Inspection Report Summary
Most inspections found no deficiencies, reflecting a generally compliant facility with appropriate infection control, safety measures, and resident care practices. Several complaint investigations were unsubstantiated, including allegations of inadequate supervision, improper staff conduct, and facility disrepair. The one substantiated deficiency occurred in August 2025 when a medication error was reported involving a substitute technician giving medication to the wrong resident; this was addressed with staff training and improved procedures, and no harm resulted. The most recent report from September 4, 2025, was a complaint investigation that found no deficiencies and unsubstantiated allegations. Overall, the facility’s record shows mostly consistent compliance with isolated issues related to medication management that have been addressed.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
70% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 3, 2025
Visit Reason
The inspection was conducted following a complaint alleging verbal abuse by a Certified Nurses Assistant (CNA A) towards Resident 1, reported by Resident 2.
Complaint Details
The complaint was substantiated based on interviews and record reviews. Resident 2 reported observing CNA A verbally abusing Resident 1 on 11/3/2025 and 11/4/2025. Resident 1 and Resident 1's family member corroborated the report. CNA A admitted to the events but stated they were performing vital signs and assisting other residents.
Findings
The facility failed to ensure Resident 1 was treated with dignity and respect, as CNA A was observed verbally abusing Resident 1 on two occasions, denying timely assistance to the bathroom, and intimidating Resident 2 for reporting the incidents.
Deficiencies (1)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Report Facts
BIMS score: 14
BIMS score: 15
Date of incident: Nov 3, 2025
Date of incident: Nov 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurses Assistant | Named in verbal abuse and intimidation findings |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 80
Deficiencies: 0
Date: Sep 4, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff did not provide adequate supervision to a resident in care and did not seek medical attention in a timely manner.
Complaint Details
The complaint investigation was unsubstantiated regarding inadequate supervision and unfounded regarding failure to seek medical attention in a timely manner. The findings concluded there was no preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found that the facility staff checked on the resident at least every two hours and contacted hospice regularly regarding the resident's condition. The written plan of care required frequent checks but did not specify exact frequency. There was insufficient evidence to prove the allegations; therefore, both allegations were found to be unsubstantiated or unfounded.
Report Facts
Capacity: 80
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brandy Strahl | Administrator | Facility administrator met during the investigation |
| Troy Ordonez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 80
Deficiencies: 1
Date: Aug 19, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff mismanaged residents' medication.
Complaint Details
The complaint alleging staff mismanagement of residents' medication was substantiated based on the preponderance of evidence.
Findings
The investigation found that a substitute medication technician accidentally gave medication intended for one resident to another resident with the same first name. The incident was immediately reported and investigated, with no ill effects to the resident. Refresher training for staff and methods to flag residents with the same names were planned.
Deficiencies (1)
Failure to develop and implement a plan for incidental medical and dental care, resulting in a medication pass error posing an immediate health and safety risk to a resident.
Report Facts
Capacity: 80
Census: 54
Deficiency count: 1
Plan of Correction Due Date: Aug 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brandy Strahl | Administrator | Facility administrator interviewed during investigation and responsible for corrective actions |
| Troy Ordonez | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 20, 2025
Visit Reason
The inspection was conducted due to an allegation of resident-to-resident abuse involving Resident #123 and Resident #115, specifically regarding failure of staff to immediately report the alleged abuse.
Complaint Details
The complaint investigation was substantiated as the facility failed to immediately report an allegation of abuse from Resident #123 who alleged Resident #115 kicked them. Staff did not report the allegation because Resident #123 was confused and the CNA did not witness the incident.
Findings
The facility failed to ensure staff immediately reported an allegation of abuse for 1 of 1 incident of alleged resident-to-resident abuse. Additionally, the facility failed to accurately code Minimum Data Set (MDS) assessments for several residents and failed to provide adequate toenail care for Resident #7.
