Inspection Reports for
St. Edna Sub-Acute and Rehabilitation Center
CA, 92706
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
26.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
558% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Deficiencies: 1
Date: Nov 26, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with background screening requirements for employees, specifically investigating the thoroughness of the background check process for a Medi-Cal excluded employee.
Findings
The facility failed to thoroughly investigate the exclusion status of a direct access employee who appeared on the new-hire background screening, potentially compromising resident safety. The background screening process was not properly followed under previous management, though new procedures have been implemented.
Deficiencies (1)
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNA 1 | Certified Nursing Assistant | Named in deficiency related to background screening and employment eligibility. |
| DSD | Interviewed regarding background screening process and deficiencies. | |
| Administrator | Interviewed regarding background screening policies and follow-up actions. | |
| DON | Director of Nursing | Interviewed regarding background screening and employee eligibility. |
| Recruitment Lead | Interviewed regarding new background screening process and follow-up on RNA 1. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 17, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan requirements, specifically to assess whether the comprehensive care plan for Resident 3 was revised to reflect current care needs and interventions related to weight loss management.
Findings
The facility failed to revise Resident 3's care plan to include new interventions ordered by the physician, such as weekly weights and administration of an appetite stimulant, posing a risk of not providing individualized and person-centered care. Interviews with staff confirmed the care plan was not updated accordingly.
Deficiencies (1)
Failure to revise Resident 3's care plan to include interventions for weight loss management as ordered by the physician.
Report Facts
Weight measurements: 7
Medication dosage: 400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Licensed Vocational Nurse | Verified that Resident 3's care plan should be revised to reflect current interventions |
| ADON | Assistant Director of Nursing | Informed of and acknowledged the findings regarding Resident 3's care plan |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of resident-to-resident physical abuse involving Resident 113 being struck by Resident 86 with a rehabilitation dowel.
Complaint Details
The complaint investigation substantiated that Resident 113 was struck by Resident 86 with a dowel causing redness and pain to Resident 113's face. The facility confirmed the incident and monitored Resident 113 for emotional distress.
Findings
The facility failed to protect Resident 113 from physical abuse by Resident 86, who hit Resident 113 in the face with a rehabilitation dowel causing pain and swelling. The incident was substantiated by the facility's investigation, and the dowel was confiscated and measured by the Maintenance Supervisor.
Deficiencies (1)
Failure to protect Resident 113 from physical abuse by another resident using a rehabilitation dowel.
Report Facts
Dowel length: 31.5
Dowel width: 0.75
Dowel circumference: 1.25
Dowel weight: 1.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 11 | Certified Nursing Assistant | Witnessed the altercation and confiscated the dowel |
| OT 1 | Occupational Therapist | Interviewed regarding dowel possession and resident safety |
| DON | Director of Nursing | Provided information on the incident and verified care plans |
| Maintenance Supervisor | Maintenance Supervisor | Measured and weighed the dowel |
| Administrator | Facility Administrator | Reviewed and substantiated the incident investigation |
Inspection Report
Routine
Deficiencies: 24
Date: May 13, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, medication management, infection control, dietary services, and other care standards.
Findings
The facility was found deficient in multiple areas including medication administration errors, infection control practices, dietary service compliance, medication storage and labeling, resident record accuracy, and implementation of antibiotic stewardship. Specific failures included improper medication administration, inadequate infection prevention measures, inaccurate resident medical records, failure to follow dietary orders and menus, and lack of monitoring of corrective action plans.
Deficiencies (24)
Failed to ensure physician's order for code status matched resident's POLST DNR status.
Failed to maintain a homelike environment due to presence of live pest on resident's bed linen.
Failed to prevent use of unnecessary psychotropic medications and ensure proper monitoring of side effects.
Failed to ensure accurate resident assessments and coding in MDS.
Failed to coordinate PASARR assessments and ensure accurate PASARR screening.
Failed to develop and implement a comprehensive care plan for resident's ability to leave the facility.
Failed to provide appropriate treatment and care according to orders, including timely communication and follow-up of diagnostic results.
Failed to provide safe and appropriate respiratory care, including proper storage and physician orders for oxygen therapy.
Failed to provide enough food/fluids to maintain resident's health as ordered.
Failed to provide safe, appropriate pain management as per physician's orders.
Failed to provide pharmaceutical services meeting residents' needs, including medication accountability, proper documentation, and medication administration safety.
