelchair without a licensed nurse's assessment after an unwitnessed fall, which is outside the CNA's scope of practice. The resident suffered a dislocated right hip as a result.

The facility failed to ensure that Resident 1 was assessed by a licensed nurse after an unwitnessed fall before being moved by a CNA, resulting in a dislocated right hip. Interviews and record reviews confirmed the CNA moved the resident without proper assessment, contrary to facility policy and scope of practice.

The complaint investigation found that Resident 1 was discharged without notifying the Ombudsman and was sent home alone without a caregiver or discharge instructions, leading to hospitalization for failure to thrive, pulmonary edema, and elevated troponin. Resident 1 was later referred to hospice care.

The facility failed to notify the Ombudsman of Resident 1's discharge and discharged Resident 1 home unsafely without a caregiver or discharge instructions, resulting in Resident 1 being hospitalized for 12 days and later referred to hospice care.

The facility failed to ensure that a Restorative Nursing Assistant program was established for one of three sampled residents, resulting in potential loss of range of motion and worsening contractures. Interviews and record reviews revealed that RNA programs recommended by therapy staff were not initiated or followed up on, despite discharge summaries indicating the need for such programs.

The facility failed to develop and implement an individualized comprehensive care plan for one sampled resident, resulting in the resident's preferences for room cleaning not being identified or implemented. Staff were removing items from the resident's room despite her expressed preferences, and no care plan addressed these preferences.

The complaint investigation focused on allegations that Resident 4 was not treated with respect and dignity by LVN 4, including emotional distress caused by the LVN's actions and false allegations. Additional complaints included failure to notify physicians and family members of changes in condition for Residents 2, 4, and 5, medication administration errors, incomplete care plans for fall risk, and inadequate staff competency and background checks.

The facility failed to ensure respectful treatment of residents, timely notification of changes in condition to physicians and family, proper medication administration and documentation, development and implementation of fall care plans, and adequate staff competency and background checks. These failures caused emotional distress to residents and had the potential to cause harm.

The facility failed to obtain a chest x-ray (CXR) ordered by the medical doctor for one resident, resulting in the CXR not being performed and the potential for abnormal results to go unidentified. The failure was attributed to confusion in ordering due to the use of two different systems.

The facility failed to conduct an interdisciplinary team (IDT) meeting to address a resident's left eye discoloration and failed to report an allegation of abuse to state agencies. These failures had the potential for minimal harm or potential for actual harm to the resident and others.

The facility failed to monitor and document the internal temperature of food prior to plating and serving for all 96 sampled residents, which could result in serving unpalatable food.

The complaint was substantiated. Resident 1 reported abuse incidents by CNA 1 during a shower and in her room. LVN 1 failed to remove CNA 1 from providing care or report the abuse. The facility was made aware of the abuse allegation eight days after the incident and reported it to the state eight days later.

The facility failed to implement its Abuse, Neglect, Exploitation and Misappropriation Prevention Program policies by not suspending CNA 1 after abuse allegations and failing to report the abuse timely. Resident 1 reported multiple incidents of abuse, which were not properly documented or acted upon by staff, including Licensed Vocational Nurse (LVN 1).

The facility was found deficient in multiple areas including resident dignity and care, medication administration, advance directives, discharge planning, wound care, infection control, staffing, and activities provision. Several residents were affected by failures in care planning, medication errors, lack of follow-up on referrals, and inadequate infection prevention practices.