Deficiencies (last 3 years)
Deficiencies (over 3 years)
18.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
368% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
125 residents
Based on a December 2024 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 20, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a physical abuse incident between two residents at the facility.
Complaint Details
The complaint investigation found substantiated physical abuse where Resident 112 physically assaulted Resident 49 by pulling her hair and hitting her. Interviews with residents and staff confirmed the incident and behavioral issues contributing to the altercation.
Findings
The facility failed to protect one resident (Resident 49) from physical abuse by another resident (Resident 112), who grabbed Resident 49 by the hair, pulled her down, and hit her. Both residents had severely impaired cognition and exhibited aggressive behaviors. The facility's medication administration records did not indicate monitoring of Resident 112's behaviors, and staff interviews confirmed the incident and behavioral challenges.
Deficiencies (1)
Failure to protect residents from physical abuse by another resident.
Report Facts
Residents Affected: 1
Sampled Residents: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant 1 | CNA | Witnessed the incident of Resident 112 pulling hair and hitting Resident 49. |
| Certified Nurse Assistant 2 | CNA | Provided information about residents' aggressive behaviors and prior altercations. |
| Licensed Nurse 1 | LN | Provided information about residents' aggressive behaviors. |
| Director of Nursing | DON | Stated expectation that facility residents are free from abuse. |
Inspection Report
Routine
Census: 125
Deficiencies: 14
Date: Dec 20, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements and evaluate the quality of care and services provided to residents.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity during meal assistance, inadequate accommodation of resident needs, inaccurate resident assessments, insufficient assistance with activities of daily living, failure to provide psychosocial activities, medication administration errors, trauma-informed care deficiencies, insufficient staffing levels, improper medication storage and labeling, food safety violations, infection prevention and control lapses, and environmental sanitation issues.
Deficiencies (14)
Failure to promote dignity and respect for residents during meal assistance, including staff standing over residents and serving meals at different times.
Failure to reasonably accommodate the needs and preferences of a resident when call light was not within reach.
Compromised resident personal privacy and confidentiality due to overfilled shred box exposing resident information.
Inaccurate Minimum Data Set (MDS) assessment for a resident's behavioral symptoms.
Failure to ensure assistance with activities of daily living including nail care and oral hygiene for residents.
Failure to provide activities that meet residents' psychosocial needs and preferences.
Failure to administer prescribed medications timely, resulting in missed doses of blood pressure and antidepressant medications.
Failure to provide trauma-informed care by not identifying trauma triggers or care planning for PTSD diagnosis.
Use of unnecessary psychotropic medication without adequate indication or target behavior.
Medications not labeled with open or use by dates and improper storage of medications.
Food safety violations including wet storage of steam table pans and improperly closed frozen food bags.
Failure to follow infection prevention and control protocols including improper use of PPE, lack of hand hygiene, and unclean shared equipment.
Failure to maintain a safe, sanitary, and comfortable environment due to dust buildup on bathroom exhaust fans.
Failure to provide sufficient nursing staff hours resulting in low direct care hours and increased resident falls.
Report Facts
Resident census: 125
Actual DHPPD: 2.66
Actual CNA DHPPD: 1.75
Resident falls: 10
Missed medication doses: 4
Missed oral hygiene opportunities: 15
Days without psychosocial activities: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 9 | CNA | Named in dignity and respect deficiency for standing over residents during feeding and failure to perform hand hygiene |
| Director of Nursing | DON | Provided statements regarding expectations for call light accessibility, staffing, infection control, and care planning |
| Director of Staff Development | DSD | Interviewed regarding dignity during feeding and meal serving times |
| Certified Nurse Assistant 12 | CNA | Confirmed call light not within reach for Resident 89 |
| Certified Nurse Assistant 3 | CNA | Confirmed blackish substance under Resident 72's fingernails |
| Infection Preventionist | IP | Provided statements on infection risks and PPE use |
| Licensed Nurse 1 | LN | Interviewed regarding trauma-informed care and infection control |
| Licensed Nurse 3 | LN | Observed not sanitizing blood pressure cuff between residents |
| Pharmacy Consultant | PC | Confirmed medication refill and delivery process |
| Consultant Pharmacist | CP | Confirmed inappropriate use of psychotropic medication |
| Staffing Coordinator | SC | Confirmed staffing levels below minimum standards |
| Housekeeping Manager | HM | Confirmed cleaning schedules and deficiencies in exhaust fan cleaning |
| Certified Nurse Assistant 10 | CNA | Did not wear PPE during transfer of resident on Enhanced Barrier Precautions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 3, 2024
Visit Reason
The inspection was conducted due to a complaint alleging physical abuse of Resident 2 by a Certified Nursing Assistant (CNA 4) at Windsor Care Center of Sacramento.