Deficiencies (3)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failure to accurately code the Minimum Data Set (MDS) for residents regarding Preadmission Screening and Record Review (PASRR) and dental concerns.
Failure to provide toenail care for Resident #7, whose toenails were painful, elongated, mycotic, and curled under the toes.
Report Facts
Residents reviewed for PASRR requirements: 2
Residents reviewed for dental concerns: 3
BIMS score: 8
BIMS score: 6
BIMS score: 11
BIMS score: 15
BIMS score: 14
Date of alleged abuse incident: Mar 17, 2025
Date of podiatric evaluation: Jan 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nursing Assistant | Did not report Resident #123's allegation of abuse because she did not see Resident #115 kick Resident #123 and stated Resident #123 was very confused. |
| Director of Nursing | Director of Nursing (DON) | Stated no staff members had reported hearing an allegation of abuse from Resident #123 and expected allegations of abuse to be reported immediately. |
| Administrator | Facility Administrator | Was not aware of the abuse allegation initially and expected immediate reporting of abuse allegations. |
| MDS Coordinator | MDS Coordinator | Responsible for coding MDS assessments and stated the facility did not have a policy regarding MDS accuracy. |
| Social Services Director | Social Services Director (SSD) | Responsible for coding PASRR status and relied on staff for resident information. |
| LVN #6 | Licensed Vocational Nurse | Completed dental/oral portion of MDS and confirmed Resident #16 had a broken tooth. |
| RN #1 | Registered Nurse | Accompanied observation of Resident #7's toenails and confirmed podiatrist visits approximately every three months. |
| LVN #2 | Licensed Vocational Nurse | Interviewed about Resident #7's toenail condition and care. |
| CNA #3 | Certified Nursing Assistant | Provided care to Resident #7 and observed toenail condition. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 20, 2025
Visit Reason
The inspection was conducted due to an allegation of resident-to-resident abuse where Resident #123 alleged that Resident #115 kicked them, and the facility failed to ensure immediate reporting of this allegation by staff.
Complaint Details
The complaint involved an allegation by Resident #123 that Resident #115 kicked them six times on 03/17/2025. The allegation was not immediately reported by staff, specifically CNA #4, who stated she did not report because Resident #123 was very confused and she did not witness the incident. The Administrator was unaware of the allegation until notified by the surveyor.
Findings
The facility failed to ensure staff immediately reported an allegation of abuse for one incident involving Resident #123 and Resident #115. Interviews and record reviews confirmed that a certified nursing assistant witnessed the allegation but did not report it because the resident was confused and the CNA did not see the incident.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
BIMS score: 8
BIMS score: 6
Number of times Resident #123 was kicked: 6
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 14, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide an environment free from accident hazards and to implement a plan of care to prevent wandering/elopement for Resident 4.
Complaint Details
The complaint investigation focused on Resident 4 who exited the facility unsupervised multiple times, including an incident on 01/12/25 where local law enforcement was called due to the resident attempting to enter the street. The resident had a history of psychosis and elopement behavior discussed at admission. Staff failed to reassess elopement risk timely and delayed implementation of a wander guard device.
Findings
The facility failed to develop and implement a plan of care to prevent Resident 4 from leaving the facility unsupervised, resulting in the resident exiting the facility and being found near a roadway. The investigation revealed inadequate risk assessment, delayed use of a wander guard device, and insufficient supervision despite known elopement risks.
Deficiencies (1)
Failure to develop and implement a plan of care to prevent wandering/elopement for Resident 4, resulting in the resident leaving the facility unsupervised and at risk of harm.
