Inspection Reports for
Walnut Creek Skilled Nursing & Rehabilitation Center
1224 Rossmoor Pkwy, Walnut Creek, CA 94595, CA, 94595
Back to Facility ProfileCitations (last 5 years)
Citations (over 5 years)
15.6 citations/year
Citations are regulatory findings recorded during state inspections.
290% worse than California average
California average: 4 citations/yearCitations per year
36
27
18
9
0
Occupancy
Latest occupancy rate
69% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Citations: 3
Date: Jun 13, 2025
Visit Reason
The inspection was conducted following complaints regarding the facility's failure to respect residents' rights to personal belongings, dignity in care, and timely notification of family members about changes in residents' conditions.
Complaint Details
The visit was complaint-related involving grievances from family members about missing personal items, disrespectful care practices, and failure to notify family of significant changes in resident condition. Substantiation status is not explicitly stated.
Findings
The facility failed to maintain Resident 53's personal belongings securely, causing distress to the family; failed to treat Resident 127 with respect and dignity by placing rolled towels in briefs causing emotional distress; and failed to notify Resident 23's representative promptly about vomiting prior to hospital transfer, potentially delaying interventions.
Citations (3)
Failure to respect Resident 53's right to maintain personal belongings securely, resulting in missing transfer sling, wheelchair, and shoes.
Failure to treat Resident 127 with respect and dignity when rolled towels were placed inside briefs, causing emotional distress.
Failure to notify Resident 23's representative of vomiting prior to hospital transfer, potentially delaying interventions.
Report Facts
Residents sampled: 18
Residents sampled: 7
Residents sampled: 4
BIMS score: 15
Temperature: 100.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 4 | Certified Nursing Assistant | Mentioned in relation to Resident 53's missing transfer sling |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Mentioned in relation to placing rolled towels in Resident 127's briefs |
| Certified Nursing Assistant 3 | Certified Nursing Assistant | Mentioned in relation to Resident 127's discomfort and rolled towels |
| Unit Manager | Unit Manager | Stated that placing rolled towels in briefs was inappropriate and that family should be notified of condition changes |
| Social Services Assistant | Social Services Assistant | Discussed reimbursement and missing items for Resident 53 |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed Resident 23's representative and notification issues |
Inspection Report
Routine
Citations: 10
Date: Jun 13, 2025
Visit Reason
Routine inspection of Walnut Creek Skilled Nursing & Rehabilitation Center to assess compliance with regulatory standards including resident rights, care, safety, infection control, medication management, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to respect residents' rights to personal belongings, inadequate care leading to emotional distress, failure to notify representatives of condition changes, unsanitary environment with unclean mattresses, inadequate grooming and hygiene care, failure to provide prescribed range of motion therapy, insufficient behavioral health care for suicidal residents, improper medication administration without pain indication, unsafe food handling practices, and failure to implement infection prevention protocols with appropriate PPE use.
Citations (10)
F 0557: The facility failed to respect Resident 53's right to maintain personal belongings securely when the resident's transfer sling, wheelchair, and shoes were missing, causing distress to the family.
F 0557: The facility failed to treat Resident 127 with respect and dignity when rolled towels were placed inside the resident's briefs, causing emotional distress.
F 0580: The facility failed to notify Resident 23's representative of vomiting on 4/5/25, resulting in delayed hospital transfer and potential delayed interventions.
F 0584: The facility failed to provide a clean, sanitary, and homelike environment for five residents when whitish grime, stains, and dried matter were observed on mattresses.
F 0677: The facility failed to provide necessary grooming care when Residents 60 and 142 had long fingernails, placing them at risk for skin irritation and infection.
F 0688: The facility failed to provide appropriate restorative nursing services to Residents 60, 120, and 126, resulting in potential further decline in range of motion.
F 0740: The facility failed to provide necessary behavioral health care for Residents 101 and 210, including lack of immediate intervention for suicidal ideation and failure to investigate a wrist wound.
F 0757: The facility failed to ensure Residents 138 and 49 were given pain medications only when indicated, administering routine pain meds without documented pain, risking masking symptoms.
F 0812: The facility failed to prevent cross-contamination when a food service worker touched ready-to-eat food with the same gloved hand used to handle oven equipment.
F 0880: The facility failed to implement infection prevention protocols when staff did not wear appropriate PPE while providing care to residents on enhanced barrier precautions.
Report Facts
Residents sampled: 18
Residents sampled: 7
Residents sampled: 4
Residents sampled: 5
Residents sampled: 3
Residents sampled: 31
Weight loss: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Reported Resident 101 feeling suicidal but took no further action |
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse | Cared for Resident 101 and reported no concerns about mental health status |
| Unit Manager | Unit Manager | Received report of Resident 101's depression and requested psychological referral |
| Restorative Nurse Assistant 1 | Restorative Nurse Assistant / Certified Nursing Assistant | Noted Residents 60 and 142 had long fingernails needing trimming |
| Director of Nursing | Director of Nursing | Stated nurses should clarify pain medication orders and wear PPE in subacute unit |
| Licensed Vocational Nurse 6 | Licensed Vocational Nurse | Administered pain medications to Resident 138 without pain indication |
| Licensed Vocational Nurse 4 | Licensed Vocational Nurse | Acknowledged routine administration of pain meds to Resident 138 without pain |
| Licensed Vocational Nurse 7 | Licensed Vocational Nurse | Administered Acetaminophen to Resident 49 as scheduled |
| Licensed Vocational Nurse 5 | Licensed Vocational Nurse | Administered Acetaminophen routinely for Resident 49 |
| Respiratory Therapist 1 | Respiratory Therapist | Did not wear gown while suctioning Resident 125 on enhanced barrier precaution |
| Certified Nursing Assistant 5 | Certified Nursing Assistant | Did not wear PPE while providing care to Resident 46 on enhanced barrier precaution |
| Infection Preventionist | Infection Preventionist | Reported PPE noncompliance risk in subacute unit |
Inspection Report
Annual Inspection
Census: 105
Capacity: 153
Citations: 0
Date: May 23, 2025
Visit Reason
The inspection was conducted as a Case Management - Annual Continuation of the Required 1 Year inspection to review compliance with licensing requirements.
Findings
The Licensing Program Analyst reviewed 5 resident and 5 staff records during an unannounced visit. No citations or deficiencies were issued during this inspection.
Report Facts
Resident records reviewed: 5
Staff records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the inspection and reviewed records |
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 105
Capacity: 153
Citations: 0
Date: May 22, 2025
Visit Reason
The inspection was an unannounced Required 1 Year inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The inspection found the facility to be in compliance with no citations issued. The facility had adequate food supplies, locked medication storage, inaccessible cleaning supplies and dangerous objects, working smoke and carbon monoxide detectors, and properly serviced fire extinguishers. The indoor temperature and hot water temperature were within acceptable ranges. Disaster and fire drills were conducted monthly.
Report Facts
Capacity: 153
Census: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the inspection and informed the Executive Director of the visit purpose |
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during inspection |
| Monique S Bindra | Administrator/Director | Named as facility administrator/director |
Inspection Report
Complaint Investigation
Citations: 1
Date: Apr 21, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure resident privacy during care transfers.
