Deficiencies (last 4 years)
Deficiencies (over 4 years)
21.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
433% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 15, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report a major injury sustained by Resident 4 after being left alone on a patio, resulting in a fall and subdural hematoma.
Complaint Details
The complaint investigation found that Resident 4 was left alone on a patio for 30 minutes by Restorative Nursing Assistant H, resulting in a fall and subdural hematoma. The injury was not reported timely by the facility. Interviews with staff including the Facility Administrator and Director of Nursing confirmed the failure to report and inadequate supervision. Resident 4 was hospitalized, placed on hospice care, and died 13 days after the fall.
Findings
The facility failed to report a major injury for Resident 4, who was left unsupervised on a patio for 30 minutes, fell, and sustained a subdural hematoma. This failure delayed investigation and resulted in Resident 4's decline and eventual death. Additionally, the facility failed to provide adequate supervision and activities consistent with Resident 4's care plan, and staff lacked appropriate competencies to care for Resident 4.
Deficiencies (4)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failure to honor an activity preference developed in the activity care plan for Resident 1, potentially impacting mental and psychosocial needs.
Failure to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, resulting in Resident 4's major head injury.
Failure to ensure nurses and nurse aides have appropriate competencies to care for every resident, resulting in Resident 4 being left alone and sustaining a major head injury.
Report Facts
Duration Resident Left Alone: 30
Subdural Hematoma Size: 3
Resident 4 Death: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Restorative Nursing Assistant H | Restorative Nursing Assistant | Left Resident 4 alone on patio leading to fall and injury. |
| Facility Administrator | Admitted facility did not report Resident 4's fall because it was not considered significant. | |
| Director of Nursing | Director of Nursing | Confirmed failure to report injury and inadequate supervision. |
| Registered Nurse C | Registered Nurse | Assigned nurse for Resident 4 on day of fall; was not informed Resident 4 was on patio. |
| Licensed Vocational Nurse E | Licensed Vocational Nurse | Stated Resident 4 did not have adequate supervision on patio. |
| Certified Nursing Assistant J | Certified Nursing Assistant | Found Resident 4 on ground after fall; was not informed Resident 4 was on patio. |
| Medical Doctor Z | Medical Doctor | Performed medical assessment confirming major injury. |
| Director of Staff Development | Provided specialized training to RNA H after fall incident. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 27, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected abuse involving Resident 4 who was slapped by another resident on 6/20/25.
Complaint Details
The complaint investigation found that the facility did not report an abuse incident involving Resident 4 being slapped by Resident 5 on 6/20/25. The facility staff misunderstood reporting requirements related to perpetrators with dementia. The abuse was not reported to the state licensing/certification agency.
Findings
The facility failed to report an abuse allegation involving Resident 4 being slapped by Resident 5 on 6/20/25. The incident was confirmed by the Administrator and Director of Nursing, who stated the facility believed reporting was not required if the perpetrator had a dementia diagnosis.
Deficiencies (1)
Failure to timely report suspected abuse of Resident 4 who was slapped by another resident.
Report Facts
Date of abuse incident: Jun 20, 2025
MDS BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator (ADN) | Confirmed abuse incident and misunderstanding of reporting requirements |
| Director of Nursing | Director of Nursing (DON) | Confirmed abuse incident and reporting misunderstanding |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 16, 2025
Visit Reason
The inspection was conducted to investigate complaints related to repeated resident falls and inadequate fall prevention measures at Bridgeview Post Acute nursing home.
Complaint Details
The investigation focused on two residents (Resident 1 and Resident 2) with multiple falls. Resident 1 had eleven falls since admission with inadequate evaluation of interventions and supervision. Resident 2 had moderate fall risk with cognitive impairment and ineffective interventions such as reminders to use call light. The Director of Nursing confirmed ongoing issues with fall prevention, lack of CNA involvement in care planning, and insufficient evaluation of intervention effectiveness.
Findings
The facility failed to ensure residents were free from accidents and hazards by not adequately evaluating post-fall causes, not reassessing care plan interventions for effectiveness, and not developing new interventions to prevent further falls. Staff lacked knowledge on identifying high fall risk residents and their fall care plans, resulting in multiple repeated falls and potential risk to all residents.
Deficiencies (4)
Post fall evaluations did not determine the reason for the falls.
Residents care plan interventions were not reevaluated for effectiveness.
New interventions were not developed to prevent further falls and injuries.