Report Facts
Elopement risk score: 0
Date of clinical note: Jan 1, 2025
Date of elopement evaluation: Jan 2, 2025
Date of care plan initiation: Jan 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Observed Resident 4's elopement risk and behavior; confirmed risk should have been reassessed. |
| DON | Director of Nursing | Acknowledged Resident 4's room placement near exit and delay in applying wander guard device; confirmed no care conference was done during admission. |
| LN C | Licensed Nurse | Reported Resident 4 was confused and ran out of the building, requiring intervention. |
| CNA A | Certified Nurse Assistant | Stopped Resident 4 from leaving the facility and called law enforcement for assistance. |
Inspection Report
Annual Inspection
Census: 54
Capacity: 80
Deficiencies: 0
Date: Jan 22, 2025
Visit Reason
Licensing Program Analysts arrived unannounced to conduct an annual inspection to ensure compliance with Title 22 regulations.
Findings
The inspection found the facility compliant with no deficiencies cited. The facility had adequate food supplies, operational safety detectors, secured medication storage, and reviewed resident and staff files.
Report Facts
Resident rooms: 54
Perishable food supply: 2
Non-perishable food supply: 7
Resident files reviewed: 5
Staff files reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Strahl | Administrator | Met with Licensing Program Analysts during inspection |
| Cassandra Mikkelson | Licensing Program Analyst | Conducted the annual inspection |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Monitoring
Census: 56
Capacity: 80
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
This unannounced case management visit was conducted in response to the facility submitting a death report.
Findings
The licensing program analyst obtained a copy of some documents from the resident's file. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Strahl | Administrator/Director | Met with during the inspection visit |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the unannounced case management visit |
| Troy Ordonez | Licensing Program Manager | Named in the report |
Inspection Report
Annual Inspection
Census: 56
Capacity: 80
Deficiencies: 0
Date: Jan 17, 2024
Visit Reason
This was an unannounced annual visit conducted as a required one-year inspection of the facility.
Findings
The inspection found no deficiencies. Several staff and resident files were reviewed, and multiple topics were discussed during the visit.
Report Facts
Resident rooms: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Strahl | Administrator | Met with during the inspection and toured the facility |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 80
Deficiencies: 0
Date: Sep 27, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff forced a resident to take medication.
Complaint Details
The complaint alleged that staff forced a resident to take medication. The investigation found conflicting statements between staff and resident regarding medication administration, resulting in an unsubstantiated finding.
Findings
The Licensing Program Analyst conducted interviews and reviewed medication records but could not prove or disprove the allegation due to conflicting accounts. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 80
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Ordonez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 80
Deficiencies: 0
Date: Sep 27, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to a complaint received on 2023-08-25 alleging that staff spoke inappropriately to a resident.
Complaint Details
The complaint alleged that staff spoke inappropriately to a resident. The allegation was investigated and found to be unsubstantiated.
Findings
The investigation found that the staff denied any ill intent and the resident felt humiliated by the staff's loud and boisterous voice. No witnesses could be contacted, and the Licensing Program Analyst was unable to prove or disprove the allegation. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Brandy Strahl | Administrator | Named as facility administrator. |
| Jamie Scott | Met with during the investigation. | |
| Troy Ordonez | Licensing Program Manager | Named in report signature section. |
Inspection Report
Routine
Deficiencies: 11
Date: Apr 20, 2023
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including medication management, food and nutrition services, and facility safety.
Findings
The facility was found deficient in multiple areas including medication privacy breaches, pharmaceutical service lapses, expired and improperly labeled medications, inadequate food and nutrition service oversight, poor food safety and sanitation practices, lack of staff training and competency, failure to meet dietary needs and preferences, unsafe food storage, and maintenance issues in the kitchen and food service areas.
Deficiencies (11)
Medication blister packs with resident personal information were left unattended on a medication cart in a hallway, violating privacy.
Emergency Kit was not replaced within 72 hours after being opened, risking insufficient emergency medication supply.
Expired medications were not removed from the medication cart and several medications lacked open date labels.
Facility failed to employ sufficient qualified food and nutrition staff and lacked adequate oversight of food safety and sanitation.
Food and Nutrition Services staff lacked training and competency; poor hand hygiene, glove use, hair restraint, and sanitation were observed.