Complaint Details
The complaint investigation found that Resident 1 was exposed during transfers in the hallway without privacy curtains, and the Director of Nursing confirmed that residents have an expectation of privacy which was not met. Resident 1's care plan required mechanical lift transfers with two-person assist.
Findings
The facility failed to ensure Resident 1's privacy during transfer from a shower chair to his room, exposing his genitals in the hallway without adequate covering or use of privacy curtains. This posed potential psychosocial harm to the resident.
Citations (1)
F 0583: The facility failed to keep residents' personal and medical records private and confidential by not adequately covering Resident 1's genitals during transfer, exposing them in the hallway. This failure had potential for psychosocial harm when Resident 1 was visibly exposed and agitated.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) 1 | Observed and interviewed regarding Resident 1's transfer and privacy issues. | |
| Director of Nursing (DON) | Interviewed and stated residents have an expectation of privacy which was not met. |
Inspection Report
Citations: 1
Date: Apr 21, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with privacy and confidentiality standards during resident care, specifically regarding the handling and transfer of Resident 1.
Findings
The facility failed to ensure Resident 1's privacy during transfer from a shower chair to his room, as his genitals were exposed and visible in the hallway without adequate covering, causing potential psychosocial harm. The facility acknowledged the issue and referenced policies supporting resident privacy rights.
Citations (1)
Failure to ensure Resident 1 had privacy during care when transferred without adequately covering genitals, resulting in exposure in the hallway.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Observed transferring Resident 1 without adequate privacy |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident privacy expectations |
Inspection Report
Complaint Investigation
Citations: 2
Date: Apr 17, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding medication administration errors for Resident 1, specifically the failure to administer Midodrine HCL as ordered by the physician on multiple occasions.
Complaint Details
The complaint investigation focused on medication administration errors for Resident 1. The failure to administer Midodrine HCL as ordered was substantiated. Interviews with nursing staff and administration confirmed the medication was held incorrectly when Resident 1's systolic blood pressure was exactly 140, contrary to physician orders. Resident 1 and the responsible party corroborated the missed doses and impact on therapy participation.
Findings
The facility failed to ensure that Resident 1 received Midodrine HCL medication as prescribed, holding doses on 2/16/2025, 2/20/2025, and 2/21/2025 despite physician orders. This failure increased the risk of symptoms related to low blood pressure, including dizziness, decreased activity, increased fall risk, and possible hospitalization.
Citations (2)
F 0726: The facility failed to ensure nurses and nurse aides had the appropriate competencies to administer medications as ordered, resulting in Resident 1 not receiving Midodrine HCL on multiple occasions despite physician orders.
F 0760: The facility failed to ensure Resident 1 was free from significant medication errors when Midodrine HCL was held and not administered on multiple occasions, causing potential harm including increased fall risk and decreased participation in therapy.
Report Facts
Medication doses held: 3
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 2 | Licensed Vocational Nurse | Named in medication error finding for holding Resident 1's Midodrine medication without notifying physician |
| LVN 1 | Licensed Vocational Nurse | Primary charge nurse on 2/20/2025 who did not administer medication; LVN 2 stepped in to help |
| Unit Supervisor | Interviewed regarding medication administration and facility expectations | |
| Administrator | Interviewed regarding adherence to physician orders |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 153
Citations: 0
Date: Mar 26, 2025
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that staff does not ensure residents' rooms are clean.
Complaint Details
The complaint alleged that staff does not ensure residents' rooms are clean. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that although there was an unexpected staff shortage and staff were moved around with additional staff brought in to ensure rooms were deep cleaned at least once a week, the data collected did not confirm the allegation. Therefore, the allegation was unsubstantiated.
Report Facts
Capacity: 153
Census: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Monique Bindra | Executive Director | Interviewed during the investigation |
Inspection Report
Complaint Investigation
Citations: 1
Date: Sep 5, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to honor Resident 3's right to choose healthcare providers, specifically concerning medication administration by a nurse the resident had refused.
Complaint Details
The complaint was substantiated. Resident 3 refused care from RN1, but RN1 administered medications anyway, causing emotional distress and inability to sleep. Staff interviews confirmed the refusal and the nurse's failure to switch assignments despite opportunities.
Findings
The facility failed to ensure Resident 3's right to refuse care from a specific nurse was respected, resulting in the nurse administering medications despite the resident's refusal, causing emotional distress. Interviews with staff and the resident confirmed the incident and lack of policy on refusal of staff.
Citations (1)
Failure to honor Resident 3's right to choose health care and providers of health care services, resulting in emotional distress.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Named in medication administration refusal and care incident with Resident 3. |
| SAM | Sub-Acute Manager | Provided information on Resident 3's history of refusing new staff. |
| CNA1 | Certified Nursing Assistant | Witnessed RN1 administering medication and Resident 3's emotional reaction. |
| ADM | Administrator | Commented on the facility's lack of specific policy and the right of residents to refuse staff. |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 153
Citations: 0
Date: Aug 6, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-01-05 regarding staff not preventing a resident from sustaining a fracture, inadequate staffing, and not serving nutritious meals.
Complaint Details
The complaint alleged staff did not prevent a resident from sustaining a fracture, inadequate staffing, and poor nutrition. The investigation found no substantiation for these allegations.
Findings
The investigation included interviews and record reviews and found that the resident who sustained a fracture was independent and the fall was the first time the resident tried to leave the facility at night. Staffing was adequate with timely response to alarms, and meals served were nutritious. The allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 153
Resident census: 108
Complaint receipt date: Jan 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Monique Bindra | Executive Director | Interviewed during the investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 153
Citations: 0
Date: Jul 12, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff were not providing residents adequate food service.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violation occurred.
Findings
The investigation included a tour of the kitchen, review of menus, and interviews with residents who expressed satisfaction with the food service. There was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.
Report Facts
Complaint Control Number: 15-AS-20240703135252
Capacity: 153
Census: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kaila Homolka | Maintenance Director | Met with Licensing Program Analyst during the investigation |
| Alona Gomez | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Citations: 1
Date: Jun 20, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide a Mechanical Lifting Device (MLD) sling, resulting in a resident being unable to be transferred from bed to chair for two days.
Complaint Details
The complaint was substantiated as the facility lacked sufficient MLD slings, confirmed by interviews with Resident 1, Certified Nurse Assistants, and the Administrator.
Findings
The facility failed to ensure the availability of MLD slings, causing Resident 1 to remain in bed for two days, potentially leading to pressure ulcers and mental health issues. Interviews with staff and the administrator confirmed the lack of sufficient slings.
Citations (1)
Failure to provide a Mechanical Lifting Device sling, resulting in Resident 1 staying in bed for two days and potential harm.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant 1 | Certified Nurse Assistant | Stated the facility did not have enough slings and Resident 1 had to stay in bed for two days. |
| Certified Nurse Assistant 2 | Certified Nurse Assistant | Stated some residents had to stay in bed for a long time due to lack of slings. |
| Administrator | Administrator | Acknowledged the lack of slings and stated all residents needing slings should have access. |
Inspection Report
Complaint Investigation
Citations: 1
Date: Jun 11, 2024
Visit Reason
The inspection was conducted due to a complaint regarding failure to provide appropriate pain management to a resident who required such services.