Failed to ensure medication error rates were below 5%, with multiple medication administration errors observed.
Failed to ensure medication side effects were monitored for residents on psychotropic medications.
Failed to ensure residents were free from unnecessary medications, including inappropriate medication orders and lack of monitoring.
Failed to ensure proper storage, labeling, and disposal of medications and supplies, including expired and soiled items.
Failed to ensure menus met nutritional needs, were prepared and followed as planned, and residents received correct portion sizes.
Failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures, including proper handling of pureed foods.
Failed to ensure therapeutic diets were prescribed and followed as ordered by the physician, including appropriate diet textures and extra entrées.
Failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including sanitation and food safety.
Failed to provide education and safe handling of food brought in by family or visitors, and failed to properly store such food.
Failed to safeguard resident-identifiable information and maintain accurate medical records, including advance directives and medication documentation.
Failed to implement an effective ongoing quality assessment and assurance program to monitor and correct deficiencies.
Failed to provide and implement an infection prevention and control program, including monitoring, staff compliance, and environmental sanitation.
Failed to implement an antibiotic stewardship program with timely monitoring and physician notification for antibiotic appropriateness.
Report Facts
Medication error rate: 26.67
Residents receiving food from kitchen: 133
Residents receiving Vietnamese menu: 22
Antibiotics ordered: 25
Temperature of medication storage room: 78
Temperature of dish machine: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 6 | Licensed Vocational Nurse | Medication administration errors and infection control non-compliance |
| LVN 4 | Licensed Vocational Nurse | Medication administration errors and infection control non-compliance |
| LVN 3 | Licensed Vocational Nurse | Medication administration errors |
| DON | Director of Nursing | Acknowledged multiple findings and deficiencies |
| Administrator | Acknowledged multiple findings and deficiencies | |
| DSS | Dietary Services Supervisor | Verified menu and food service deficiencies |
| IP | Infection Preventionist | Interviewed regarding infection control program deficiencies |
| Unit Manager | Verified medication storage and labeling deficiencies | |
| CNA 1 | Certified Nursing Assistant | Failed to don gown for high-contact care on resident with enhanced barrier precautions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 13, 2025
Visit Reason
The inspection was conducted due to a complaint or concern regarding the facility's failure to monitor and document the daily fluid restriction for a resident requiring dialysis care.
Complaint Details
The visit was complaint-related, focusing on the failure to monitor and document fluid intake for Resident 2. The deficiency was substantiated with findings based on observation, interview, and medical record review.
Findings
The facility failed to ensure that Resident 2's daily fluid intake was monitored and documented as ordered by the physician, which could lead to fluid overload and negatively affect the resident's health and continuity of care during dialysis treatments.
Deficiencies (1)
Failure to ensure the daily fluid restriction for Resident 2 was monitored and documented as ordered by the physician.
Report Facts
Fluid restriction amount: 1500
Fluid allocation: 840
Fluid allocation: 660
Inspection date: Feb 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 2 | Licensed Vocational Nurse | Interviewed regarding fluid intake monitoring and documentation for Resident 2 |
| RN 1 | Registered Nurse | Interviewed and acknowledged findings about failure to follow fluid restriction orders |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, and safety protocols at Citrus Post-Acute facility.
Findings
The facility failed to develop and implement an accurate and complete care plan for a resident with a PICC line, failed to conduct and document necessary PICC line assessments and maintenance, and failed to administer ordered medications due to lack of availability without notifying the physician. These deficiencies posed risks for complications such as infection, thrombosis, and negative health outcomes.
Deficiencies (4)
Failed to develop and implement an accurate care plan for Resident 1 addressing the use of a PICC line.
Failed to ensure PICC line assessments were conducted and documented, including flushing unused lumens and measuring arm circumference.
Failed to conduct and document a change of condition assessment for Resident 1's pain and swelling at the PICC site.
Failed to ensure Resident 1's medications were administered as ordered due to lack of availability and failed to notify the physician.
Report Facts
Deficiencies cited: 4
Medication doses not administered: 8
Dates of missed medication administration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding PICC line care protocol and documentation failures. |
| RN 2 | Registered Nurse | Interviewed and verified failure to obtain orders and document PICC line care. |
| LVN 1 | Licensed Vocational Nurse | Documented inability to administer medications due to lack of availability and failure to notify physician. |
| LVN 2 | Licensed Vocational Nurse | Obtained Doppler order for Resident 1 and verified lack of change of condition assessment documentation. |
| DON | Director of Nursing | Interviewed regarding facility PICC line care process and verified documentation failures. |
| Physician 1 | Physician | Interviewed and stated facility did not notify him of missed medication administration. |
Inspection Report
Routine
Deficiencies: 4
Date: Jul 30, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on adherence to infection control practices while cleaning resident rooms with Enhanced Barrier Precautions (EBP).