Complaint Details
The complaint investigation was substantiated based on interviews with RN 1 and the Director of Nursing, review of Resident 2's records, and the facility's policies. Resident 2 was found to have been physically abused by CNA 4 on 9/25/24 at approximately 1727 hours.
Findings
The facility failed to protect Resident 2 from physical abuse when CNA 4 slapped the resident's face, aggressively pulled her arm, and covered her face with a gown. The incident was witnessed by a Registered Nurse and confirmed through interviews and record reviews.
Deficiencies (1)
Failure to protect Resident 2 from physical abuse by a staff member who slapped the face, pulled the arm aggressively, and covered the face with a gown.
Report Facts
Residents Affected: 4
Residents Affected: 1
Date of Incident: Sep 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 4 | Certified Nursing Assistant | Named as the staff member who physically abused Resident 2 |
| RN 1 | Registered Nurse | Witnessed the abuse incident and reported details |
| DON | Director of Nursing | Provided statement on resident protection from abuse |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding abuse incidents involving Resident 1 physically assaulting Resident 2 and Resident 3.
Complaint Details
The complaint investigation was substantiated based on observations, interviews, and record reviews confirming Resident 1 assaulted Resident 2 and Resident 3. Resident 2 had a scratch on the lower lip and Resident 3 had a skin tear on the right hand. The facility staff and administration acknowledged the incidents and the failure to have a care plan for Trazodone medication.
Findings
The facility failed to protect two residents from abuse when Resident 1 punched Resident 2 and bit Resident 3, resulting in minor injuries. Additionally, the facility failed to develop a person-centered care plan for Resident 1's use of the medication Trazodone.
Deficiencies (2)
Failed to protect residents from abuse when Resident 1 punched Resident 2 and bit Resident 3 causing minor injuries.
Failed to develop a person-centered care plan for Resident 1's use of Trazodone medication.
Report Facts
Medication dosage: 50
Medication dosage: 100
Wound size: 2
Wound size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Witnessed the physical altercation and described the events involving Resident 1, Resident 2, and Resident 3 |
| Licensed Nurse 2 | Licensed Nurse | Observed the incident and provided details about the altercation and resident behaviors |
| Social Services Assistant Director | Social Services Assistant Director | Interviewed regarding the incident and resident behaviors |
| Director of Nursing | Director of Nursing | Confirmed medication orders and lack of care plan for Trazodone; provided statements on resident safety expectations |
| Administrator | Administrator | Provided statements on the incident and expectations for resident safety |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 23, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where Resident 2 physically abused Resident 1 by kicking him multiple times on the right side of his torso.
Complaint Details
The complaint investigation found that Resident 2 kicked Resident 1 multiple times after Resident 1 tried to enter Resident 2's room through a shared restroom and get into his belongings. Resident 2 admitted to pushing Resident 1 in self-defense. The incident was witnessed and reported by CNAs.
Findings
The facility failed to protect Resident 1 from physical abuse by Resident 2, who kicked Resident 1 several times causing potential for serious physical injury. Resident 1 had severe cognitive impairment and was known to exhibit intrusive behaviors, while Resident 2 had significant cognitive impairment and a history of agitation when others entered his room.
Deficiencies (1)
Failure to protect Resident 1 from physical abuse by Resident 2 who kicked Resident 1 on the right side of his torso.
Report Facts
BIMS score: 3
BIMS score: 5
Number of kicks: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | CNA 1 witnessed the incident and reported Resident 2 kicking Resident 1 | |
| Certified Nursing Assistant | CNA 3 witnessed and intervened during the incident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 11, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an alleged abuse incident where Resident 3 physically harmed Resident 2.