Direct care staff did not know how to identify high risk fall residents and find their fall plan of care.
Report Facts
Number of falls for Resident 1: 11
Date of Minimum Data Set for Resident 1: Feb 6, 2025
Date of Minimum Data Set for Resident 2: Feb 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed issues with fall prevention program, lack of CNA involvement in care planning, and ongoing efforts to improve fall program. |
| CNA B | Certified Nursing Assistant | Reported Resident 2 was falling frequently and did not use Point of Care system for fall risk interventions. |
| CNA A | Certified Nursing Assistant | Observed Resident 2's care plan and noted lack of fall risk identification and incomplete care plans. |
Inspection Report
Deficiencies: 1
Date: Jan 15, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding the safe, clean, and homelike environment for residents, specifically addressing concerns about improper storage of construction materials in resident rooms.
Findings
The facility failed to maintain a safe and homelike environment when construction materials, including laminate flooring and paint/adhesive cans, were improperly stored in a resident room, creating potential hazards and discomfort for residents. The facility acknowledged the issue and planned to move the materials to a proper storage area.
Deficiencies (1)
Improper storage of construction materials in the room of three residents, creating potential hazards and an environment not considered homelike.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility Administrator A | Facility Administrator | Named in relation to the storage of construction materials and OSHA inquiry. |
| Licensed Vocational Nurse B | Licensed Vocational Nurse | Mentioned regarding family concerns about flooring materials stored in resident room. |
| Maintenance Director C | Maintenance Director | Discussed the storage of flooring and glue cans and the facility's plan of correction. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Oct 8, 2024
Visit Reason
The inspection was conducted based on complaints and allegations regarding failure to provide privacy during personal care, staff speaking non-English languages in front of residents, loud night shifts, and abuse allegations involving physical and emotional mistreatment of residents.
Complaint Details
The complaint investigation was triggered by multiple allegations including failure to provide privacy during personal care, staff speaking non-English languages in front of residents, loud night shifts, and abuse allegations involving physical and emotional mistreatment of residents. The investigation found substantiated issues of dignity violations, abuse, neglect, and failure to report and investigate abuse allegations.
Findings
The facility failed to ensure residents were treated with dignity and respect, including failure to provide privacy during personal care, staff speaking non-English languages in front of residents, and loud noise during night shifts. The facility also failed to protect residents from abuse, including physical abuse by staff and neglect, and failed to timely report and investigate allegations of abuse. Emotional distress and potential harm to residents were noted.
Deficiencies (7)
Failure to provide privacy during personal care for Resident 101.
Facility staff spoke non-English languages in front of residents 46, 90, and 100.
Night shift staff were loud, disturbing residents.
Resident 40 was instructed to clean her own toilet with feces present by Housekeeper A.
Certified Nursing Assistant E grabbed and held Resident 35's arm during care and continued to be assigned to Resident 35's room after the incident.
Failure to timely report suspicions and allegations of abuse for Residents 22, 35, and 40.
Failure to investigate allegations of abuse and protect residents during investigations for Residents 22, 35, and 40.
Report Facts
Residents sampled: 22
Residents affected by dignity and respect issues: 6
Residents affected by abuse and neglect issues: 2
Residents affected by failure to report abuse: 3
BIMS scores: 15
BIMS score: 7
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Acknowledged failure to provide privacy during dressing Resident 101 |
| HSK A | Housekeeper | Made Resident 40 clean her own toilet and was suspended pending investigation |
| CNA E | Certified Nursing Assistant | Grabbed and held Resident 35's arm during care and continued to be assigned to Resident 35's room |
| CNA J | Certified Nursing Assistant | Did not report allegation of Resident 40 being made to clean her own toilet |
| CNA M | Certified Nursing Assistant | Did not report suspicions of abuse when Resident 22 showed fear during care |
| DSD | Director of Staff Development | Provided education on English-only policy and confirmed knowledge of abuse incidents |
| Admin | Administrator | Confirmed ongoing issues with staff speaking non-English, noise complaints, and failure to report abuse |
| HSK M | Housekeeping Manager | Reported switching HSK A's assignment and suspension pending investigation |
| IP | Infection Preventionist | Informed about CNA E incident but did not follow up |
| SC | Staffing Coordinator | Confirmed CNA E was assigned to Resident 35 after incident and should not have been |
Inspection Report
Routine
Deficiencies: 16
Date: Oct 8, 2024
Visit Reason
The inspection was a routine regulatory survey of Bridgeview Post Acute nursing home to assess compliance with resident rights, abuse prevention, medication management, food service, social services, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, failure to prevent and report abuse, inadequate investigation of abuse allegations, incomplete transfer documentation, failure to ensure non-skid footwear for fall prevention, improper gastrostomy tube care, incomplete physician progress notes, inadequate nursing competencies, failure to limit psychotropic medication use, improper medication storage and labeling, failure to provide timely dental care, failure to honor food preferences, poor food quality and temperature, inadequate social services, and unsanitary kitchen conditions.