Findings
The facility failed to follow infection control practices during cleaning, including not using new cloths between residents, not wearing gowns while cleaning rooms with EBP signage, improper use of toilet scrub brushes, and failure to clean restroom grab bars. These failures had the potential to spread infection among residents.
Deficiencies (4)
Housekeepers did not use a new cloth while cleaning individually used equipment between residents.
Housekeepers did not wear a gown while cleaning resident rooms with EBP signage.
Housekeeper scrubbed toilet seats with a toilet bowl brush intended only for inside the toilet bowl.
Housekeeper failed to clean restroom grab bars in shared restrooms.
Report Facts
Residents affected: 12
Physician's order dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper 1 | Observed failing to follow infection control practices including not wearing gown and improper cleaning methods | |
| Housekeeper 2 | Observed failing to wear gown and using same cloth to clean multiple residents' equipment | |
| Environmental Services Supervisor | Interviewed and stated housekeeping staff should not use same cloth between residents and should wear gowns when cleaning rooms with EBP | |
| Infection Preventionist | Interviewed and stated housekeeping staff should always wear gowns when cleaning rooms with EBP |
Inspection Report
Routine
Deficiencies: 5
Date: Jun 21, 2024
Visit Reason
The inspection was conducted to assess compliance with nursing home regulations including post-fall assessments, medical record accuracy, medication administration, bed safety, and entrapment risk related to bed rails.
Findings
The facility failed to complete appropriate post-fall neurological assessments for two residents, maintain accurate and complete medical records for several residents, ensure proper medication administration documentation, and conduct thorough bed entrapment assessments for residents using side rails. These deficiencies posed potential risks of delayed care, inaccurate clinical information, medication errors, and resident entrapment.
Deficiencies (5)
Incomplete post fall neuro checks for Resident 42 for two falls.
Failure to monitor and document assessment every shift for 72 hours post fall for Resident 124.
Incomplete or inaccurate medical records including missing or incomplete POLSTs for Residents 7, 23, 56, 540, and failure to document CPR initiation for Resident 138.
Medication administration record incomplete for Resident 23 with missing documentation of several medications and blood sugar checks.
Failure to complete entrapment assessments and record measurements for Zones 2, 3, and 7 on bed rails for Residents 30, 79, and 87.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 3
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Verified lack of documented post-fall monitoring for Resident 124 |
| LVN 9 | Licensed Vocational Nurse | Verified missing POLST for Resident 7 |
| LVN 8 | Licensed Vocational Nurse | Acknowledged medication administration documentation error for Resident 7 |
| LVN 12 | Licensed Vocational Nurse | Reported CPR initiation for Resident 138 was not documented |
| ADON | Assistant Director of Nursing | Verified incomplete post-fall neurological assessments and medication administration findings |
| Maintenance Director | Responsible for bed entrapment assessments; unable to explain assessment markings and confirmed incomplete assessments | |
| CNA 3 | Certified Nursing Assistant | Verified Resident 87's use of side rails |
| RN 2 | Registered Nurse | Observed Resident 138's condition leading to code call |
| DON | Director of Nursing | Verified lack of CPR documentation for Resident 138 |
| Administrator | Acknowledged findings related to bed entrapment assessments |
Inspection Report
Routine
Deficiencies: 29
Date: Jun 21, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, food services, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including medication management, informed consent for psychotropic medications, self-administration of medications, call light accessibility, advance directives documentation, care plan accuracy, medication administration errors, infection control practices, food service operations, equipment maintenance, bed rail entrapment assessments, and pest control. Several residents' rights and safety were compromised due to these deficiencies.
Deficiencies (29)
Failed to ensure informed consents were obtained prior to administering psychotropic medications for Residents 32 and 540.
Failed to determine if Resident 95 was safe to self-administer medications; medications were left at bedside without proper assessment or orders.
Call lights were not within reach for Residents 81, 96, and 540, potentially delaying care.
