Deficiencies (last 4 years)
Deficiencies (over 4 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
24
18
12
6
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 related to COVID-19 protective measures.
Findings
The facility failed to ensure proper use of personal protective equipment by one staff member while caring for residents with confirmed COVID-19, potentially exposing others to the virus.
Deficiencies (1)
F 0880: The facility failed to ensure one of three staff did not properly wear a surgical mask covering both mouth and nose while caring for residents with confirmed COVID-19, risking virus transmission.
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 investigation regarding failure to follow physician orders for Resident #1 to wear a right wrist brace 24/7 after a fracture.
Complaint Details
The complaint investigation found that Resident #1 was not wearing the prescribed wrist brace on 2/10/25 and 2/11/25. The facility admitted responsibility during a care conference attended by family and facility leadership. Communication gaps with private sitters were noted as a contributing factor.
Findings
The facility staff failed to ensure Resident #1 wore the prescribed right wrist brace continuously from 2/10/25 to 2/11/25, risking improper healing of the fracture. Communication failures between nursing staff and private sitters contributed to the brace not being applied as ordered.
Deficiencies (1)
F 0684: Facility staff did not follow physician orders from 2/10/25 to 2/11/25 to ensure Resident #1 wore a right wrist brace at all times, risking improper healing of the fracture.
Report Facts
Residents Affected: 3
Date of fall: Jan 26, 2025
Date of physician order: Jan 28, 2025
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 investigation was conducted due to complaints regarding improper transfer of residents from Summerfield Health Care Center to other skilled nursing facilities without adequate reason or proper documentation.
Complaint Details
The complaint investigation found that Resident 1 and Resident 2 were transferred without proper consent or valid reasons. Resident 1 experienced emotional distress due to the transfer, and Resident 2 was transferred while in poor health and later passed away. The Social Services Director and Director of Nursing could not provide documentation supporting the transfers or resident initiation.
Findings
The facility failed to provide adequate justification and documentation for transferring two residents to other skilled nursing facilities, causing emotional distress to one resident and potential distress to another. The facility did not document resident or family initiation of transfers and incorrectly cited health improvement as the reason for transfer.
Deficiencies (1)
F 0622: The facility transferred two residents to other skilled nursing facilities without evidence that their health had improved sufficiently to no longer need the services provided. Documentation and resident consent for transfers were inadequate or absent.
Report Facts
BIMS Score: 15
BIMS Score: 7
Length of Stay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Interviewed regarding transfer documentation and consent; unable to provide valid reasons or documentation for transfers. |
| Director of Nursing | Director of Nursing | Interviewed and unable to provide documentation of resident initiation of transfers. |
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
Deficiencies: 10
Date: Mar 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, food service, and facility operations at Summerfield Health Care Center.
Findings
The facility had multiple deficiencies including incomplete and non-comprehensive pain management care plans, improper oxygen therapy administration, medication errors including incorrect administration of Polycarbophil and failure to maintain medication refrigerator temperatures within acceptable ranges. Additionally, food service issues were noted including failure to honor alternate meal requests and improper food storage practices. Clinical documentation for blood glucose rechecks was incomplete.
Deficiencies (10)
F 0656: The facility failed to develop and implement comprehensive nursing care plans for pain management that included specific pharmacological and non-pharmacological interventions for two residents.
F 0695: The facility did not provide respiratory care consistent with resident's care plan and physician orders for oxygen therapy, risking respiratory complications.
F 0697: The facility failed to provide appropriate pain management for a resident lacking a physician's order for severe pain, resulting in administration of moderate pain medication during severe pain episodes.
F 0756: The pharmacy consultant failed to identify medication administration errors involving Polycarbophil given concurrently with other medications, contrary to manufacturer guidelines.
F 0759: The facility failed to maintain a medication error rate below 5%, with a 21% error rate observed during medication passes involving improper administration of medications and lack of knowledge of medication guidelines.