Complaint Details
The complaint investigation found that Resident 1 did not receive pain medication for 13 hours on the night of admission due to medication prescription issues. Interviews with nursing staff and the Director of Nursing confirmed the failure to manage pain and lack of documentation. The resident reported severe pain and feeling neglected.
Findings
The facility failed to manage pain for one resident who did not receive pain medication as desired for 13 hours, resulting in severe pain and a feeling of neglect. Interviews and record reviews confirmed the lack of timely pain medication administration and inadequate documentation.
Citations (1)
Failure to provide safe, appropriate pain management for a resident requiring such services, resulting in severe pain and neglect.
Report Facts
Duration without pain medication: 13
Pain scale scores: 9
Pain scale scores: 8
Pain scale scores: 7
Pain scale score: 4
Pain scale score: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse (LVN) | Admitted Resident 1 and stated pain medication was not available; administered Tylenol and ice pack |
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse (LVN) | Charge nurse during Resident 1's admission; unable to recall giving pain medication |
| Director of Nursing | Director of Nursing (DON) | Stated LVN 1 should have addressed Resident 1's pain and found no documentation of pain management |
Inspection Report
Complaint Investigation
Citations: 1
Date: May 30, 2024
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to provide emergency basic life support, including CPR, to a resident who was found without a pulse and no spontaneous respiration.
Complaint Details
The complaint investigation found that the facility did not initiate CPR promptly for Resident 1, who was full code. Interviews with staff revealed delays in calling a code and starting chest compressions. The resident was pronounced deceased 42 minutes after being found without a pulse. The complaint was substantiated with findings of delayed emergency response.
Findings
The facility failed to provide timely emergency basic life support to Resident 1, who was found with no pulse and no spontaneous respiration. Despite the resident's full code status, there was a delay in initiating CPR and calling a code, resulting in the resident being pronounced deceased 42 minutes after being found unresponsive.
Citations (1)
Failure to provide emergency basic life support, including CPR, prior to the arrival of emergency medical personnel as per physician orders and resident's advance directives.
Report Facts
Time until resident pronounced deceased: 42
Time resident pronounced deceased: 5.52
Time paramedics arrived: 5.2
Time code called: 5.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) 1 | Interviewed regarding the delayed CPR and code response for Resident 1 | |
| Respiratory Therapist (RT) 1 | Interviewed regarding the events during Resident 1's code; found bagging Resident 1 but did not start chest compressions | |
| Respiratory Therapist (RT) 2 | Interviewed regarding the events during Resident 1's code; assisted in resuscitation efforts | |
| Respiratory Therapist (RT) 3 | Entered Resident 1's room and started chest compressions |
Inspection Report
Annual Inspection
Census: 106
Capacity: 153
Citations: 0
Date: May 1, 2024
Visit Reason
The inspection was an unannounced required annual inspection of the facility conducted by the Licensing Program Analyst.
Findings
The Licensing Program Analyst inspected the physical plant, verified staff training and emergency preparedness, reviewed resident and staff files, and found no citations issued during the inspection.
Report Facts
Fire extinguisher last serviced date: Jan 3, 2024
Fire suppression system inspection dates: Jan 3, 2024
Fire alarm inspection date: Feb 22, 2024
Resident files reviewed: 5
Staff files reviewed: 5
Staff interviewed: 5
Residents interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monique Bindra | Executive Director | Met with Licensing Program Analyst during inspection |
| James Sampair | Licensing Program Analyst | Conducted the inspection |
| Harpreet Humpal | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 153
Citations: 0
Date: Apr 29, 2024
Visit Reason
The visit occurred to deliver amended findings related to a complaint (15-AS-20230718113231) at the facility.
Complaint Details
The visit was related to complaint 15-AS-20230718113231. Amended findings were delivered during the unannounced visit.
Findings
The Licensing Program Analyst delivered amended findings from previous reports dated 7/25/2023 and 7/26/2023, which were signed by the Executive Director. An exit interview was conducted and a copy of the report was provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monique Bindra | Executive Director | Met during the visit and signed amended findings. |
| James Sampair | Licensing Program Analyst | Conducted the unannounced visit and delivered amended findings. |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Citations: 2
Date: Mar 20, 2024
Visit Reason
The inspection was conducted following complaints regarding the facility's failure to provide adequate assistance to a resident dependent on staff for eating and activities of daily living.
Complaint Details
The complaint was substantiated based on interviews and record reviews showing Resident 1 was not fed during a special event and was left wet due to delayed assistance with catheter care. Resident 1 expressed feelings of neglect and unfair treatment.
Findings
The facility failed to ensure Resident 1 was treated with dignity and respect during a candlelight dinner by not providing feeding assistance. Additionally, the facility failed to provide timely assistance with activities of daily living, resulting in Resident 1 being left wet from an overflowing catheter bag and feeling neglected.
Citations (2)
F 0550: The facility failed to honor Resident 1's right to dignity and respect by not providing feeding assistance during the candlelight dinner, causing the resident to feel neglected and left out.
F 0677: The facility failed to provide timely assistance with activities of daily living for Resident 1, resulting in an overflowing urinary catheter bag and compromised dignity and comfort.
Report Facts
Residents sampled: 4
Residents affected: 1
BIMS score: 15
MDS date: Jan 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in feeding assistance deficiency and interview regarding candlelight dinner |
| CNA 2 | Certified Nursing Assistant | Named in delayed assistance with catheter care and ADL support |
| CNA 3 | Certified Nursing Assistant | Named in assignment changes and lack of timely care for Resident 1 |
| LVN 1 | Licensed Vocational Nurse | Named in interview regarding ADL care and catheter bag emptying |
| Director of Nursing | Director of Nursing | Named in interview acknowledging failures in care and staff communication |
| Activity Assistant 1 | Activity Assistant | Named in interview regarding feeding assistance policy and event communication |
Inspection Report
Citations: 2
Date: Mar 20, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights and provision of care, specifically focusing on dignity, respect, and assistance with activities of daily living for residents dependent on staff.
Findings
The facility failed to ensure that Resident 1, who was dependent on staff for eating and activities of daily living, was treated with dignity and respect during a candlelight dinner event and did not receive timely assistance with toileting and catheter care. This resulted in Resident 1 feeling neglected and experiencing discomfort due to an overflowing catheter bag.
Citations (2)
Failed to ensure Resident 1 was treated with dignity and respect when not aided with eating during the candlelight dinner.
Failed to provide timely assistance with activities of daily living, resulting in Resident 1's urinary catheter bag overflowing and compromising dignity and comfort.
