Deficiencies (last 4 years)
Deficiencies (over 4 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 1
Date: Sep 5, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on staff compliance with personal protective equipment (PPE) protocols while caring for residents with confirmed COVID-19.
Findings
The facility failed to ensure that one of three staff members (Unlicensed Staff A) properly used PPE, specifically wearing a surgical mask that did not cover the nose while caring for residents with confirmed COVID-19, posing a risk of virus transmission to staff, residents, and visitors.
Deficiencies (1)
Failure to ensure proper use of personal protective equipment (PPE) by Unlicensed Staff A while caring for residents with confirmed COVID-19, specifically wearing a surgical mask that did not cover the nose.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 3, 2025
Visit Reason
The inspection was conducted due to a complaint regarding failure of facility staff to follow physician orders to ensure Resident #1 wore a wrist brace on her right wrist at all times, which could affect healing of a wrist fracture.
Complaint Details
The complaint investigation found that Resident #1 did not have the wrist brace on as ordered from 2/10/25 evening through 2/11/25 lunch, with staff and private sitters unaware or failing to communicate about the brace. The facility admitted responsibility during a care conference.
Findings
The facility staff failed to ensure Resident #1 wore the prescribed right wrist brace continuously from 2/10/25 to 2/11/25, despite physician orders. Multiple staff and private sitters were unaware or did not communicate about the brace, increasing the risk of improper healing of the fracture.
Deficiencies (1)
Failure to follow physician orders to ensure Resident #1 wore a wrist brace on her right wrist at all times.
Report Facts
Residents Affected: 1
Date of fall: Jan 26, 2025
Date of physician order: Jan 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Rehabilitation Services | Reviewed medical record and confirmed physician orders for wrist splint | |
| Assistant Director of Nursing | Stated physician ordered wrist splint 24/7 and staff communication responsibilities | |
| Licensed Staff E | Unaware of wrist brace requirement for Resident #1 | |
| Licensed Staff I | Stated caregivers should notify nurses if wrist brace was off | |
| Private Sitter S | Reported Resident #1 kept trying to remove wrist brace and staff did not replace it |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 5, 2024
Visit Reason
The inspection was conducted due to concerns about the facility transferring residents without adequate reason or proper documentation, specifically regarding two residents who were transferred to other skilled nursing facilities without evidence that their health had improved sufficiently.
Complaint Details
The investigation was complaint-driven, focusing on transfers of Resident 1 and Resident 2 without proper consent or valid reasons. The Social Services Director and Director of Nursing could not provide documentation of resident-initiated transfers or valid rationale. Family members expressed surprise and distress over the transfers. The complaint was substantiated with findings of improper transfer procedures.
Findings
The facility failed to permit two sampled residents to remain when transferred to other skilled nursing facilities without valid reasons or proper documentation. Transfers caused emotional distress to Resident 1 and had potential for distress for Resident 2. Documentation and consent processes were inadequate, and the facility could not provide valid rationale or evidence of resident-initiated transfers.
Deficiencies (1)
Failure to provide adequate reason and documentation for transferring residents, resulting in emotional distress and potential harm.
Report Facts
BIMS Score: 15
BIMS Score: 7
Length of Stay: 3
Length of Stay: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Named in relation to transfer and discharge findings and inability to provide valid documentation or rationale |
| Director of Nursing | Director of Nursing | Named in relation to inability to provide documentation of resident-initiated transfers |
Inspection Report
Routine
Deficiencies: 10
Date: Mar 15, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, food service, and facility safety at Summerfield Health Care Center.
Findings
The facility was found deficient in multiple areas including incomplete and non-specific pain management care plans, improper oxygen therapy administration, medication errors including improper administration of Polycarbophil and other medications, failure to maintain proper medication refrigerator temperatures, failure to honor resident meal preferences, inadequate food storage and sanitation practices, uncovered trash receptacles in the kitchen, and incomplete clinical documentation of blood glucose monitoring.
Deficiencies (10)
Failure to ensure nursing care plans for pain management were comprehensive, resident-centered, and included specific pharmacological and non-pharmacological interventions for two residents.
Failure to provide respiratory care consistent with resident's care plan and physician's orders for oxygen therapy for one resident.
Failure to provide pain management based on comprehensive care plan and lack of physician order for severe pain for one resident.
Pharmacy consultant failed to identify medication administration errors related to Polycarbophil given concurrently with other medications.
Medication error rate of 21% observed during medication pass, including improper administration of Polycarbophil, potassium chloride, metformin, and substitution of fish oil for Lovaza.
Failure to maintain proper temperature controls for medication refrigerator from December 2023 through February 2024 with no corrective actions taken.
Failure to honor resident meal preference resulting in resident receiving incorrect meal causing frustration.
Failure to ensure safe food storage practices including lack of knowledge of sanitizing procedures and failure to monitor and record temperatures in dry and emergency food storage areas.
Failure to ensure trash cans in kitchen were completely covered, allowing exposure of garbage and potential for pest infestation.
Failure to ensure clinical documentation was complete and accurate for blood glucose rechecks as ordered by physician for one resident.