F 0761: The facility did not maintain proper temperature controls for medication storage; medication refrigerator temperatures were frequently outside the acceptable range without documented corrective actions.
F 0806: The facility failed to ensure resident food preferences were honored, resulting in a resident receiving the incorrect meal multiple times.
F 0812: The facility failed to ensure safe food storage practices; staff lacked knowledge of sanitizing procedures and food storage areas lacked temperature monitoring and documentation.
F 0814: The facility failed to ensure kitchen trash cans were properly covered, with large holes in lids allowing exposure of garbage, risking pest infestation and contamination.
F 0842: The facility failed to ensure complete and accurate clinical documentation for a resident's blood glucose rechecks, resulting in inability to verify compliance with physician orders.
Report Facts
Medication error rate: 21
Medication administration count: 44
Medication administration count: 32
Temperature excursions: 15
Temperature excursions: 4
Temperature excursions: 11
Polycarbophil administration: 3
Blood glucose reading: 384
Blood glucose reading: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN J | Licensed Vocational Nurse | Named in medication administration and blood glucose recheck documentation findings. |
| LVN K | Licensed Vocational Nurse | Reviewed pain care plans and commented on their lack of comprehensiveness. |
| Registered Nurse L | Registered Nurse | Reviewed pain care plans and acknowledged inappropriate medication administration. |
| Pharmacy Consultant E | Pharmacy Consultant | Failed to identify medication administration errors involving Polycarbophil. |
| Dietary Manager | Dietary Manager | Involved in food service observations and interviews regarding meal errors and food storage. |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen therapy, medication administration, and clinical documentation. |
| LVN A | Licensed Vocational Nurse | Administered medications including Polycarbophil and involved in medication error findings. |
| Registered Nurse B | Registered Nurse | Administered medications including Polycarbophil and involved in medication error findings. |
| LVN C | Licensed Vocational Nurse | Administered incorrect medication and involved in medication error findings. |
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 assess compliance with food preparation and storage standards, specifically to ensure residents receive food prepared in a form designed to meet individual needs and that food supplies are safely stored and labeled.
Findings
The facility failed to provide food of appropriate consistency for three residents on modified diets, serving regular consistency pork instead. Additionally, expired and improperly labeled food items were found in the kitchen, dry storage, and utility room refrigerator, posing a risk of foodborne illness.
Deficiencies (2)
F 0805: The facility failed to provide food prepared in a form designed to meet individual needs for 3 of 12 residents on modified consistency diets, serving regular consistency pork instead of mechanical soft or ground meat. This posed a choking hazard.
F 0812: The facility failed to safely store food supplies and residents' food, with expired and unlabeled items found in the kitchen, dry storage, and utility room refrigerator for four residents. This posed a risk of foodborne illness.
Report Facts
Residents affected: 3
Residents affected: 4
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 error rates, 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 oxygen therapy tasks outside their scope, had an 8% medication error rate due to improper administration techniques, improperly stored refrigerated vaccines below recommended temperatures, and failed to implement adequate infection prevention and control practices including hand hygiene and environmental cleanliness.
Deficiencies (5)
F 0554: The facility failed to assess 2 of 12 sampled residents' ability to self-administer medications, including lack of reassessment after cognitive and visual impairments developed.
F 0695: The facility failed to provide respiratory care in accordance with professional scope, allowing unlicensed staff to switch oxygen delivery devices.
F 0759: The facility failed to ensure medication error rates below 5%, with an 8% error rate due to improper inhaler and insulin administration techniques.
F 0761: The facility did not ensure refrigerated vaccines were stored at proper temperatures, with documented refrigerator temperatures below recommended range on multiple days.
F 0880: The facility failed to implement infection prevention and control practices, including improper hand hygiene during wound care and placing meal trays on unsanitized bedside tables with urinals present.
Report Facts
Medication error rate: 8
Medications observed: 25
Residents sampled for self-administration assessment: 12
Residents affected by deficiencies: 2
Refrigerator temperature readings below 36°F: 3
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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