Deficiencies (16)
Failure to ensure resident privacy and dignity during personal care.
Failure to prevent and report abuse and neglect of residents.
Failure to investigate allegations of abuse and protect residents during investigations.
Incomplete documentation of resident transfer to hospital including date, time, location, and disposition of personal effects.
Failure to ensure resident wore non-skid footwear to prevent falls as per care plan.
Failure to follow physician orders for gastrostomy tube feeding and care; excessive fluid administration and undocumented care.
Incomplete and unsigned physician progress notes for residents.
Failure to ensure nursing staff demonstrated appropriate competencies including abuse reporting, gastrostomy tube care, and meal tray checks.
Failure to limit PRN psychotropic medication orders to 14 days and failure to discontinue unnecessary medications.
Medications and medical supplies were not stored or labeled properly; expired items and loose pills found.
Failure to provide timely dental care and follow-up for resident with extracted teeth and insurance issues.
Failure to ensure resident care plans were updated quarterly or as needed and discharge planning was incomplete.
Failure to honor resident food preferences resulting in residents receiving disliked foods.
Food served was overcooked, undercooked, cold, or burnt; food temperatures were not maintained properly.
Unsanitary kitchen conditions including dirty floors, food debris, unclean equipment, improper sanitizer levels, and contaminated utensils.
Resident food improperly stored in resident refrigerators with unlabeled, expired, or spoiled food items.
Report Facts
PRN Ativan order duration: 120
Resident 61 BIMS score: 8
Resident 101 BIMS score: 7
Resident 87 total water intake: 3600
Resident 214 total water intake: 3907
Sanitizer solution strength: 500
Sanitizer solution strength: 50
Resident 77 BIMS score: 15
Resident 84 BIMS score: 7
Resident 11 BIMS score: 15
Resident 35 BIMS score: 15
Resident 215 BIMS score: 15
Resident 90 BIMS score: 15
Resident 106 BIMS score: 3
Resident 98 BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Acknowledged failure to provide privacy during personal care for Resident 101. |
| CNA E | Certified Nursing Assistant | Involved in abuse allegation of holding down Resident 35 and failure to report. |
| Director of Staff Development | Provided education on English only policy and noise level; confirmed knowledge of abuse incident with Resident 35. | |
| Housekeeper A | Housekeeper | Alleged to have made Resident 40 clean own toilet and hit bed with mop; suspended pending investigation. |
| Housekeeping Manager | Housekeeping Manager | Switched Housekeeper A's assignment after complaint. |
| CNA J | Certified Nursing Assistant | Received complaint from Resident 40 about Housekeeper A; did not report incident. |
| Administrator | Administrator | Confirmed ongoing issues with staff speaking non-English, noise complaints, and abuse reporting failures. |
| Assistant Director of Nursing | Confirmed no investigation of CNA holding down Resident 35; confirmed assignment errors. | |
| Infection Preventionist | Confirmed CNA E reported aggression but no follow-up investigation. | |
| Scheduler | Responsible for arranging appointments and transportation; unaware of Resident 98's eye surgery appointments. | |
| Licensed Nurse O | Licensed Nurse | Reviewed gastrostomy tube orders and medication administration records; acknowledged documentation errors. |
| Registered Dietitian | Reviewed gastrostomy tube orders and food safety concerns. | |
| Dietary Manager | Acknowledged food complaints, kitchen cleanliness issues, and food preference errors. | |
| Certified Dietary Manager | Acknowledged food temperature and sanitation issues in kitchen. | |
| Social Service Director | Failed to update care plans timely and follow up on dental and eye care referrals. | |
| Social Service Assistant | Acknowledged Resident 61's behavioral changes and participated in medication reviews. | |
| CNA P | Certified Nursing Assistant | Reported Resident 61's verbal aggressive behaviors. |
| CNA N | Certified Nursing Assistant | Reported Resident 61's verbal aggressive behaviors. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Mar 7, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding the care of Resident 1, specifically related to the administration of psychotropic medication without informed consent and failure to implement physician-ordered respiratory treatment (BiPAP).