Report Facts
Medication error rate: 21
Polycarbophil administration: 3
Medication administration count: 44
Temperature excursions: 15
Temperature excursions: 4
Temperature excursions: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN K | Licensed Vocational Nurse | Reviewed pain care plans and indicated they were not comprehensive. |
| Registered Nurse L | Registered Nurse | Reviewed pain care plans and agreed they were too generalized; administered Hydrocodone-Acetaminophen for severe pain contrary to orders. |
| LVN A | Licensed Vocational Nurse | Administered medications including Polycarbophil improperly; unaware of proper administration guidelines. |
| Registered Nurse B | Registered Nurse | Administered medications including Polycarbophil and metformin improperly; unaware of administration guidelines. |
| LVN C | Licensed Vocational Nurse | Administered Polycarbophil improperly and substituted fish oil for Lovaza due to lack of knowledge. |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen therapy, medication refrigerator temperature excursions, and blood glucose documentation. |
| Dietary Manager | Dietary Manager | Interviewed regarding missed alternate meal order and food storage practices. |
| Occupational Therapist I | Occupational Therapist | Assisted Resident 107 with meal change request form. |
| Pharmacy Consultant E | Pharmacy Consultant | Unaware of Polycarbophil administration issues. |
| Pharmacy Consultant D | Pharmacy Consultant | Provided in-services on medication refrigerator temperature control. |
| Dietary Aid F | Dietary Aid | Unable to describe three-compartment dishwashing method and unable to find policy. |
| Maintenance Director | Maintenance Director | Checked resident room temperatures but not kitchen or food storage. |
| Director of Staff Development | Director of Staff Development | Interviewed regarding documentation practices for blood glucose rechecks. |
Inspection Report
Routine
Deficiencies: 2
Date: May 11, 2023
Visit Reason
The inspection was conducted to evaluate compliance with food preparation and safety standards, specifically to ensure residents receive food prepared in a form designed to meet individual needs and that food supplies are stored and handled according to professional standards.
Findings
The facility failed to provide food of appropriate consistency for three residents on modified diets, serving regular consistency pork instead, posing a choking risk. Additionally, the facility failed to properly store and label food supplies, with expired and undated food items found in the kitchen, dry storage, and utility room refrigerators, risking foodborne illness.
Deficiencies (2)
Failed to provide food of appropriate consistency for 3 residents on modified diets, serving regular consistency pork instead.
Failed to safely store food supplies and residents' food, with expired and undated items found in kitchen, dry storage, and utility room refrigerators.
Report Facts
Residents affected: 3
Residents affected: 4
Pieces of muffins: 4
Pieces of burger buns: 8
Egg sandwiches: 3
Bottles of Nepro shake: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unlicensed Staff L | Mentioned in relation to food preparation errors and expired food items | |
| Director of Food and Nutrition | Confirmed diet orders and acknowledged expired food items | |
| Administrator | Present during exit interview and informed of findings | |
| Director of Nursing | Present during exit interview and informed of findings | |
| CNA A | Assisted Resident 1 during meal observation | |
| CNA B | Observed Resident 2's meal and commented on food consistency | |
| Registered Dietitian | Asked about food preparation errors |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 14, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, respiratory care, medication administration, vaccine storage, infection prevention and control, and other aspects of resident care at Summerfield Health Care Center.
Findings
The facility failed to properly assess residents' ability to self-administer medications, allowed unlicensed staff to perform tasks outside their scope such as switching oxygen delivery devices, had medication administration errors exceeding acceptable rates, improperly stored refrigerated vaccines at unsafe temperatures, and failed to implement adequate infection prevention and control practices including hand hygiene and environmental cleanliness.
Deficiencies (5)
Failure to assess and re-assess residents' ability to self-administer eye drop medications, potentially affecting eye health.
Unlicensed staff switched oxygen delivery devices, risking inappropriate oxygen administration.
Medication administration errors occurred in 2 of 25 observed medications, resulting in an 8% error rate.
Refrigerated vaccines were stored at temperatures below the recommended range, risking reduced vaccine effectiveness.
Failure to perform proper hand hygiene during wound care and placing meal trays on unsanitized bedside tables with urinals present, risking cross-contamination.
Report Facts
Medication error rate: 8
Medication room refrigerator temperature readings: 28
Medication room refrigerator temperature readings: 26
Medication room refrigerator temperature readings: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff A | Interviewed regarding residents' medication self-administration and medication administration observations. | |
| Management Staff F | Interviewed regarding medication self-administration assessments, oxygen therapy responsibilities, and vaccine storage policies. | |
| Licensed Staff G | Observed and interviewed regarding medication administration errors and infection control practices. | |
| Licensed Staff C | Interviewed regarding care plans, infection control, and medication self-administration monitoring. | |
| Licensed Staff B | Observed medication storage and interviewed about vaccine refrigerator temperature monitoring. | |
| Licensed Staff D | Interviewed regarding resident's ability to self-administer eye drops. | |
| Licensed Staff J | Interviewed regarding medication self-administration assessments and care plans. | |
| Licensed Staff E | Observed switching oxygen delivery devices outside scope of practice. | |
| Unlicensed Staff H | Observed and interviewed regarding infection control practices related to bedside table sanitation. | |
| Unlicensed Staff K | Observed serving meals without sanitizing bedside table. |
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