Inspection Reports for
St. John Of God Retirement

The facility was found to have multiple deficiencies including failure to maintain appropriate room temperatures, inaccurate resident assessments, incomplete care plans, improper pressure ulcer care, inadequate supervision, failure to provide bladder training, unsafe respiratory care, inadequate pain management, incomplete staff competency assessments, medication management issues, food safety violations, incomplete facility-wide contingency planning, inaccurate resident documentation, lack of hospice service coordination, incomplete infection control practices, and environmental safety hazards.

The complaint investigation found that Resident 1 had a bump on the back of her head noted on 2/21/2025 and 2/22/2025, but the injury was not reported to CDPH until 2/22/2025 at 11:00 a.m., exceeding the required two-hour reporting timeframe. Staff interviews confirmed the delay and acknowledged the risk of not reporting in a timely manner.

The facility failed to report Resident 1's injury of unknown origin in a timely manner, resulting in a delay of an onsite investigation by CDPH and potential risk for abuse to all residents. Interviews with staff confirmed the delay in reporting, and the facility's policy requires reporting within two hours.

The complaint investigation found the deficiency substantiated as the facility did not have a care plan addressing Resident 1's heparin medication, confirmed by the Director of Nursing during an interview.

The facility failed to develop and implement a complete care plan for Resident 1 who was receiving heparin, placing the resident at risk for side effects such as bleeding. The Director of Nursing confirmed no care plan was initiated despite the medication order, violating the facility's policy on comprehensive, person-centered care plans.

The facility was found deficient in multiple areas including resident dignity and care, call light accessibility, notification of physician for significant changes, accuracy and timeliness of assessments, care planning, medication labeling, infection control, and hospice coordination. Several residents were observed with unmet needs such as not being properly dressed, lack of call light within reach, and absence of care plans for significant conditions. Infection control practices and documentation were also found lacking.

The facility failed to ensure that Direct Care Service Hours Per Patient Day (DHPPD) staffing information was updated and posted daily, with observed postings dated 3-4 days prior to the inspection date, potentially leaving residents, staff, and visitors unaware of accurate staffing levels.

The facility failed to ensure the head of bed was elevated to 30 to 45 degrees as ordered during gastrostomy tube feeding for one resident, which posed a risk of aspiration, breathing difficulties, infections, and hospitalization. The facility's policy requires elevating the head of bed to at least 30 degrees during and after feeding to prevent aspiration.

The complaint investigation found that the responsible party for Resident 1 was not notified of the xray performed on 5/29/2024 or the results. Interviews with family member and licensed vocational nurse confirmed the lack of notification.

The facility failed to notify the responsible party for one resident about the right wrist and right elbow skin discoloration, the physician's xray order, and the xray results. This failure resulted in the responsible party being unaware of the change in condition and the intervention ordered by the physician.

The complaint was substantiated based on interviews with Resident 1, CNA 1, Licensed Vocational Nurse 1, Social Services Director, and the Director of Nursing. Resident 1 reported being handled roughly by CNA 1, who admitted to being too rough and apologized. The facility acknowledged the incident and confirmed no injuries were found.

The facility failed to ensure Resident 1 was free from abuse when CNA 1 grabbed Resident 1's wrist roughly, causing psychological distress and feelings of humiliation. The facility also failed to follow its Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, placing Resident 1 and others at risk of further abuse.

The complaint investigation focused on Resident 1's multiple falls and the facility's failure to follow neurological assessment protocols and fall prevention orders. The investigation substantiated that the facility did not complete required neuro checks and failed to apply a soft belt restraint as ordered, contributing to Resident 1's injury.

The facility failed to complete timely 72-hour neuro checks after Resident 1's falls and did not implement the physician's order to apply a soft belt restraint while Resident 1 was in a wheelchair. Resident 1 fell three times within eight days, resulting in a nasal fracture and hospitalization. The care plan was not updated after the second fall to prevent further incidents.

The facility failed to develop or implement a communication care plan for Resident 1 that identified the resident's preferred language and communication aids, creating potential for miscommunication and refusal of care. Interviews with staff confirmed that care planning for preferred language and communication interventions was not routinely done.

The complaint investigation found that Resident 1 sustained an acute medial supracondylar fracture of the distal femur of unknown origin. The injury was not reported to the CDPH within the required two-hour period, delaying the investigation. The Director of Nursing acknowledged the failure to report timely during an interview.