Complaint Details
The complaint investigation focused on Resident 1's care related to psychotropic medication administration without informed consent and failure to implement physician-ordered BiPAP treatment, resulting in respiratory decline and hospitalization.
Findings
The facility failed to ensure Resident 1 was informed and consented before administering psychotropic medication, resulting in unnecessary medication use. The facility also failed to create accurate admission assessments and baseline care plans including BiPAP treatment, leading to a 14-day delay in BiPAP implementation and subsequent respiratory decline requiring hospitalization. Additionally, the facility lacked adequate staff training and oversight by the Medical Director in these areas.
Deficiencies (7)
Failed to ensure informed consent before administering psychotropic medication to Resident 1.
Failed to create an accurate comprehensive admission assessment including BiPAP treatment for Resident 1.
Failed to create a baseline care plan including respiratory treatment for Resident 1.
Failed to provide safe and appropriate respiratory care by not implementing BiPAP for 14 days, resulting in emergent hospitalization.
Failed to ensure nursing staff had appropriate competencies and training to implement respiratory care plan including BiPAP use.
Failed to implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medication; psychotropic medication prescribed without clinical indication.
Failed to ensure Medical Director supervised implementation of resident care policies including BiPAP orders and psychotropic medication oversight.
Report Facts
Days BiPAP not implemented: 14
Hospitalization duration: 5
Psychotropic medication dose: 5
Oxygen saturation target: 90
Oxygen saturation target: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Documented ordering Lexapro and noted lack of informed consent; unable to recall clinical need for psychotropic medication. |
| Medical Director | MDir | Stated need for clinical justification and informed consent for psychotropic medications; acknowledged failure in BiPAP order implementation and oversight. |
| Licensed Vocational Nurse 1 | LVN 1 | Signed for BiPAP machine delivery; documented Resident 1 had no changes in mood or behavior. |
| Minimum Data Set Registered Nurse | MDS RN | Confirmed BiPAP was not included in admission assessment or baseline care plan. |
| Director of Nursing | DON | Confirmed lack of BiPAP documentation and training; stated nursing staff should verify physician orders and document respiratory assessments. |
| Social Services Director | SSD | Received family concerns about BiPAP; confirmed BiPAP machine was found after family inquiry. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jun 28, 2023
Visit Reason
The inspection was conducted due to complaints alleging staff to resident abuse and failure to report such allegations to mandated agencies, as well as concerns about resident care, assessments, and treatment.
Complaint Details
The complaint investigation was triggered by allegations of staff to resident abuse involving three residents (Resident 63, 74, and 86). The facility failed to report these allegations to mandated agencies and failed to investigate them properly.
Findings
The facility failed to timely report suspected abuse allegations for three residents, failed to provide accurate assessments and baseline care plans, did not ensure professional standards of care for skin conditions, failed to provide scheduled bathing and grooming assistance, and did not have physician orders for certain treatments applied.
Deficiencies (6)
Failed to timely report suspected abuse allegations for three sampled residents to mandated agencies.
Failed to provide an accurate and complete assessment for one resident with known open skin areas.
Failed to develop and implement a baseline care plan within 48 hours of admission for one resident.
Failed to meet professional standards of care by not identifying and reporting a skin condition, resulting in resident refusal of care.
Failed to provide routine grooming and scheduled showers for six sampled residents.
Failed to ensure medical care was supervised by a physician; applied lidocaine spray without physician order.