Report Facts
Residents sampled: 4
Residents affected: 1
BIMS score: 15
Dates of incidents: Feb 22, 2024
Dates of incidents: Feb 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in failure to feed Resident 1 during candlelight dinner |
| Activity Assistant 1 | Activity Assistant | Named in communication about feeding restrictions during candlelight dinner |
| Director of Nursing | Director of Nursing | Provided statements regarding staff responsibilities and resident care |
| CNA 2 | Certified Nursing Assistant | Assisted Resident 1 after delay and apologized for neglect |
| CNA 3 | Certified Nursing Assistant | Discussed assignment changes and lack of care provided to Resident 1 |
| LVN 1 | Licensed Vocational Nurse | Assisted Resident 1 by emptying catheter bag and discussed staff responsibilities |
Inspection Report
Complaint Investigation
Citations: 2
Date: Jan 26, 2024
Visit Reason
The inspection was conducted following a complaint alleging abuse by a Certified Nursing Assistant (CNA 7) toward Resident 8.
Complaint Details
The complaint investigation involved allegations of abuse by CNA 7 toward Resident 8. The investigation found the facility did not provide abuse training to CNA 7 before returning to work and allowed CNA 7 to continue working in resident care areas despite the allegation.
Findings
The facility failed to develop and implement policies requiring re-training of staff accused of abuse before returning to work. Additionally, the facility allowed the alleged abuser to continue working in resident care areas, exposing residents to potential further abuse.
Citations (2)
F 0607: The facility failed to develop and implement written policies and procedures that included re-training and re-education of staff accused of abuse before returning to work with residents.
F 0610: The facility failed to ensure Resident 8 was protected from further potential abuse when the alleged abuser continued to work in resident care areas after the abuse allegation was reported.
Report Facts
Residents affected: 1
Date of admission: 202311
CNA 7 work hours on incident day: 8.77
Date of incident: Jan 5, 2024
Date CNA 7 returned to work: Jan 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 7 | Certified Nursing Assistant | Alleged abuser who was not re-trained before returning to work. |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident 8 care and facility policies on abuse training. |
| Administrator | Administrator | Interviewed about disciplinary actions and training refusal by CNA 7. |
| Licensed Vocational Nurse 8 | Licensed Vocational Nurse | Interviewed about CNA 7's failure to receive abuse training before returning to work. |
| Director of Staff Development | Director of Staff Development | Stated CNA 7 should have received one-on-one abuse training before returning to work. |
| Licensed Vocational Nurse 4 | Licensed Vocational Nurse | Reported Resident 8 was upset with CNA 7's behavior. |
| Employee Services Director | Employee Services Director | Reviewed CNA 7's timecard for the incident day. |
| Licensed Vocational Nurse 3 | Licensed Vocational Nurse | Reviewed nursing staffing assignment and sign-in sheet for incident day. |
Inspection Report
Routine
Citations: 18
Date: Jan 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, staffing, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and hygiene, failure to notify family of significant condition changes, inadequate abuse prevention policies, delayed and incomplete resident assessments, inaccurate PASARR assessments, incomplete care plans, improper catheter care, failure to provide therapeutic diets, late administration of medications, insufficient nursing staff leading to medication delays, failure to act on pharmacist recommendations, improper medication labeling and storage, unsafe food preparation and storage practices, and failure to implement policies for food brought by visitors.
Citations (18)
Failure to ensure resident's appearance maintained dignity and self-esteem related to facial hair and nail care for Resident 24.
Failure to notify family representative of significant weight loss for Resident 138.
Failure to develop and implement abuse prevention policies including re-training of staff accused of abuse before returning to work.
Failure to complete and submit quarterly and annual Minimum Data Set assessments timely for 13 residents.
Failure to accurately complete PASARR assessment for Resident 121 reflecting mental health diagnoses.
Failure to develop and implement comprehensive care plans for Residents 120, 12, 69, and 219.
Failure to provide proper grooming and nail care for Residents 84, 12, 24, and 95.
Failure to complete skin assessments for bruising on Resident 156's arms.
Failure to provide appropriate catheter care and monitoring for Residents 12 and 130.
Failure to provide therapeutic diet as ordered for Resident 138, including fortified foods and double protein portions.
Failure to administer scheduled pain medication in a timely manner for Resident 93, resulting in severe pain.
Insufficient licensed nursing staff leading to late administration of high-risk medications for Residents 93, 2, 72, and 77.
Failure to ensure monthly drug regimen reviews and follow-up on pharmacist recommendations for Residents 51, 69, and 93.
Failure to ensure Resident 51 was free from unnecessary drugs due to lack of monitoring for side effects of amoxicillin.
Failure to implement appropriate psychotropic medication use and monitoring for Resident 219, including duplicate antidepressant therapy and lack of target behavior monitoring.
Failure to ensure medications were labeled properly and expired medications and medications for discharged residents were stored with active medications.
Failure to ensure safe and sanitary food preparation and storage practices in the kitchen, including unclean conveyor toaster, dirty floor in dry storage, and use of expired sanitizer test strips.
Failure to implement policy for foods brought by visitors, resulting in expired food stored in residents' refrigerator.
Report Facts
Weight loss percentage: 13.68
Days late for MDS completion: 45
Days late for MDS completion: 48
Days late for MDS completion: 51
Days late for MDS completion: 52
Days late for MDS completion: 54
Days late for MDS completion: 56
Days late for MDS completion: 57
Days late for MDS completion: 57
Days late for MDS completion: 57
Days late for MDS completion: 58
Days late for MDS completion: 59
Days late for MDS completion: 60
Weight: 117
Weight: 101
Medication delay: 4
Medication delay: 1.95
Medication delay: 4.17
Medication delay: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 5 | Certified Nursing Assistant | Reported Resident 24 refused shaving and nail care. |
| RN 2 | Registered Nurse | Interviewed regarding Resident 24's refusal of shaving and nail care. |
| Director of Nursing | Director of Nursing | Reviewed care plans and facility policies; interviewed regarding multiple deficiencies. |
| CNA 7 | Certified Nursing Assistant | Involved in abuse incident and did not receive required re-training before returning to work. |
| LVN 8 | Licensed Vocational Nurse | Confirmed CNA 7 did not receive abuse training before returning to work. |
| MDS Coordinator | MDS Coordinator | Interviewed regarding late MDS submissions. |
| Registered Dietitian 1 | Registered Dietitian | Reviewed Resident 138's weight and diet orders. |
| CNA 4 | Certified Nursing Assistant | Observed Resident 138's meal tray and care refusals. |
| LVN 3 | Licensed Vocational Nurse | Reviewed Resident 95's care plan and nail care. |
| LVN 10 | Licensed Vocational Nurse | Administered medications on 1/20/24 and reported late medication administration. |
| Consultant Pharmacist 1 | Consultant Pharmacist | Provided medication regimen review and recommendations. |
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen sanitation and food preparation. |
| Cook [NAME] | Cook | Interviewed regarding cleaning of conveyor toaster. |
Inspection Report
Census: 104
Capacity: 153
Citations: 0
Date: Jan 9, 2024
Visit Reason
The visit was an unannounced case management check to pick up documents requested during a complaint inspection on 2024-01-08 and to complete the health and safety check of the facility.
Findings
No citations were issued during the visit. The Licensing Program Analyst confirmed that the facility's fire protection systems were last inspected in April 2023.