Complaint Details
The complaint investigation found that Resident 3 physically harmed Resident 2 on 7/5/24 by twisting and hitting Resident 2's arm. CNA 1 witnessed the incident but did not report it immediately, instead informing CNA 2 who also did not report it. The nurse assigned to the residents did not learn of the incident until the next day. Resident 2's Responsible Party was informed by CNA 1 on 7/6/24 and reported the incident to staff, after which Resident 2 was moved to another room. The facility failed to separate the residents immediately after the incident, placing Resident 2 at risk.
Findings
The facility failed to follow its policy and procedure for reporting and investigating abuse by not reporting the alleged abuse incident on the day it occurred. Resident 3 was observed twisting and hitting Resident 2's arm, but staff delayed reporting, and both residents remained roommates until the following day when Resident 2 was moved to another room. The Director of Nursing and other staff confirmed the failure to report timely and the risk posed to both residents.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Date of alleged abuse: Jul 5, 2024
Date of interview with DON: Jul 10, 2024
Date Resident 2 moved rooms: Jul 6, 2024
Resident 3 admission date: Dec 22, 2023
Resident 2 admission date: Apr 19, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Witnessed the abuse incident but failed to report it immediately |
| CNA 2 | Certified Nursing Assistant | Was informed of the abuse incident by CNA 1 but did not report it |
| LN 1 | Licensed Nurse | Assigned nurse who did not learn of the abuse incident until the next day |
| Director of Nursing | Director of Nursing | Confirmed failure to report abuse timely and stated expectations for staff |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged physical abuse of a resident by a Certified Nursing Assistant (CNA 1).
Complaint Details
The complaint investigation substantiated physical abuse by CNA 1 against Resident 1, confirmed through video evidence and interviews with the Health Information Director, Director of Nursing, and Administrator.
Findings
The facility failed to ensure one of three sampled residents was free from physical abuse when CNA 1 forcefully pulled the resident into a chair, pushed her chest down, and struck her hand and arm. The abuse was confirmed by video review and interviews with facility staff.
Deficiencies (1)
Failure to protect Resident 1 from physical abuse by a Certified Nursing Assistant who forcefully handled and struck the resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Named in physical abuse finding involving forceful handling and striking of Resident 1. |
| Director of Nursing | Director of Nursing | Provided progress notes confirming abuse and participated in interviews confirming abuse. |
| Health Information Director | Health Information Director | Confirmed physical abuse after video review and interview. |
| Administrator | Administrator | Confirmed physical abuse during interview on 5/8/24. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 20, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to recognize and accommodate a resident's food allergy, which resulted in the resident being served fish despite an allergy to fish and shellfish.
Complaint Details
The complaint investigation found that Resident 1 was allergic to fish and shellfish but was served fish on 12/1/23. The resident required diphenhydramine to treat the allergic reaction. The allergy was documented upon admission but missed by dietary staff. The complaint was substantiated.
Findings
The facility's dietary services failed to recognize Resident 1's allergy to fish and shellfish, resulting in the resident being served fish for lunch and requiring medication to prevent a severe allergic reaction. Interviews with the Director of Nursing and Dietary Supervisor confirmed the allergy was missed upon admission and the fish was served on 12/1/23.
Deficiencies (1)
Failure to ensure each resident receives food that accommodates allergies, intolerances, and preferences, resulting in Resident 1 being served fish despite a known allergy.
Report Facts
Date of survey completion: Dec 20, 2023
Date of allergy documentation: Nov 30, 2023
Date of allergic reaction medication order: Dec 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed Resident 1's allergies and transfer documents during interview |
| Dietary Supervisor | Dietary Supervisor | Confirmed missing Resident 1's allergies and serving fish during interview |
Inspection Report
Routine
Census: 109
Deficiencies: 14
Date: Nov 16, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, safety, medication administration, food service, and facility maintenance.
Findings
The facility was found deficient in multiple areas including unsafe and unclean resident environment, inaccurate resident assessments, untimely care plan revisions, inadequate nail care, missing annual CNA performance evaluations, failure to post daily nurse staffing, unsecured controlled medication storage, medication administration errors, improper food texture preparation, unsafe food storage and distribution, unlabeled resident food brought from outside, broken wheelchair equipment, call lights out of reach for residents, and unclean shared bathroom conditions.