Menus and diet manuals were not reviewed or signed by the Registered Dietitian; fortified diets and vegetarian menus were inadequate or inconsistent.
Resident meals did not consistently meet dietary orders; some residents received unwanted or inappropriate foods.
Food safety and sanitation practices were inadequate, including improper hand hygiene, glove use, hair covering, food storage, cleaning, and pest control.
Dishwasher final rinse temperature was not displayed and sanitizer concentration was inconsistently tested and maintained.
Cold food preparation room temperature was excessively high and kitchen maintenance issues included peeling paint, damaged drywall, and ceiling leaks.
Pest control was inadequate with live and dead ants found in kitchen and nursing unit food storage areas.
Report Facts
Expired medications: 4
Fortified diet residents receiving whole milk instead of skim milk: 6
Vegetarian meals containing curry: 37
Room temperature in cold food prep room: 84.2
Sanitizer concentration: 100
Sanitizer concentration: 300
Dishwasher wash temperature: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Acknowledged medication privacy breach and pharmacy refill issues. |
| Licensed Nurse 1 | Licensed Nurse (LN) | Acknowledged expired medications and E-Kit renewal delays. |
| Food Service Director | Food Service Director (FSD) | Provided information on food service operations, sanitizer testing, and kitchen maintenance. |
| Registered Dietitian | Registered Dietitian (RD) | Discussed diet manual, food service oversight, and diet order inconsistencies. |
| Interim Food Service Manager | Interim Food Service Manager (IFSM) | Discussed food service staff training and kitchen sanitation. |
| Dietary Aide 1 | Dietary Aide (DA 1) | Described food preparation practices and acknowledged lack of temperature logs. |
| Dishwasher 2 | Dishwasher (DW 2) | Described dishwasher operation and sanitizer testing. |
| Dietary Aide 3 | Dietary Aide (DA 3) | Demonstrated sanitizer testing and cleaning procedures. |
| Food Service Manager | Food Service Manager (FSM) | Discussed sanitizer testing and food service contractor transition. |
| Housekeeping Head | Head of Housekeeping (HHSK) | Discussed cleaning responsibilities for nursing unit pantries. |
| Quality Compliance Analyst | Maintenance Staff | Discussed pest control and facility maintenance. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 80
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff caused a resident to fall while in care and that the facility does not have backup emergency services for residents.
Complaint Details
The complaint investigation was unannounced and conducted by Evaluator Kerry Hiratsuka. The allegation that staff caused a resident to fall was unsubstantiated due to insufficient evidence. The allegation that the facility lacks backup emergency services was found to be unfounded as the facility has appropriate emergency plans and procedures.
Findings
The investigation found the allegation that staff caused a resident to fall while in care to be unsubstantiated due to conflicting accounts and lack of evidence. The complaint regarding lack of backup emergency services was found to be unfounded as the facility has a written emergency plan and complies with regulations.
Report Facts
Capacity: 80
Census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Hiratsuka | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Carol Pickard | Administrator | Facility administrator mentioned in the report |
| Brandy Strahl | Person met with during the investigation | |
| Lauren Crocker | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 23, 2023
Visit Reason
The inspection was conducted due to a complaint alleging that a resident was assaulted by an employee, and the facility failed to remove the employee from resident care during the investigation.
Complaint Details
The complaint was substantiated based on interviews and record review indicating that Resident 1 was assaulted by a Certified Nursing Assistant (CNA A) who was not suspended but reassigned during the investigation period from 6/28/22 to 7/3/22.
Findings
The facility failed to protect Resident 1 from abuse when a staff member allegedly assaulted him and was not suspended during the investigation but reassigned to another area. The investigation lasted from 6/28/22 to 7/3/22, and the accused employee continued working with residents during this period.
Deficiencies (1)
Failure to remove an employee from resident care during an abuse investigation after Resident 1 reported assault by the employee.