Report Facts
Capacity: 153
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monique Bindra | Executive Director | Met with Licensing Program Analyst during the visit |
| Joanne Bustos | Resident Services Director | Provided requested documents to Licensing Program Analyst |
| Kaila Homolka | Maintenance Director | Confirmed last inspection of fire protection systems |
| James Sampair | Licensing Program Analyst | Conducted the inspection visit |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Census: 104
Capacity: 153
Citations: 0
Date: Jan 8, 2024
Visit Reason
The visit was an unannounced health and safety check conducted by the Licensing Program Analyst to assess the facility's compliance with health and safety standards.
Findings
The inspection found that the facility maintained appropriate environmental conditions including temperature and food supplies, medications were securely stored, first-aid kits were complete, and fire extinguishers were properly serviced. No citations were issued during this visit.
Report Facts
Facility capacity: 153
Resident census: 104
Fire extinguisher last serviced: Jan 3, 2024
Facility temperature: 73.7
Hot water temperature: 112.8
Non-perishable food supply: 7
Perishable food supply: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Monique Bindra | Executive Director | Met with during inspection and named in report |
| James Sampair | Licensing Program Analyst | Conducted the inspection |
| Bennett Fong | Licensing Program Manager | Named in report |
Inspection Report
Routine
Citations: 2
Date: Jan 5, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with respiratory care standards, specifically regarding tracheostomy tube changes and related respiratory therapy practices.
Findings
The facility failed to provide necessary respiratory care consistent with professional standards for four sampled residents by changing tracheostomy tubes without physician orders and using incorrect tube types and sizes, which potentially contributed to respiratory distress and the death of Resident 1.
Citations (2)
Respiratory Therapy Consultant changed Resident 1's tracheostomy tube with an incorrect tube type and size, contributing to respiratory distress and death.
Residents 1, 2, 3, and 4 received tracheostomy tube changes without a physician's order.
Report Facts
Outside diameter of Shiley 8 XLT tube: 13.3
Outside diameter of Portex SXC tube: 11.9
Length of Portex SXC tube: 75.5
Length of Shiley 8 XLT tube: 105
Pulse rate: 111
Respiration rate: 30
Oxygen saturation: 99
Oxygen saturation: 94
Pulse rate: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RT 1 | Respiratory Therapist | Noticed incorrect trach tube and reported it; involved in trach tube changes |
| RTM | Respiratory Therapy Manager | Reviewed care plans and trach tube change lists; stated no physician orders for trach tube changes |
| PMD | Pulmonary Medicine Doctor | Stated physician orders were not needed for routine trach tube changes |
| IDON | Interim Director of Nursing | Stated any procedure done on residents should have a written physician's order |
| MRD | Medical Records Director | Confirmed no physician orders for trach tube changes in Resident 1's clinical records |
Inspection Report
Annual Inspection
Citations: 2
Date: Jan 4, 2024
Visit Reason
The inspection was conducted to assess compliance with documentation and medical record-keeping standards at Walnut Creek Skilled Nursing & Rehabilitation Center, focusing on completeness of skin reports and ADL entries.
Findings
The facility failed to ensure complete documentation of medical records for one resident, including missing seven weekly skin reports and twenty-six ADL entries, resulting in incomplete medical records that could potentially affect the resident's care and well-being.
Citations (2)
Missing seven weekly skin reports for Resident 1
Missing twenty-six ADL (activities of daily living) entries for Resident 1
Report Facts
Missing weekly skin reports: 7
Missing ADL entries: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding missing skin and survey reports and documentation issues |
| Director of Staff Development | Director of Staff Development | Interviewed regarding electronic chart system and audit processes |
| Wound Care Nurse | Wound Care Nurse | Interviewed regarding skin condition and care requirements |
Inspection Report
Complaint Investigation
Citations: 2
Date: Jan 3, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide showers for personal hygiene and failure to provide medically related social services, specifically transportation to dialysis treatments for two sampled residents.
Complaint Details
The investigation was complaint-driven, focusing on allegations that Resident 2 did not receive scheduled showers and Resident 1 was not provided transportation to dialysis treatments, resulting in potential harm and safety risks. The complaints were substantiated based on interviews, record reviews, and observations.
Findings
The facility failed to ensure showers were provided to maintain grooming and personal hygiene for one resident totally dependent on staff. The facility also failed to provide medically related social services for another resident when transportation to and from dialysis treatments was not provided, creating potential safety risks.
Citations (2)
F 0677: The facility failed to provide showers to maintain grooming and personal hygiene for Resident 2, who was totally dependent on staff for activities of daily living. Resident 2 missed three scheduled showers over a 10-day period.
F 0745: The facility failed to provide medically related social services for Resident 1 when transportation to and from dialysis treatments was not provided. Resident 1 was pushed in a wheelchair by staff and at times had to return alone after dialysis, posing a safety risk.
Report Facts
Missed showers: 3
BIMS score: 15
MDS assessment date: Nov 15, 2023
MDS assessment date: Aug 28, 2023
COVID positive test date: Oct 13, 2023
Transportation provided date: Nov 23, 2023
Inspection Report
Citations: 2
Date: Jan 3, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, specifically focusing on activities of daily living assistance and medically related social services.
Findings
The facility failed to ensure showers were provided to maintain grooming and personal hygiene for one resident totally dependent on staff for ADLs, and failed to provide medically related social services for another resident by not arranging transportation to and from dialysis treatments, posing potential risks of poor hygiene, skin irritation, and avoidable accidents.
Citations (2)
Failed to ensure showers were provided to maintain grooming and personal hygiene for a resident totally dependent on staff for ADLs.
Failed to provide medically related social services by not providing transportation to and from dialysis treatments for a resident.
Report Facts
Missed showers: 3
BIMS score: 15
Dialysis transportation time: 5.15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Interviewed regarding Resident 2's missed showers and care documentation. |
| Registered Nurse Supervisor | Registered Nurse Supervisor | Coordinated staff for Resident 1's dialysis transportation. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about Resident 1's dialysis schedule and transportation. |
| Administrator | Administrator | Interviewed about dialysis transportation arrangements for Resident 1. |
| Infection Preventionist Registered Nurse | Infection Preventionist Registered Nurse | Reviewed facility's COVID infection control program and Resident 1's COVID status. |
| Social Services Director | Social Services Director | Interviewed about transportation company contact and documentation. |
| Transportation Company Staff | Transportation Company Staff | Interviewed about transportation scheduling for Resident 1. |
| Registered Nurse Supervisor | Registered Nurse Supervisor | Expressed safety concerns about escorting Resident 1 to dialysis center early morning. |
Inspection Report
Citations: 3
Date: Dec 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, accident prevention, and medication storage at Walnut Creek Skilled Nursing & Rehabilitation Center.
Findings
The facility failed to ensure care plans were reviewed and updated for a resident with multiple new wounds, failed to prevent accidents resulting in skin tears, and failed to store medications in locked compartments, leaving medication unattended at a resident's bedside.