Deficiencies (14)
Resident 61's room had a broken closet door, two missing drawers, trash in the bottom drawer, and an unclean shared bathroom with urine smell and brown-like substance on the floor.
Resident 102's immediate environment was empty and the walls were bare, and the resident had food particles in bed.
Minimum Data Set (MDS) assessments were inaccurate for three residents, including incorrect discharge status, active pneumonia diagnosis, and insulin administration without physician order.
Care plans for Resident 93 were not reviewed and revised timely, specifically for indwelling urinary catheter and acute pain related to catheter placement.
Resident 8's fingernails were long and packed with brownish-black substance, indicating failure to maintain nail care.
Annual performance evaluations were not completed for eight sampled CNAs.
Facility failed to post daily nurse staffing information for licensed and unlicensed nursing staff.
Expired or discontinued controlled medications were stored in a file cabinet not permanently affixed to a permanent structure.
Medication administration error rate was 9.38%, exceeding the 5% threshold, including missed doses, wrong formulation, and improper patch application.
Food for residents on Minced and Moist and Soft and Bite-size diets was not prepared to proper size specifications, creating choking hazards.
Freezer door had ice buildup and floor ice, and meal trays were delivered without tray tickets, risking food safety and incorrect meal delivery.
Foods brought in by visitors were stored without proper labeling with resident name and date, risking food safety and misidentification.
Wheelchairs for Resident 20 and Resident 32 were in disrepair with a broken brake handle and torn arm rest respectively.
Call lights were not within reach for four residents, decreasing their ability to summon timely assistance.
Report Facts
Census: 109
Medication error rate: 9.38
Medication pass opportunities: 32
Medication errors observed: 3
Number of CNAs without annual performance evaluations: 8
Number of residents affected by food texture deficiency: 24
Number of residents with call light out of reach: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 7 | CNA | Verified missing drawers and trash in Resident 61's room |
| Licensed Nurse 6 | LN | Verified missing drawers and broken closet door in Resident 61's room |
| Social Services Director | SSD | Discussed Resident 61's broken drawers and plan for replacement |
| Maintenance Supervisor | MS | Discussed awareness and repair status of broken drawers in Resident 61's room |
| Director of Nursing | DON | Confirmed expectations for care plan revisions, medication administration, and call light placement |
| Licensed Nurse 2 | LN | Observed medication administration errors including missed dose and improper patch application |
| Licensed Nurse 5 | LN | Observed medication administration error with aspirin formulation |
| Registered Dietician | RD | Confirmed improper food sizing for modified diets |
| Dietary Supervisor | DS | Explained diets and confirmed improper food sizing and freezer ice buildup |
| Certified Nursing Assistant 10 | CNA | Confirmed broken wheelchair brake handle and torn arm rest |
| Licensed Nurse 7 | LN | Discussed policy for labeling outside food and confirmed unlabeled food items |
| Certified Nursing Assistant 1 | CNA | Confirmed call lights were out of reach for residents |
| Assistant Director of Nursing | ADON | Discussed meal tray delivery process and labeling, and food labeling policy |
| Administrator | ADM | Confirmed observations of torn wheelchair arm rest and bathroom cleanliness issues |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 10, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to submit the results of an abuse allegation investigation involving two residents within the required 5 working days.
Complaint Details
The complaint investigation was substantiated by the finding that the facility did not submit the required investigative summary within 5 working days after the incident involving Resident 1 and Resident 2.
Findings
The facility failed to submit an investigative summary of an abuse allegation involving two residents to the Department of Public Health within 5 working days, decreasing the potential to protect residents from abuse.
Deficiencies (1)
Failure to submit the results of an abuse allegation investigation involving two residents within 5 working days to the Department of Public Health.
Report Facts
Working days for report submission: 5
Working days delay: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator (ADM) | Confirmed the 5 day follow up should have been sent and stated no fax confirmation was available |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to protect a resident from unconsented sexual contact with another resident.
Complaint Details
The complaint investigation found that Resident 1, with severe cognitive impairment, was found in Resident 2's room engaged in sexual intercourse without consent. Resident 2 was found to have capacity to consent, but Resident 1 did not. The facility's policies prohibit abuse and require consent for sexual activity.