Report Facts
Investigation timeframe (days): 6
Staff assignment days: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in abuse allegation and investigation |
| DSD A | Director of Staff Development | Provided interview details about the abuse allegation and investigation |
Inspection Report
Deficiencies: 0
Date: Mar 21, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for The Fountains nursing home, summarizing the results of a regulatory survey completed on 2023-03-21.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Census: 54
Capacity: 80
Deficiencies: 0
Date: Dec 20, 2022
Visit Reason
This was an unannounced annual inspection visit conducted as a required one-year evaluation of the facility.
Findings
The inspection found no deficiencies. The facility was observed to have appropriate infection control measures with staff wearing surgical masks, and the physical environment was described in detail.
Report Facts
Resident rooms: 54
Restrooms: 2
Inspection Report
Complaint Investigation
Census: 54
Capacity: 80
Deficiencies: 0
Date: Dec 16, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-09-22 alleging multiple issues including improper staff training, unattended residents, untimely response to alerts, retention of residents needing higher care, uncomfortable accommodations, and forced early sleeping.
Complaint Details
The complaint investigation was unannounced and addressed allegations of improper staff training, unattended residents, untimely response to alerts, retention of residents requiring higher care, uncomfortable accommodations, forced early sleeping, denial of restroom use, lack of privacy, residents left soiled, falls, and delayed medical attention. The findings determined the allegations were unfounded or unsubstantiated due to lack of evidence and interviews.
Findings
The investigation found all allegations to be unfounded or unsubstantiated. Staff training met requirements, residents and staff interviews indicated no issues with supervision or care, and no evidence supported the complaint allegations.
Report Facts
Capacity: 80
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Pickard | Administrator | Facility administrator met during the investigation |
| Kerry Hiratsuka | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Troy Ordonez | Licensing Program Manager | Manager overseeing the complaint investigation |
Inspection Report
Census: 54
Capacity: 80
Deficiencies: 0
Date: Nov 2, 2022
Visit Reason
This unannounced case management visit was conducted in response to an incident reported to the Licensing Program Analyst (LPA) while conducting an annual inspection at the sister facility. The visit addressed the evacuation of the facility due to smoke in the building earlier that morning.
Findings
The facility was evacuated at approximately 6:30 AM due to smoke, with residents outside for about fifteen minutes. The fire department cleared the building for re-occupation, and all residents returned inside. The licensee's engineering staff checked and cleared the building, and emergency evacuation procedures were properly conducted. No residents or staff were injured during the evacuation. No deficiencies were cited.
Report Facts
Evacuation duration (minutes): 15
Time of evacuation: 630
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Pickard | Administrator | Met with during the visit and mentioned in the incident report |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the unannounced case management visit |
| Troy Ordonez | Licensing Program Manager | Named in the report header |
Inspection Report
Census: 51
Capacity: 80
Deficiencies: 0
Date: Jul 13, 2022
Visit Reason
The visit was an unannounced Case Management - Incident visit conducted in response to an incident reported by the Director of Assisted Living Services regarding a resident who died unexpectedly on 2022-07-06.
Findings
The Licensing Program Analyst discussed the incident with the facility representative and determined that no extra documentation was required at this time, but further investigation is needed. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Pickard | Director of Assisted Living Services | Reported the incident of a resident's unexpected death. |
| Kerry Hiratsuka | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Troy Ordonez | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 22
Capacity: 80
Deficiencies: 0
Date: Jan 4, 2022
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain as part of the annual case management continuation.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Pickard | Administrator | Met with Licensing Program Analyst during inspection and involved in infection control domain review. |
| Dawn Keane | Licensing Program Analyst | Conducted the inspection and infection control domain review. |
Inspection Report
Annual Inspection
Census: 48
Capacity: 80
Deficiencies: 0
Date: Dec 22, 2021
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure health and safety compliance at the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Pickard | Administrator | Met with Licensing Program Analyst during inspection and involved in infection control domain completion. |
| Dawn Keane | Licensing Program Analyst | Conducted the Required-1 Year Inspection and infection control domain evaluation. |
| Rayna L Bryson | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Routine
Deficiencies: 12
Date: May 6, 2021
Visit Reason
The inspection was a routine survey of The Fountains nursing home to assess compliance with regulatory requirements related to resident care, safety, abuse prevention, fall prevention, dental care, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to honor resident care plan participation and CPR wishes, inadequate cleaning of shower rooms, failure to prevent and report resident-to-resident abuse, failure to update care plans after falls, inadequate supervision and safety devices for fall prevention, failure to ensure staff competency in CPR wishes, failure to provide routine dental care, food safety violations, and failure to perform proper hand hygiene during wound care.