Report Facts
Resident complaints related to nursing and CNA care: 7
Bathing frequency for Resident 23: 2
Bathing frequency for Resident 29: 1
Bathing frequency for Resident 33: 0
Bathing frequency for Resident 302: 1
Baseline care plan completion delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in findings related to failure to report abuse allegations and skin condition management. |
| Social Service Director | Social Service Director (SSD) | Named in findings related to failure to report abuse allegations and grievance follow-up. |
| Physical Therapy Assistant | Physical Therapy Assistant (PTA) | Reported resident complaints related to CNA care that were not reported as abuse. |
| Licensed Vocational Nurse | Licensed Vocational Nurse (LVN) | Treatment nurse who applied lidocaine spray without physician order. |
| Nurse Practitioner | Nurse Practitioner (NP) | Unaware of resident's skin condition until late in investigation; no wound consult in 2 years. |
| Director of Staff Development | Director of Staff Development (DSD) | Confirmed need for staff education on bathing and grooming. |
Inspection Report
Routine
Deficiencies: 22
Date: Jun 28, 2023
Visit Reason
Routine inspection of Bridgeview Post Acute nursing home to assess compliance with regulatory standards including resident rights, care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, communication barriers, unresolved resident complaints, failure to notify physicians of significant weight loss, privacy concerns, environmental maintenance issues, abuse reporting and investigation failures, incomplete care plans, inadequate assistance with activities of daily living, hearing aid management, pressure ulcer care, nutritional monitoring, pain management, staffing shortages, CNA competency, food service and safety, and quality assurance program implementation.
Deficiencies (22)
Failure to provide resident dignity and respect related to clothing and personal belongings.
Failure to ensure communication needs met for a Spanish-speaking resident without use of interpreter services.
Failure to timely address and resolve resident complaints and grievances.
Failure to notify physician of significant weight loss and complete change of condition assessment.
Failure to ensure privacy during resident showers due to lack of communication system indicating shower use.
Environmental maintenance issues including disrepair of walls, window screens, blinds, and cluttered rooms.
Failure to timely report and investigate allegations of staff to resident abuse.
Failure to protect residents during abuse investigations and ensure mandated reporting.
Failure to develop comprehensive care plan addressing depression for a resident with documented PHQ-9 score.
Failure to provide assistance with activities of daily living including grooming and scheduled showers.
Failure to provide hearing aids or appropriate hearing amplification in a timely manner.
Failure to prevent development and progression of pressure ulcers and provide timely wound care.
Failure to maintain adequate nutritional status and timely intervene for severe weight loss.
Failure to provide timely pain management for residents with new onset pain.
Insufficient nursing staff to meet resident care needs including answering call lights, providing showers, and meal assistance.
Failure to conduct annual performance reviews for Certified Nursing Assistants.
Failure to follow proper food preparation procedures including pureeing, portion control, and gravy addition.
Failure to accommodate resident food preferences and provide appealing food options.
Failure to maintain food safety and sanitation including ice machine cleanliness, food cooling logs, food storage, equipment cleanliness, and proper plumbing air gaps.
Failure to implement policy for safe handling and storage of foods brought by family or visitors.
Failure to maintain trash bin lids in good condition to prevent pest infestation.
Failure to implement an effective Quality Assessment and Performance Improvement (QAPI) plan addressing key resident care concerns.
Report Facts
Weight loss: 12.8
Weight loss: 15
Weight loss: 17.2
CNA staffing: 4
CNA staffing: 3
CNA staffing: 3
CNA staffing: 2
CNA staffing: 4
CNA staffing: 4
Portion size: 4
Portion size: 3
Portion size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Assistant | Named in resident abuse complaint for rough care and withholding call light device |
| Social Services Director | Interviewed regarding clothing policies and abuse complaint handling | |
| Laundry Manager | Interviewed regarding clothing replacement process | |
| Administrator | Interviewed regarding clothing replacement and abuse complaint handling | |
| Director of Nursing | Interviewed regarding weight loss notification and abuse complaint handling | |
| Certified Nursing Assistant L | Interviewed regarding resident nail care | |
| Certified Nursing Assistant M | Interviewed regarding shower privacy and hearing impaired resident | |
| Certified Nursing Assistant H | Interviewed regarding hearing impaired resident and pain management | |
| Treatment Nurse LVN | Licensed Vocational Nurse | Interviewed regarding wound care and pressure ulcer |
| Director of Staff Development | Interviewed regarding CNA competencies and abuse training | |
| Certified Dietary Manager | Interviewed regarding food preparation and portion control | |
| Maintenance Assistant | Interviewed regarding ice machine cleaning | |
| Director of Maintenance | Interviewed regarding ice machine cleaning and kitchen equipment air gaps | |
| Director of Rehabilitation | Interviewed regarding abuse complaint reporting | |
| Licensed Vocational Nurse 2 | Interviewed regarding resident food preferences |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 14, 2023
Visit Reason
The inspection was conducted based on a complaint regarding the facility's failure to ensure the responsible party was informed of changes in Resident 1's plan of care related to psychotropic medication and concerns about behavioral health evaluations and unnecessary psychotropic medication use.