Findings
The facility failed to protect one resident from unconsented sexual contact by another resident, violating the resident's right to be free from sexual abuse. Interviews and record reviews confirmed the incident and the residents' cognitive impairments and consent capacities.
Deficiencies (1)
Failure to protect a resident from unconsented sexual contact by another resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Interviewed regarding the incident and described the scene in Resident 2's room. |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Discovered the residents engaged in sexual intercourse and reported the incident. |
| Social Service Director | Social Service Director | Interviewed and confirmed residents' capacity to consent and details of the incident. |
| Director of Nursing | Director of Nursing | Interviewed and confirmed expectation that residents must give consent before sexual interaction. |
Inspection Report
Routine
Census: 119
Deficiencies: 2
Date: Jul 28, 2023
Visit Reason
The inspection was conducted to ensure the facility provided adequate care and treatment to residents, particularly those with episodes of wandering, and to verify compliance with professional standards of practice.
Findings
The facility failed to ensure three residents with episodes of wandering received appropriate treatment and care, specifically regarding the application of sunscreen to prevent sunburn and skin irritation during high temperatures. Documentation and staff adherence to physician orders for sunscreen application were lacking, and the facility was unable to provide policies for following physician orders and providing adequate care upon request.
Deficiencies (2)
Failure to ensure residents with wandering episodes received sunscreen treatment as ordered, with missing staff signatures on Treatment Administration Records and lack of documented sunscreen application on 7/14/23.
Facility unable to provide policy and procedure for following physician orders and providing adequate care and treatment according to resident's needs upon request.
Report Facts
Residents affected: 3
Census: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 (LN 1) | Interviewed regarding resident supervision and sunscreen application | |
| Treatment Nurse (TN) | Interviewed regarding sunscreen distribution and application | |
| Director of Nursing (DON) | Interviewed regarding resident orders for sunscreen and staff encouragement | |
| Infection Preventionist (IP) | Interviewed regarding Treatment Administration Record documentation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2023
Visit Reason
The inspection was conducted following a complaint alleging sexual abuse between two residents, where Resident 1 was observed performing oral sex on Resident 2.
Complaint Details
The complaint was substantiated based on CNA 1's observation on 4/14/23 of Resident 1 performing oral sex on Resident 2. Interviews with the Director of Nursing and CNA 1 confirmed the incident. Both residents were cognitively impaired and unable to consent.
Findings
The facility failed to ensure Resident 2 was free from sexual abuse when Resident 1 was observed performing oral sex on Resident 2. Both residents had severe cognitive impairments and were not capable of consenting. The facility's policies prohibit abuse and require consent from legal guardians for sexual relationships.
Deficiencies (1)
Failure to protect Resident 2 from sexual abuse by Resident 1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Witnessed the sexual abuse incident between Resident 1 and Resident 2. |
| Director of Nursing | Director of Nursing | Interviewed regarding the incident and facility expectations on sexual interactions between residents. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 12, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the use of physical restraints on a resident, specifically an incident where a nurse held a resident's door closed, restricting the resident's movement.
Complaint Details
The complaint was substantiated based on interviews and record review indicating that a nurse held Resident 2's door closed while the resident was trying to exit, restricting the resident's movement.
Findings
The facility failed to ensure one of three sampled residents was free from restraints when Licensed Nurse 1 held Resident 2's door closed, restricting the resident's ability to move about the facility. This was confirmed through interviews, record reviews, and policy examination.
Deficiencies (1)
Failure to ensure Resident 2 was free from physical restraints when Licensed Nurse 1 held the resident's door closed, restricting movement.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Named in the finding for holding Resident 2's door closed, restricting movement. | |
| Director of Nursing | Interviewed and stated the incident should never have happened. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision that led to an incident where one resident hit another, and the licensed nurse failed to intervene.
Complaint Details
The complaint investigation found that Licensed Nurse 2 failed to intervene when Resident 2 struck Resident 1, and the facility could not provide its policy and procedure for follow-up on resident safety. The level of harm was minimal and affected a few residents.
Findings
The facility failed to provide adequate supervision to ensure the safety and security of residents, specifically when Licensed Nurse 2 hid behind a door and did not prevent Resident 2 from striking Resident 1. The facility was also unable to provide its policy and procedure for follow-up on resident safety.