Deficiencies (12)
Failed to include Resident 101 in quarterly care plan meetings resulting in potential unwanted CPR.
Failed to provide a sanitary environment in shower room NS1, including feces on shower chair and floor.
Failed to protect residents from abuse by Resident 118 wandering into rooms uninvited causing anxiety and risk of injury.
Failed to timely report suspected resident-to-resident abuse involving Resident 118 to required agencies.
Failed to investigate resident-to-resident abuse involving Resident 118.
Failed to develop and update care plans with effective fall prevention interventions for Residents 26, 66, 110, and 118.
Failed to ensure Resident 26 and Resident 66 had functional anti-rollback devices on wheelchairs and proper fall prevention measures.
Failed to ensure adequate supervision and accident hazard prevention for Resident 118 with multiple falls.
Failed to ensure CNAs CNA Q and CNA P were competent to locate and honor residents' CPR wishes.
Failed to provide routine dental care for five sampled residents resulting in pain, choking risk, and unnecessary therapeutic diets.
Failed to maintain ice machine in sanitary condition, failed to discard expired food, and failed to cover food during transport.
Failed to ensure licensed vocational nurse performed hand hygiene between changing soiled and clean gloves during wound care.
Report Facts
Residents affected: 2
Residents affected: 3
Incidents of resident to resident abuse: 6
Falls: 7
Falls: 5
Falls: 12
Fall risk assessment score: 27
Fall risk assessment score: 24
Years CNA experience: 10
Date survey completed: May 6, 2021
Use by date: Apr 30, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN L | Licensed Vocational Nurse | Documented multiple resident abuse incidents involving Resident 118 |
| Director of Nursing | Director of Nursing | Admitted lack of awareness and failure to report resident abuse involving Resident 118 |
| CNA T | Certified Nursing Assistant | Reported Resident 118 wandering into rooms uninvited |
| CNA Q | Certified Nursing Assistant | Unable to locate resident CPR wishes and verbalized starting CPR on DNR resident |
| CNA P | Certified Nursing Assistant | Unable to locate resident CPR wishes and verbalized starting CPR on DNR resident |
| Infection Preventionist | Infection Preventionist | Confirmed lack of CPR drills and education lapse |
| LVN K | Licensed Vocational Nurse | Failed to perform hand hygiene between glove changes during wound care |
| Director of Rehabilitation | Director of Rehabilitation | Recommended gait belt use for Resident 26 transfers |
| Social Worker | Social Worker | Discussed dental care follow-up issues |
| Registered Dietitian | Registered Dietitian | Assessed residents' swallowing and dentition issues |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 80
Deficiencies: 0
Date: Feb 23, 2021
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 12/18/2020 regarding the facility being in disrepair.
Complaint Details
The complaint alleged that the facility was in disrepair. After investigation, the complaint was found to be unsubstantiated due to lack of preponderance of evidence.
Findings
The Licensing Program Analyst concluded that the complaint was unsubstantiated after interviews and investigation, finding no evidence of violations. No deficiencies were cited.
Report Facts
Capacity: 80
Census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Misty Valencia | Licensing Program Analyst | Conducted the complaint investigation and concluded findings |
| Carol Pickard | Administrator | Facility administrator interviewed during investigation |
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