Failed to clarify and honor Resident 32's full code status; POLST form was signed by another individual and care plan was inaccurate.
Care plans for Residents 30 and 32 were not revised to reflect current care needs, including wound care and code status.
Failed to provide appropriate treatment and care according to orders for Residents 8 and 107, including IV antibiotic administration and nutritional supplements.
Post-fall assessments were incomplete for Residents 42 and 124, including neuro checks and monitoring for 72 hours.
Failed to accurately monitor hydration status for Resident 539, including fluid intake and output documentation.
Failed to provide safe and appropriate IV care for Residents 12 and 539, including catheter site assessments and dressing maintenance.
Failed to ensure safe and appropriate respiratory care for Residents 8, 12, 16, 79, and 86, including oxygen orders, equipment labeling, and storage.
Failed to provide pharmaceutical services to meet residents' needs, including medication administration errors, incomplete orders, and inaccurate controlled substance logs.
Failed to ensure proper medication storage and sanitation, including expired medications, unlabeled insulin pens, and unclean medication carts.
Failed to employ competent food service staff and ensure proper food safety practices, including hand hygiene, cooling logs, thawing procedures, and sanitizing.
Menus did not meet nutritional needs; Vietnamese menus lacked puree recipes and nutritional analysis; meal substitutes were not nutritionally equivalent.
Failed to ensure food and drink were palatable and nutritive content preserved, especially for pureed foods.
Failed to accommodate resident allergies, intolerances, and preferences; meal substitutes were not equivalent in nutritive value.
Failed to implement infection prevention and control program, including inaccurate infection surveillance, improper linen storage, urinary catheter care, and trash disposal.
Failed to maintain complete and accurate medical records, including missing or incomplete POLST forms, incomplete MARs, and lack of CPR documentation.
Medication error rate was 10.34%; observed medication administration errors by licensed nurse including failure to check vital signs prior to medication administration.
Failed to ensure medication administration per physician orders, including insulin coverage and medication holds.
Failed to ensure proper medication administration documentation and medication availability.
Failed to ensure proper medication storage, labeling, and disposal, including expired medications, unclean medication bottles, and improper storage of insulin pens.
Failed to ensure food brought in by family or visitors was stored and prepared safely; no designated refrigerator and no written education provided.
Failed to dispose of garbage properly; food debris and egg shell found on ground outside kitchen back door attracting flies.
Failed to safeguard resident-identifiable information and maintain complete medical records including advance directives and CPR documentation.
Failed to implement infection prevention and control program including hand hygiene, controlled medication counting, and trash disposal.
Failed to maintain essential equipment in safe operating condition including ice machine cleaning, dish machine temperature, kitchen door and window screens, and fire sprinkler maintenance.
Failed to regularly inspect bed frames, mattresses, and bed rails for safety and complete entrapment assessments for residents using side rails.
Failed to maintain pest control program; flies observed in kitchen and dining room, damaged window screens and open doors allowing pest entry.
Report Facts
Medication error rate: 10.34
Residents receiving pureed diet: 23
Residents in facility: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Verified findings related to medication storage and administration |
| LVN 7 | Licensed Vocational Nurse | Observed medication administration errors and verified findings |
| ADON | Assistant Director of Nursing | Verified multiple findings including medication management, infection control, and resident care |
| Maintenance Director | Verified findings related to equipment maintenance, bed entrapment assessments, pest control | |
| CDM | Certified Dietary Manager | Provided information on food service deficiencies and training |
| RD | Registered Dietitian | Provided information on food service deficiencies and training |
Inspection Report
Routine
Deficiencies: 5
Date: May 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to the development and revision of comprehensive care plans, medication administration, and proper storage of medications for residents.
Findings
The facility failed to develop and revise comprehensive care plans for Resident 1 to address allergy medication and insulin changes, failed to monitor blood sugar levels as ordered, and failed to ensure proper storage and self-administration protocols for medications, including Flonase nasal spray. These deficiencies posed risks of inconsistent care, medication errors, and potential harm to the resident.
Deficiencies (5)
Failed to develop a care plan problem to address Resident 1's allergy requiring medication (Flonase nasal spray).
Failed to revise Resident 1's care plan to address the change in insulin and monitoring of blood sugar.
Failed to monitor blood sugar levels daily as ordered for Resident 1 receiving insulin glargine.
Failed to ensure Resident 1's medications were stored properly; Flonase nasal spray was left on the overbed table without proper lockable storage.