Citations (3)
F 0657: The facility failed to ensure care plans were reviewed and revised by the interdisciplinary team after assessments when Resident 1 had multiple new wounds, resulting in repeated skin damage and new wounds.
F 0689: The facility failed to ensure Resident 1 was free from accidents, resulting in a skin tear with bleeding and pain during transfer to the shower.
F 0761: The facility failed to ensure all drugs and biologicals were stored in locked compartments when medication was found unattended at Resident 1's bedside, risking incorrect dosing.
Report Facts
Skin damage incidents: 6
Skin tear measurement: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Assistant (ADON) | Interviewed and reviewed Resident 1's records regarding skin damage and care plans | |
| Director of Nursing (DON) | Interviewed regarding medication left unattended at Resident 1's bedside | |
| Administrator | Interviewed regarding facility policies on accident prevention |
Inspection Report
Annual Inspection
Citations: 3
Date: Dec 28, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning, accident prevention, and medication storage regulations as part of a regulatory survey.
Findings
The facility failed to ensure timely revision of care plans for residents with new wounds, failed to prevent accidents resulting in skin tears during transfers, and failed to store medications securely at the bedside, posing risks to resident safety and care.
Citations (3)
Failure to develop and revise care plans for Resident 1 with multiple new wounds.
Failure to ensure Resident 1 was free from accidents, resulting in a skin tear during transfer to the shower.
Failure to store all drugs and biologicals in locked compartments; medication found unattended at Resident 1's bedside.
Report Facts
Dates of new skin damages: 6
Measurement of skin tear: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Assistant | ADON | Interviewed and confirmed findings related to Resident 1's skin wounds and care plan deficiencies |
| Director of Nursing | DON | Interviewed regarding medication left unattended at Resident 1's bedside |
| Administrator | Interviewed regarding facility policies on accident prevention |
Inspection Report
Complaint Investigation
Citations: 2
Date: Dec 22, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify a resident or the resident's representative about bed hold rights during a hospital transfer and the facility's refusal to allow the resident to return after hospitalization.
Complaint Details
The complaint investigation found that Resident 1 was not issued a bed hold notice during hospital transfer and was refused return to the facility after hospital discharge due to staffing and sitter issues. The resident's representative confirmed no bed hold notice was received. The facility acknowledged refusal to accept Resident 1 back without agreement on sitter provision.
Findings
The facility failed to provide bed hold notice to Resident 1 or the resident's representative during hospital transfer, violating the resident's right to return to their bed. Additionally, the facility did not allow Resident 1 to return after hospital discharge, resulting in an unnecessary extended hospital stay due to staffing and sitter provision issues.
Citations (2)
Failure to notify the resident or resident's representative in writing about bed hold rights during hospital transfer.
Failure to allow a resident to return to the nursing home after hospitalization exceeding bed-hold policy, resulting in an unnecessary hospital stay.
Report Facts
Days Resident 1 stayed in hospital pending facility approval to return: 37
Bed hold period: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Stated bed hold period and bed hold notice procedures. |
| Administrator | Administrator | Stated facility's willingness to accept Resident 1 back under conditions and staffing limitations. |
| ADON | Assistant Director of Nursing | Provided information on staffing and supervision of Resident 1 and facility assessment. |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 153
Citations: 0
Date: Dec 13, 2023
Visit Reason
The inspection was conducted due to a complaint alleging that the facility license was not posted for public viewing.
Complaint Details
The complaint alleged that the facility license was not posted for public viewing. The allegation was investigated and determined to be unfounded.
Findings
The Licensing Program Analyst confirmed that the facility license was posted in the same location as during the previous visit, and the allegation was found to be unfounded.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation and confirmed findings. |
| Monique Bindra | Administrator | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Citations: 1
Date: Oct 31, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide Resident 1 with showers three times per week as ordered by the physician.
Complaint Details
The complaint was substantiated as the facility did not follow the physician's order for Resident 1's shower schedule, providing only two showers per week instead of three. Resident 1 expressed dissatisfaction and emotional distress due to this issue.
Findings
The facility failed to provide Resident 1 with the ordered three showers per week, instead providing only two showers weekly. This failure caused emotional distress and impacted the resident's rights and dignity.
Citations (1)
Facility failed to provide three showers per week as ordered by physician for Resident 1.
Report Facts
Residents Affected: 1
Shower frequency ordered: 3
Shower frequency provided: 2
Date of survey completion: Oct 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Reviewed Order Information Report and stated shower schedule was twice a week |
| Assistant Director of Nursing | ADON | Interviewed regarding shower schedule and confirmed showers were provided twice a week |
| Certified Nursing Assistant 1 | CNA | Stated shower schedule was twice a week, not matching physician's order |
| Unit Manager | UM | Confirmed unit was not following physician's order for showers |
| Director of Nursing | DON | Confirmed Resident 1 was to have showers three times a week and facility was investigating |
| Licensed Vocational Nurse 2 | LVN | Documented Resident 1's complaints about shower schedule in Progress Notes |
| Social Services Assistant | SSA | Documented Resident 1's requests and complaints about shower schedule |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 153
Citations: 0
Date: Jul 28, 2023
Visit Reason
The visit was conducted to deliver findings from a complaint (15-AS-20230718113231) regarding resident R1 and to verify the level of care provided to the resident.
Complaint Details
The visit was complaint-related, triggered by complaint 15-AS-20230718113231. The complaint was investigated and found to be unsubstantiated as the resident was receiving appropriate care.
Findings
The Licensing Program Analyst confirmed through interviews that resident R1 was fully receiving the level of care as written in her Plan of Care. No citations were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joann Bustos | Resident Services Director | Interviewed about the level of care provided to resident R1. |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 153
Citations: 0
Date: Jul 26, 2023
Visit Reason
This was an unannounced complaint investigation visit conducted in response to allegations received on 07/18/2023 regarding staff assistance, respect, and facility conditions at Atria Valley View.
Complaint Details
The complaint included allegations that staff did not assist residents when needed, disturbed residents' sleep, treated residents disrespectfully, had a toilet in disrepair, and did not empty residents' trash receptacles. The investigation concluded these allegations were unsubstantiated.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff were observed to provide assistance and respect to residents appropriately, and the facility's toilet was fully functional.
Report Facts
Capacity: 153
Census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
| Kawana Anthony | Administrator | Facility administrator met during the investigation |
Inspection Report
Annual Inspection
Census: 95
Capacity: 153
Citations: 0
Date: Jun 27, 2023
Visit Reason
The inspection was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate the facility's compliance with regulatory requirements.
Findings
During the inspection, files of residents and staff were reviewed, the facility was toured, and interviews were conducted with residents and staff. No citations were issued during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kawana Anthony | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 153
Citations: 0
Date: May 12, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2023-05-08 regarding inadequate resident care and facility conditions.
Complaint Details
The complaint included allegations that staff did not assist a resident with showering and dressing as needed, did not provide appropriate food service for a diabetic resident, did not disinfect visibly soiled surfaces, the resident's air conditioning was in disrepair, and staff did not safeguard the resident's valuables. The investigation concluded these allegations were unsubstantiated.