Complaint Details
The complaint investigation found that the facility did not obtain informed consent before administering lorazepam, failed to conduct behavioral health evaluations or psychiatric referrals for Resident 1, and administered unnecessary psychotropic medication without clinical justification, resulting in potential harm and risk of falls.
Findings
The facility failed to obtain informed consent before administering lorazepam to Resident 1, did not provide necessary behavioral health evaluations or psychiatric services, and administered an unnecessary psychotropic medication without clinical justification, putting Resident 1 at risk for adverse effects and falls.
Deficiencies (3)
Failed to ensure the responsible party was informed of a change in Resident 1's plan of care before administering psychotropic medication.
Failed to provide necessary behavioral health evaluation and services to meet Resident 1's psychiatric behavioral needs.
Failed to ensure Resident 1 was free from unnecessary psychotropic medication without clinical justification or consent.
Report Facts
Days lorazepam administered: 11
Psychotropic medications prescribed: 5
Anxious behaviors documented: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed informed consent was not obtained before administering lorazepam and facility policy was not followed; confirmed lack of psychiatric telehealth contract and no IDT psychotherapeutic reviews. |
| Pharmacy Consultant | Pharmacy Consultant (Pharm D) | Stated IDT should monitor psychotropic medications and confirmed lorazepam order lacked specific behavior justification. |
Inspection Report
Deficiencies: 1
Date: May 24, 2023
Visit Reason
The inspection visit was conducted to assess the facility's compliance with regulations regarding maintaining a safe, clean, comfortable, and homelike environment for residents.
Findings
The facility failed to maintain two shower rooms in a safe and clean condition, with tile in disrepair and dirty standing water present, which could promote the growth and spread of disease-causing germs and cause resident anxiety.
Deficiencies (1)
Tile in two shower rooms was in disrepair with worn white coating, large tan stains, blackened grout, and dirty standing water on the floor.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed the appearance of one of the shower rooms during observation and interview | |
| Certified Nursing Assistant (CNA) A | Confirmed the condition of a second shower room during observation and interview |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 8, 2023
Visit Reason
The inspection was conducted following a complaint regarding a resident bringing a firearm into the facility and concerns about food quality and meal delivery times.
Complaint Details
The visit was complaint-related due to a resident bringing a firearm into the facility and multiple complaints about food quality and meal delivery times. The firearm incident was substantiated with policy violations noted. Food complaints were supported by resident interviews and observations.
Findings
The facility failed to follow its firearms policy when a resident brought a gun into the facility, creating a potentially dangerous environment. Additionally, multiple residents reported that meals were often late, unpalatable, and difficult to eat, with observations confirming poor food quality and late delivery.
Deficiencies (2)
Failure to ensure the facility was free from accident hazards related to a resident bringing a firearm into the facility and not following the stated firearms policy.
Failure to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature, with multiple residents reporting tough, cold, or unpalatable food and frequent late meal delivery.
Report Facts
Residents sampled: 22
Residents affected: 8
Residents affected: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON A | Director of Nursing | Provided interviews regarding the firearm incident and food service issues |
| LVN B | Licensed Vocational Nurse | Provided interview about the firearm incident |
| DM C | Dietary Manager | Provided interview about meal service delays and food quality issues |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly review, revise, and implement a care plan for Resident 1 after a significant change in condition, which included oxygen requirement, increased insulin usage, and holding heart medications due to low blood pressure.
Complaint Details
The complaint investigation focused on Resident 1, who experienced a significant change in condition including shortness of breath requiring oxygen, elevated blood sugars, and low blood pressure leading to holding of heart medications. The facility failed to update the care plan, notify the physician fully, and monitor the resident adequately. This resulted in Resident 1's condition worsening and requiring ICU admission for severe sepsis and pneumonia.
Findings
The facility failed to ensure that Resident 1's care plan was updated by the interdisciplinary team following a significant change in condition. This failure led to inadequate monitoring, lack of communication with the physician, and delayed interventions, resulting in Resident 1's condition deteriorating and requiring emergency hospital admission to the ICU with diagnoses including sepsis and pneumonia.
Deficiencies (2)
Failure to develop and revise the complete care plan within 7 days of the comprehensive assessment by the interdisciplinary team after a significant change in Resident 1's condition.
Failure to recognize, monitor, and report a significant change in condition to the physician, resulting in delayed treatment and emergency transfer to acute care hospital.