The facility failed to implement its abuse policy and procedure by not reporting Resident 1's acute medial supracondylar fracture of the distal femur, considered an injury of unknown origin, to the CDPH within two hours. This delay resulted in a postponed investigation by the CDPH.

The complaint investigation found that Resident 1, identified as a high fall risk, was not adequately supervised. Staff interviews revealed that a Certified Nursing Assistant left Resident 1 unattended, leading to a fall. The Director of Nursing confirmed the need for more vigilant supervision and proper handoff protocols.

The facility failed to provide adequate supervision to prevent a fall of Resident 1, who was restless and repeatedly tried to get out of bed unassisted. Interviews with staff confirmed lapses in supervision and handoff communication, resulting in Resident 1 falling and sustaining injury.

The complaint investigation was substantiated as the facility failed to provide required supervision to Resident 1, leading to a fall and fracture. The investigation also found failure to report a COVID-19 outbreak to licensing and certification as required.

The facility failed to provide adequate supervision to prevent a resident fall that caused a fracture requiring hospitalization. Additionally, the facility failed to report a COVID-19 outbreak to licensing and certification, potentially risking further spread of infection.

The complaint investigation involved Resident 2 who alleged that CNA 5 lowered her bed against her wishes, slapped her arm, and shushed her. The facility did not report the conclusion of the investigation to the State Agency within five working days as required. The Administrator stated the delay was due to the State Agency already conducting an investigation.

The facility failed to report the results of the investigation regarding staff to resident abuse allegations within the required timeframe, resulting in an incomplete investigation and overlooked concerns that placed Resident 2 and other residents at risk. Resident 2 reported that a Certified Nurse Assistant lowered her bed against her wishes, slapped her arm, and shushed her during the incident.

The investigation was complaint-driven, focusing on allegations that the facility failed to provide adequate fall prevention care plans and interventions for residents who had sustained falls, resulting in injuries including a fractured femur and repeated falls.

The facility failed to develop and implement fall risk care plans and appropriate interventions for multiple residents following falls, leading to increased risk of avoidable physical harm. Specific failures included lack of updated care plans after falls, inaccurate fall risk assessments, and failure to implement recommended interventions such as frequent visual checks and use of alarms.

The facility failed to provide accurate resident assessments, develop comprehensive care plans, ensure timely PASRR submissions, administer medications correctly, maintain safe and sanitary food storage and preparation, monitor laundry machine temperatures, and provide adequate supervision and safety for residents, particularly Resident 92 who had a cluttered room with a hazardous candle maker. The facility also failed to properly manage controlled substances and maintain proper documentation.

The complaint investigation found substantiated deficiencies related to infection control, including failure to revise a resident's care plan after COVID-19 exposure and failure of a housekeeper to perform hand hygiene, increasing infection risk.

The facility failed to revise the care plan for a resident (Resident 4) exposed to COVID-19 by a positive roommate, and a housekeeper failed to perform proper hand hygiene between cleaning rooms, potentially increasing the risk of infection transmission.

The complaint investigation found that Resident 1 did not have a COVID-19 care plan despite being at risk during a facility COVID-19 outbreak. The deficiency was substantiated with interviews from the Infection Preventionist, Registered Nurse, and Director of Nursing confirming the lack of a care plan.

The facility failed to develop and implement a care plan for Resident 1 to address COVID-19 exposure risk despite the resident being in a high-risk group and the facility experiencing a COVID-19 outbreak. Interviews with staff confirmed the absence of a COVID-19 care plan placed the resident at risk for inadequate care.

The facility failed to notify the California Department of Public Health within 48 hours of unusual occurrences involving two residents who sustained fractures, resulting in delayed investigations and potential neglect risks to other residents.

The complaint investigation found the facility did not report an unusual occurrence involving Resident 1's fall and death to the CDPH within 48 hours as required. The deficiency was substantiated with interviews and record reviews confirming the delayed reporting.

The facility failed to follow its policy and state regulations by not reporting Resident 1's fall and subsequent death to the CDPH within the required timeframe, resulting in a delayed investigation and potential neglect risk to other residents. Interviews with the Director of Nursing and Administrator confirmed the incident was not reported as required.