Findings
The investigation found no evidence to substantiate the allegations related to resident assistance with showering and dressing, food service for diabetic residents, disinfection of surfaces, air conditioning functionality, or safeguarding of residents' valuables. Therefore, all allegations were unsubstantiated.
Report Facts
Capacity: 153
Census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation |
| Kawana Anthony | Interim Executive Director | Met with during the investigation |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 153
Citations: 0
Date: May 2, 2023
Visit Reason
The visit was an unannounced case management incident inspection concerning a gastrointestinal outbreak at the facility and an unusual incident report regarding a resident-on-resident fight dated 02/08/2023.
Complaint Details
The visit was triggered by a complaint related to a resident-on-resident fight. The investigation found no further incidents and no citations were issued.
Findings
The Resident Services Director reported no additional incidents involving the resident who instigated the assault and that the resident was scheduled to move out the following day. No citations were issued during the visit.
Report Facts
Capacity: 153
Census: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kawana Anthony | Interim Executive Director | Met during the inspection and involved in addressing the incident |
| Joanne Bustos | Resident Services Director | Provided update on resident involved in the incident |
| James Sampair | Licensing Program Analyst | Conducted the inspection visit |
| Harpreet Humpal | Licensing Program Manager | Named in the report header |
Inspection Report
Census: 101
Capacity: 153
Citations: 0
Date: May 2, 2023
Visit Reason
The visit was an unannounced case management health check concerning a gastrointestinal (GI) outbreak at the facility reported on 05/01/2023.
Findings
At the time of the visit, 11 residents were ill with Norovirus, including two who had been hospitalized and returned. Measures to stop the spread included masking, cessation of group dining and activities, and serving meals in residents' rooms. No new cases had been reported since noon, and no staff infections were noted. No citations were issued during the visit.
Report Facts
Residents ill with Norovirus: 11
Hospitalized residents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kawana Anthony | Interim Executive Director | Provided information on the outbreak and measures taken |
| Joanne Bustos | Resident Services Director | Provided additional information during the visit |
| James Sampair | Licensing Program Analyst | Conducted the unannounced visit |
Inspection Report
Complaint Investigation
Citations: 2
Date: Apr 20, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication errors involving Resident 1, specifically the failure to clarify and accurately account for the resident's azathioprine medication dosage upon admission, which led to an excessive dose administration.
Complaint Details
The complaint investigation focused on medication mismanagement related to Resident 1's azathioprine dosing. The investigation substantiated that the resident received six times the prescribed dose, leading to toxic effects and clinical decline. The facility failed to follow its medication reconciliation policy and did not resolve discrepancies in medication orders.
Findings
The facility nurses failed to ensure proper medication reconciliation and clarification of Resident 1's azathioprine order, resulting in the resident receiving six times the therapeutic dose previously administered in the hospital. This overdose caused toxic effects including bone marrow depression, thrombocytopenia, and hepatotoxicity, contributing to the resident's clinical deterioration and eventual death.
Citations (2)
Failure to clarify and accurately account for Resident 1's azathioprine medication dosage upon admission, leading to administration of an excessive dose.
Failure to identify the excessive dose of azathioprine and to contact the resident's Attending Physician or Medical Director to discuss concerns.
Report Facts
Azathioprine dose: 200
Azathioprine dose frequency: 3
Total bilirubin level: 19.4
Platelet count: 73
Platelet count: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Created the azathioprine order dated 9/2/22. |
| Physician 1 | Physician | Signed the azathioprine order dated 9/2/22. |
| Director of Nursing (DON 1) | Director of Nursing | Reviewed Resident 1's EMR and acknowledged drug reference did not support the excessive dose. |
| Director of Nursing (DON 2) | Director of Nursing | Acknowledged lack of documentation for medication reconciliation and inability to identify hospital dose in referral documents. |
| RN 1 | Registered Nurse | Administered azathioprine doses and interviewed regarding medication administration process. |
| RN 2 | Registered Nurse | Administered azathioprine doses and interviewed regarding medication administration process. |
| LVN 2 | Licensed Vocational Nurse | Administered azathioprine doses and interviewed regarding medication administration process. |
| Nurse Practitioner 1 | Nurse Practitioner | Reviewed Resident 1's EMR and stated hospital administered azathioprine 100 mg once daily. |
| Physician 2 | Hospitalist Physician | Wrote history and physical note documenting low platelets and high bilirubin. |
| Physician 3 | Physician | Wrote Critical Care Consult noting azathioprine toxicity and decompensation. |
| Physician 4 | Physician | Wrote Critical Care Progress Note confirming toxicity due to azathioprine overdose. |
| Clinical Bioethicist 1 | Clinical Bioethicist | Authored Ethics Consultation expressing concern about medication mismanagement. |
| Nurse Practitioner 2 | Nurse Practitioner | Authored discharge summary noting transition to comfort care and death. |
| Coordinator 1 | Hospital Coordinator | Reviewed Resident 1's EMR and admission details. |
| Health Risk Officer (Officer 1) | Health Risk Officer | Reviewed EMR and documented azathioprine toxicity and Resident 1's death. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 153
Citations: 0
Date: Jan 26, 2023
Visit Reason
The visit was an unannounced Case Management inspection triggered by an Unusual Incident Report describing a supposed verbal threat made by one resident to another on 01/18/2023.
Complaint Details
The complaint involved a verbal threat incident reported on 01/18/2023. The alleged aggressor did not recall the event and there were no witnesses. The complaint was not substantiated as no citations were issued.
Findings
The Licensing Program Analyst reviewed the residents' records and actions taken by the facility to reduce further conflicts and was satisfied that appropriate measures were in place. No citations were issued.
Report Facts
Census: 95
Total Capacity: 153
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelli L Greene | Executive Director | Met with Licensing Program Analyst during the visit and involved in review of residents' records |
| James Sampair | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 153
Citations: 0
Date: Jan 4, 2023
Visit Reason
The inspection was conducted as a Case Management Inspection concerning an Unusual Incident Report about a missed prescription for a resident on 12/30/2022.
Complaint Details
The visit was complaint-related due to an Unusual Incident Report about a missed prescription. Based on staff interview, the incident was managed promptly and no citations were issued.
Findings
The facility reacted quickly enough that the medication arrived in time for the resident to take it on the scheduled day. No citations were issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosario Holandez | Community Business Director | Met with during the inspection and involved in the case management inspection. |
Inspection Report
Annual Inspection
Census: 104
Capacity: 153
Citations: 0
Date: Jul 25, 2022
Visit Reason
The inspection was an infection control annual inspection conducted as a required one-year unannounced visit.
Findings
The facility has an infection control plan in place and is following it, with the administrator designated as the infection control leader. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelli L Greene | Administrator | Designated infection control leader and met with Licensing Program Analyst during inspection. |
| James Sampair | Licensing Program Analyst | Conducted the infection control annual inspection. |
| Harpreet Humpal | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 153
Citations: 0
Date: Dec 30, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 03/20/2020 regarding residents being confined to their rooms and inadequate food service.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included residents being confined to their rooms and inadequate food service. Interviews and document reviews did not support these allegations.