Report Facts
Oxygen saturation: 83
Blood sugar readings: 400
Blood pressure: 99
Medication hold dates: 4
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN C | Licensed Nurse | Documented oxygen saturation and administered oxygen on 2/19/23; failed to perform SBAR and fully notify physician |
| Director of Nursing | Director of Nursing (DON) | Confirmed lack of care plan updates and SBAR documentation; confirmed failure to notify physician |
| LN B | Licensed Nurse | Notified Nurse Practitioner on 2/22/23; documented resident's deteriorating condition |
| Nurse Practitioner | Nurse Practitioner (NP) | Saw Resident 1 on 2/22/23; confirmed lack of full information from nursing staff |
| LN D | Licensed Nurse | Cared for Resident 1 on 2/20/23; did not notify physician despite abnormal findings |
| Resident 1's physician | Medical Doctor (MD) | Confirmed he was not fully informed of Resident 1's condition on 2/19/23 and would have sent resident to ER if fully informed |
| Administrator | Administrator | Described IDT process and reliance on SBAR documentation for identifying changes in condition |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Oct 16, 2019
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to obtain accurate code status and advance directives for residents, specifically Residents 212 and 106, potentially placing residents at risk for not having their healthcare decisions honored.
Complaint Details
The complaint investigation focused on the facility's failure to obtain accurate code status and advance directives for residents, specifically Residents 212 and 106, which posed a risk of not honoring residents' healthcare decisions.
Findings
The facility failed to obtain accurate Physician Orders for Life-Sustaining Treatment (POLST) and advance directives reflecting residents' wishes for two residents, R212 and R106. Additional deficiencies included failure to assess significant changes in condition, inaccurate Minimum Data Set (MDS) assessments, incomplete PASARR screenings, lack of care planning for edentulous residents, failure to provide adequate incontinence care, inadequate hand hygiene during wound care, and unsafe environmental conditions such as hazardous decorations and broken faucet knobs.
Deficiencies (9)
Failure to obtain accurate code status and advance directives for Residents 212 and 106.
Failure to assess significant change in condition for Resident 79.
Failure to ensure accurate Minimum Data Set (MDS) assessments for Residents 32 and 56.
Failure to ensure accurate PASARR screening for Residents 108, 40, and 65.
Failure to develop a care plan for edentulous Resident 70.
Failure to provide screening and/or services to regain lost function for Resident 79.
Failure to provide thorough incontinence care for dependent Resident 73.
Failure to perform effective hand hygiene during wound care for Resident 107.
Failure to maintain a safe environment including fire hazards in Resident 12's room and jagged faucet knobs in room shared by Residents 19 and 49.
Report Facts
Residents reviewed for advance directives: 39
Residents sampled: 23
Deficiencies cited: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 90 | Licensed Vocational Nurse | Entered DNR status for Resident 212 without contacting resident's representative. |
| RN 176 | Registered Nurse | Verified POLST form signature dates and lack of training on POLST completion. |
| Medical Records Director (MRD) 115 | Medical Records Director | Confirmed POLST, Advance Directive form, and admission forms were not completed timely. |
| Admission Coordinator 84 | Admission Coordinator | Verified Advance Directives and POLST were not completed upon admission and conflicting legal representative information. |
| Social Service Director | Social Service Director | Spoke with resident's family but did not confirm code status. |
| LVN 92 | Licensed Vocational Nurse | Confirmed POLST form was signed by physician but not resident's representative; checked code status for residents. |
| RN 130 | Registered Nurse | Signed POLST as person assisting with the form for Resident 106. |
| Director of Nursing (DON) | Director of Nursing | Expected nurses to determine resident capacity and complete POLST; stated hand hygiene expectations. |
| MDS Coordinator | MDS Coordinator | Verified coding errors in MDS assessments and PASARR screenings. |
| CNA 67 | Certified Nursing Assistant | Failed to provide thorough incontinence care for Resident 73. |
| LVN 91 | Licensed Vocational Nurse | Observed performing inadequate hand hygiene during wound care. |
| Maintenance Director | Maintenance Director | Identified fire hazard in Resident 12's room decorations. |
| Maintenance Supervisor | Maintenance Supervisor | Acknowledged failure to identify and repair jagged faucet knob posing risk to Residents 19 and 49. |
| Administrator | Administrator | Expected accurate PASARR completion and immediate repair of hazards. |
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