Failed to document assessment, physician order, and care plan for self-administration of Flonase nasal spray by Resident 1.
Report Facts
Units of insulin ordered: 18
Units of insulin ordered: 10
MAR review period: 4
BIMS score: 13
Date of Flonase nasal spray label: Apr 14, 2024
Date of Flonase nasal spray label: Jan 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Verified Resident 1 received Flonase nasal spray and lack of care plan for allergy and self-administration; verified insulin orders and care plan deficiencies; verified blood sugar monitoring failures. |
| DON | Director of Nursing | Verified lack of care plans for allergy and insulin changes; acknowledged blood sugar monitoring failures; stated requirements for self-administration assessment, physician order, care plan, and safe medication storage. |
| LVN 3 | Licensed Vocational Nurse | Observed Flonase nasal spray on Resident 1's overbed table, removed it to medication cart, and explained self-administration requirements. |
| LVN 4 | Licensed Vocational Nurse | Verified blood sugar monitoring was discontinued after Novolog insulin was stopped and not resumed for insulin glargine as ordered. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 3, 2024
Visit Reason
The inspection was conducted to investigate complaints related to failure to timely report suspected abuse, failure to report investigative findings to the state authorities, failure to include a resident in care plan meetings, and failure to provide appropriate pressure ulcer care.
Complaint Details
The investigation was complaint-driven, focusing on allegations of abuse and neglect including failure to report sexual abuse allegations timely, failure to report investigative findings to state authorities, failure to include a resident in care planning, and failure to provide appropriate pressure ulcer care.
Findings
The facility failed to timely report Resident 3's sexual abuse allegation to the proper authorities, failed to report investigative findings for Resident 1's abuse allegation to the CDPH within five working days, failed to invite Resident D to his care plan meetings, and failed to ensure Resident 6's low air loss mattress was set correctly according to the resident's weight.
Deficiencies (4)
Failure to timely report Resident 3's sexual abuse allegation to CDPH L&C Program and local law enforcement.
Failure to report investigative findings for Resident 1's staff to resident abuse allegation to CDPH L&C Program within five working days.
Failure to invite Resident D to his care plan meetings, posing risk of non-participation in his plan of care.
Failure to ensure Resident 6's low air loss mattress was set at the correct weight setting, risking inappropriate pressure ulcer care.
Report Facts
Residents sampled: 6
Date of survey completion: Apr 3, 2024
Resident 6 weight: 129
Low air loss mattress setting: 400
Correct mattress setting range: 120-130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| acting DON | Verified failure to report Resident 3's sexual abuse allegation and acknowledged it should have been reported | |
| LVN 1 | Prepared alleged abuse reports and reported Resident 3's allegation to acting DON | |
| Administrator | Verified lack of fax confirmation for reporting Resident 1's investigative findings to CDPH | |
| SSD | Acknowledged failure to fax investigative findings for Resident 1 to CDPH | |
| LVN 3 | Verified Resident 6's mattress setting was incorrect and acknowledged it should be set to resident's weight | |
| DON | Verified Resident D was not invited to care plan meetings |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 14, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to allow a resident (Resident 2) to return after hospitalization within the bed-hold policy period, and concerns about pressure ulcer care for Resident 3.
Complaint Details
The complaint investigation focused on Resident 2's delayed return to the facility after hospitalization and Resident 3's pressure ulcer care. The facility was found to have refused Resident 2's return despite hospital requests and delayed wound care assessments for Resident 3.
Findings
The facility failed to allow Resident 2 to return to the nursing home after discharge from the acute care hospital, causing an approximately 10-day delay. Additionally, the facility failed to provide appropriate pressure ulcer care for Resident 3, including lack of weekly wound measurements and delayed wound specialist notification.
Deficiencies (2)
Failed to permit Resident 2 to return to the nursing home after hospitalization within the bed-hold policy, resulting in extended hospital stay.
Failed to provide appropriate pressure ulcer care for Resident 3, including lack of weekly wound assessments and delayed wound specialist notification.
Report Facts
Extended hospital stay: 10
Pressure injury measurement: 3
Wound specialist initial assessment date: Nov 2, 2023
Admission date of Resident 2 to hospital: Jan 23, 2024
Psychiatric evaluation date: Jan 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Admissions Coordinator 1 | Admissions Coordinator | Interviewed regarding refusal to accept Resident 2 back and bed-hold policy. |
| Admissions Coordinator 2 | Admissions Coordinator | Interviewed regarding admission criteria and Resident 2's case. |
| DON | Director of Nursing | Interviewed and verified refusal to accept Resident 2 back and wound care findings. |
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding wound care system and Resident 3's wound assessments. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 20, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to assess or identify fall risk for Resident 8, who had a history of falls and was admitted after a fall with fracture.