Findings
The investigation included interviews with residents, staff, and review of facility documents. It was found that residents were encouraged to stay in their apartments due to COVID-19 guidance, but could leave if needed, and food service was adequate with meals delivered hot and residents having microwaves to warm food. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 153
Census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Luk | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during investigation |
| Jill Libhart | Administrator | Facility Administrator named in report |
Inspection Report
Annual Inspection
Census: 27
Citations: 6
Date: Dec 10, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for skilled nursing facilities.
Findings
The facility was found deficient in multiple areas including failure to notify responsible parties of resident condition changes, delayed completion of Minimum Data Set assessments, failure to assist a resident with hearing aids, medication administration errors, improper food storage, and inadequate infection control practices.
Citations (6)
F 0552: The facility failed to notify the responsible party for three days of a change in the skin condition of one resident, preventing timely communication about health status and care options.
F 0636: The facility failed to complete Minimum Data Set assessments within 14 calendar days for five residents, delaying care plan development and implementation.
F 0685: The facility failed to assist one resident with insertion of hearing aids, resulting in the resident being unable to hear and feeling anxious.
F 0755: The facility administered half the prescribed dosage of two medications to one resident, risking inadequate treatment of diabetes and heart failure.
F 0812: The facility failed to ensure food was stored and served under sanitary conditions, including expired juices and unlabeled opened juice boxes, risking food-borne illness.
F 0880: The facility failed to perform hand hygiene between glove changes when administering medication to a resident, risking infection.
Report Facts
Residents sampled: 27
Residents with delayed MDS: 5
Residents affected by hearing aid failure: 1
Residents affected by medication dosage error: 1
Expired apple juice cases: 2
Expired drink glasses: 5
Opened juice boxes without labeling: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Named in skin condition notification deficiency |
| CNA 1 | Certified Nursing Assistant | Named in skin condition notification and hearing aid assistance deficiencies |
| LVN 1 | Licensed Vocational Nurse | Named in medication administration deficiency |
| LVN 2 | Licensed Vocational Nurse | Named in hearing aid assistance deficiency |
| LVN 3 | Licensed Vocational Nurse | Named in hearing aid assistance deficiency |
| RN 1 | Registered Nurse | Named in infection control deficiency |
| IP | Infection Preventionist | Named in infection control deficiency |
| MDSC | MDS Coordinator | Named in delayed MDS assessment deficiency |
| RD | Registered Dietitian | Named in food storage deficiency |
| DS | Dietary Supervisor | Named in food storage deficiency |
Inspection Report
Annual Inspection
Citations: 6
Date: Dec 10, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, assessment completion, pharmaceutical services, food safety, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to notify responsible parties of resident condition changes, delayed completion of Minimum Data Set assessments, failure to assist a resident with hearing aids, medication administration errors, improper food storage, and inadequate hand hygiene practices by staff.
Citations (6)
Failure to notify the responsible party for three days of a change in the skin condition of one resident.
Failure to complete Minimum Data Set assessments within 14 calendar days for five residents.
Failure to assist one resident with insertion of hearing aids, resulting in anxiety and difficulty hearing.
Failure to meet pharmaceutical needs of one resident by administering half the prescribed dosage of medications.
Failure to ensure food was stored, prepared, and served under sanitary conditions, including expired items and unlabeled opened juice boxes.
Failure to perform hand hygiene between glove changes when administering medication to a resident.
Report Facts
Residents sampled: 27
Residents with delayed MDS assessments: 5
Medication dosage: 40
Medication dosage: 1000
Expired apple juice: 45
Used-by-date exceeded: 1
Boxes of juice: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | CNA | Notified RN 2 about resident's skin discoloration; unaware of resident's hearing aid use |
| Registered Nurse 2 | RN | Confirmed presence of skin discoloration; documented skin alteration |
| Assistant Director of Nursing | ADON | Unable to find documentation of skin discoloration |
| Licensed Vocational Nurse 1 | LVN | Administered half the prescribed medication doses to Resident 119 |
| Licensed Vocational Nurse 2 | LVN | Assigned nurse for Resident 14; unaware of hearing aid needs |
| Licensed Vocational Nurse 3 | LVN | Found Resident 14's hearing aids stored in medication room |
| Registered Nurse 1 | RN | Failed to perform hand hygiene between glove changes during medication administration |
| Infection Preventionist | IP | Stated hand hygiene expectations for staff |
| Dietary Supervisor | DS | Observed expired food items in kitchen |
| Registered Dietitian | RD | Confirmed expired food items should be discarded |
| MDS Coordinator | MDSC | Reviewed delayed MDS assessments |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 153
Citations: 2
Date: Oct 22, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff spoke inappropriately to a resident and that the facility did not report suspected abuse in a timely manner.
Complaint Details
The complaint investigation was substantiated. Staff spoke inappropriately to a resident, and the facility failed to report suspected abuse in a timely manner.
Findings
Both allegations were substantiated. Staff member S1 admitted to verbally abusing resident R1, and the facility failed to report suspected elder abuse in a timely manner, including not completing the required unusual incident report.
Citations (2)
Residents in all residential care facilities for the elderly shall have dignity in their personal relationships with staff, residents, and others. This was not met as S1 admitted to verbally abusing R1, posing a potential health and safety risk.
Any suspected physical abuse resulting in serious bodily injury must be reported within two hours to the local ombudsman, licensing agency, and law enforcement. This was not met as the SOC 341 report was not submitted in a timely manner, posing a potential health and safety risk.
Report Facts
Capacity: 153
Census: 104
Plan of Correction Due Date: Nov 8, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the complaint investigation |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
| Kelli L Greene | Administrator | Facility administrator named in report |
| Rosario Holandez | Community Business Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 153
Citations: 0
Date: Aug 17, 2021
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by allegations received on 2021-06-22 regarding resident care and involvement of the Resident Representative.
Complaint Details
The complaint involved allegations that a resident was provided services without Resident Representative's approval, the Resident Representative was not allowed to participate in care planning, and staff did not provide a copy of the care plan to the Resident's Representative. The complaint was found to be unfounded.
Findings
The investigation found the complaint to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis. The complaint was dismissed after interviews and review of records.
Report Facts
Complaint Control Number: 15-AS-20210622140830
Capacity: 153
Census: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Hall | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kelli Greene | Executive Director | Met with Licensing Program Analyst during investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Routine
Census: 100
Capacity: 153
Citations: 0
Date: Jun 28, 2021
Visit Reason
Unannounced Infection Control Inspection conducted as a required 1 Year visit.
Findings
The inspection found that the facility had proper infection control measures in place including hand sanitizer, COVID-19 signage, visitor and temperature logs, and sufficient PPE. No deficiencies were cited during this inspection.
Report Facts
Capacity: 153
Census: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelli L Greene | Executive Director | Met with Licensing Program Analysts during inspection |
| Jennifer Coons | Senior Executive Director | Met with Licensing Program Analysts during inspection |
| Laura Hall | Licensing Program Analyst | Conducted the inspection |
| Harpreet Humpal | Licensing Program Manager | Named in report header |
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