Deficiencies (2)
Failure to provide supervision to ensure safety and security of residents, allowing Resident 2 to hit Resident 1 without intervention by Licensed Nurse 2.
Facility was unable to provide policy and procedure for follow-up on resident safety.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 2 | Licensed Nurse | Named in finding for failing to intervene during resident altercation. |
| Director of Nursing | Director of Nursing | Interviewed regarding the incident and stated the story was confusing. |
Inspection Report
Routine
Deficiencies: 12
Date: Dec 9, 2021
Visit Reason
The inspection was conducted as a routine regulatory survey of Windsor Care Center of Sacramento to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, accommodation of resident needs and preferences, accurate resident assessments, provision of appropriate care, medication storage and handling, food safety and sanitation, infection prevention and control, and staff adherence to policies. Several residents experienced unmet needs, privacy violations, and improper care practices.
Deficiencies (12)
Failure to protect privacy rights when CNA sat on resident's bed while assisting with eating.
Failure to treat resident with dignity and respect when staff referred to resident as a feeder in public.
Failure to reasonably accommodate resident needs including call light placement, shower scheduling, and social dining participation.
Failure to ensure privacy during personal care due to missing or inadequate curtains.
Failure to ensure accurate resident assessment resulting in inaccurate medical record.
Failure to provide appropriate treatment and care including missed showers, ignoring food preferences, and not following diet orders.
Failure to maintain resident's health by not documenting severe weight loss.
Failure to ensure licensed nursing staff understand safe storage of medication pass supplements.
Failure to ensure safe and secure labeling and storage of medications and biologicals including expired supplies, improper refrigerator temperatures, and expired emergency kits.
Failure to ensure food safety and sanitation including improper sanitizing procedures, expired thawed health shakes, unrefrigerated peanut butter and jelly sandwiches, wet pans stored ready for use, dirty kitchen equipment, damaged storage containers, and inadequate facility maintenance.
Failure to accommodate resident food preferences and provide beverages of choice.
Failure to maintain an infection prevention and control program including damaged resident furniture, staff sitting on resident beds, improper mask wearing, and torn/soiled masks worn by staff.
Report Facts
Residents sampled: 21
Facility census: 101
Weight loss percentage: 11.5
Medication pass supplement open time: 4
Refrigerator temperature range: 36-46
Observed refrigerator temperature: 30
Health shake storage duration: 14
Peanut butter and jelly sandwich count: 20
Sanitizer submersion time: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Sat on resident's bed while assisting with eating and referred to resident as a feeder |
| Director of Staff Development | Interviewed regarding CNA sitting on bed and staff training | |
| Assistant Director of Nursing | Interviewed regarding CNA sitting on bed, shower documentation, diet orders, medication storage, and mask policy | |
| Resident 67 | Reported not receiving showers, food dislikes ignored, and emotional distress | |
| Resident 21 | Reported preference for coffee not honored | |
| Licensed Nurse 2 | Interviewed about medication pass supplement storage | |
| Licensed Nurse 4 | Interviewed about medication pass supplement storage | |
| Licensed Nurse 5 | Interviewed about medication pass supplement storage | |
| Nursing Supervisor 1 | Interviewed about expired glucose strips and emergency kits | |
| Dietary Manager | Interviewed about sanitizing procedures and food storage | |
| Dietary Aide | Interviewed about beverage dispenser sanitizing | |
| Regional Clinical Director | Interviewed about emergency kit expiration | |
| Pharmacy Consultant | Interviewed about expired supplies and emergency kit expiration | |
| Certified Nursing Assistant 2 | Assisted resident with meal substitution | |
| Maintenance Supervisor | Interviewed about refrigerator gasket and facility maintenance | |
| Dietitian | Interviewed about food preferences and kitchen attire policy | |
| Cook 1 | Observed and interviewed about sanitizing solution testing and kitchen attire | |
| Cook 2 | Observed with improper kitchen attire | |
| Certified Nursing Assistant 4 | Observed wearing torn and soiled face mask | |
| Licensed Nurse 3 | Observed wearing mask under nose | |
| Nursing Supervisor 2 | Observed wearing mask under nose |
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