Complaint Details
The complaint investigation found that Resident 8 had an unwitnessed fall resulting in a small bump to the forehead. The facility failed to assess the resident's fall risk and did not develop or implement a care plan addressing fall prevention. The Director of Nursing acknowledged these failures during the investigation.
Findings
The facility failed to complete a fall risk assessment and did not develop or implement a baseline care plan to address Resident 8's fall risk, despite the resident's unsteady gait, poor balance, and recent fall history. Resident 8 experienced an unwitnessed fall in the facility resulting in a minor injury, and the facility acknowledged the failure to assess and plan for fall risk.
Deficiencies (1)
Failure to assess or identify fall risk for Resident 8 and failure to develop and implement a fall prevention care plan.
Report Facts
Residents sampled: 8
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Evening shift nurse who reported last seeing Resident 8 before the fall | |
| Director of Nursing (DON) | Acknowledged the facility's failure to assess and plan for Resident 8's fall risk |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 27, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify the family of a resident after a fall incident.
Complaint Details
The complaint investigation found that the family notification was not made after Resident 1's fall on 4/7/23, and the Director of Nursing confirmed this failure.
Findings
The facility failed to ensure that the family of Resident 1 was notified when the resident had an unwitnessed fall on 4/7/23, despite notifying the physician. The Director of Nursing acknowledged the family was not informed, which could impact the family's ability to make appropriate care decisions.
Deficiencies (1)
Failure to notify the resident's family of a fall incident.
Report Facts
Date of fall incident: Apr 7, 2023
Date of survey completion: Apr 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and acknowledged family was not informed of the fall |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 21, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pressure ulcer care and medication administration for sampled residents.
Findings
The facility failed to complete timely and weekly wound assessments for Resident 1's pressure ulcers, and failed to ensure medications were administered as ordered for Resident 2, posing risks to residents' health.
Deficiencies (2)
Failed to complete wound assessments when first identified and weekly wound assessments for Resident 1's pressure ulcers.
Failed to ensure medications were administered as ordered for Resident 2, with multiple doses not signed as administered.
Report Facts
Medication doses not signed as administered: 11
Wound measurement: 15
Wound measurement: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Wound treatment nurse | Interviewed about wound assessment process and failure to complete weekly assessments |
| LVN 5 | Wound treatment nurse | Interviewed about wound assessment list and Resident 1 not being on the list |
| DON | Director of Nursing | Verified wound assessments were not completed and medication administration findings |
| LVN 4 | Interviewed about medication administration documentation process |
Inspection Report
Routine
Deficiencies: 7
Date: Feb 2, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, infection prevention and control, vaccination policies, and COVID-19 management at Citrus Post-Acute facility.
Findings
The facility failed to properly assess and document self-administration of medications for a resident, maintain accurate infection control surveillance including classification and notification of infections, ensure proper hand hygiene and GT feeding tube management, offer and document influenza, pneumococcal, and COVID-19 vaccinations appropriately, and notify residents and families timely about COVID-19 cases.
Deficiencies (7)
Failure to determine if Resident 2 was safe to self-administer medications and lack of physician's order and care plan for self-administration.
Failure to implement infection control surveillance program accurately including classification of infections, notification to physicians, and inclusion of residents with symptoms but no antibiotics.
Failure to ensure GT feeding tubing end ports were capped for Residents B and 3, posing risk of complications.
Failure of staff to perform proper hand hygiene before and after resident care, increasing risk of infection transmission.
Failure to offer and document influenza and pneumococcal vaccinations to Resident E upon readmission.
Failure to notify residents and families of all new COVID-19 cases during ongoing outbreak, only notifying at outbreak start.
Failure to document offering and ineligibility of COVID-19 vaccination to Resident E upon readmission.
Report Facts
Residents with COVID-19 cases: 5
Residents with COVID-19 cases: 7
Residents with COVID-19 cases: 14
Residents with COVID-19 cases: 7
GT feeding rate: 52
GT feeding duration: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 2 | Verified Resident 2 had medications at bedside without physician's order | |
| DON | Director of Nursing | Verified Resident 2 lacked physician's order, assessment, and care plan for self-administration; verified GT feeding and hand hygiene findings |
| IP | Infection Preventionist | Provided information on infection surveillance program and acknowledged deficiencies in classification and notification |
| ADON | Assistant Director of Nursing | Verified GT feeding tubing findings for Resident B |
| CNA 4 | Certified Nursing Assistant | Observed not performing hand hygiene during resident care |
| LVN 3 | Licensed Vocational Nurse | Observed and interviewed regarding hand hygiene and GT feeding tubing for Resident 3 |
| CNA 1 | Certified Nursing Assistant | Observed not performing hand hygiene prior to resident care |
| DSD | Director of Staff Development | Verified vaccination offering procedures and COVID-19 notification practices |
Inspection Report
Routine
Deficiencies: 13
Date: Jan 12, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication self-administration, care planning, wound care, respiratory care, pharmaceutical services, dietary services, infection control, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to assess residents for safe self-administration of medications, incomplete and inaccurate care plans, failure to provide ordered wound care, improper respiratory care, medication administration errors, expired medications in storage, inaccurate diet orders and meal ticket mismatches, improper food handling and storage, overflowing garbage receptacles, and inadequate infection control practices including inaccurate infection surveillance and failure to perform hand hygiene.
Deficiencies (13)
Failed to assess Resident 35 for safe self-administration of medications and lacked physician's order and care plan for self-administration.
Failed to develop and implement comprehensive care plans for Residents 42 and 83, including fall prevention and use of Podus boots.
Failed to revise Resident 42's care plan to reflect physician's order for pureed diet.
Failed to provide wound care consultation as ordered for Resident 83, resulting in untreated skin breakdown.
Failed to provide safe respiratory care for Residents 85, 110, and 364, including incorrect oxygen rates and improper nebulizer mask storage.
Failed to provide necessary pharmaceutical services including proper medication administration instructions and accurate controlled medication reconciliation.
Medication error rate was 10% due to failure to wait appropriate time between administration of eye drops for Resident 655.
Expired medications and supplies were stored in medication storage rooms accessible for resident use.
Failed to ensure residents received food prepared in the correct texture as ordered, with multiple mismatches between physician orders and meal tickets.
Failed to ensure food items were covered during transport and failed to label food items with received and opened dates.
Garbage dumpster was overflowing and lid could not fully close, risking pest attraction.
Failed to accurately identify and classify infections as community-acquired or healthcare-associated, and failed to perform hand hygiene during medication administration.
Failed to maintain a safe and sanitary environment by improperly storing boxes of foam plates and cups near sprinkler heads.
Report Facts
Medication error rate: 10
Resident infections: 215
Residents with HAIs and CAIs: 36
Residents with HAIs and CAIs: 46
Residents with HAIs and CAIs: 34
Residents with HAIs and CAIs: 29
Residents with HAIs and CAIs: 43
Residents with HAIs and CAIs: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 4 | Licensed Vocational Nurse | Failed to instruct Resident 665 properly on inhaler use, failed hand hygiene during medication administration, and failed to wait appropriate time between eye drop administrations. |
| LVN 5 | Licensed Vocational Nurse | Failed to document administration of lorazepam to Resident 15 and failed to reconcile controlled medication record. |
| RN 2 | Registered Nurse | Verified care plan and medication self-administration deficiencies for Resident 35 and Resident 42. |
| DON | Director of Nursing | Acknowledged multiple deficiencies including care plan, medication self-administration, wound care, infection control, and dietary errors. |
| IP | Infection Preventionist | Responsible for infection surveillance; failed to classify infections accurately per McGeer's criteria. |
| Pharmacy Consultant | Pharmacy Consultant | Verified medication administration errors and proper pharmaceutical service standards. |
| LVN 6 | Licensed Vocational Nurse | Verified oxygen administration errors and medication storage deficiencies. |
| LVN 7 | Licensed Vocational Nurse | Observed wound care deficiencies and failure to follow physician's wound care orders for Resident 83. |
| CNA 2 | Certified Nursing Assistant | Observed Resident 42 receiving incorrect diet texture. |
| CNA 3 | Certified Nursing Assistant | Verified wound care and Podus boot care deficiencies for Resident 83. |
| Cook 1 | Cook | Verified food storage deficiencies including unlabeled fruits and spices. |
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