Citations (last 3 years)
Citations (over 3 years)
16 citations/year
Citations are regulatory findings recorded during state inspections.
300% worse than California average
California average: 4 citations/yearCitations per year
28
21
14
7
0
Inspection Report
Citations: 1
Date: Aug 8, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control requirements, specifically focusing on the use and implementation of personal protective equipment (PPE) during a Covid-19 outbreak.
Findings
The facility failed to ensure consistent implementation and proper use of PPE, including improper or absent use of N95 respirators and face masks by staff and visitors. These failures posed a potential risk to the health and safety of residents and visitors due to exposure to respiratory illness.
Citations (1)
F 0880: The facility failed to ensure consistent implementation and proper use of personal protective equipment (PPE). Staff and visitors were observed not wearing or improperly wearing N95 respirators and face masks during a Covid-19 outbreak.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Infection Preventionist | Named in observations and interviews regarding PPE use and infection control. |
| Licensed Vocational Nurse 1 | LVN | Observed not wearing face mask properly. |
| Housekeeper 1 | Housekeeper | Observed not wearing face mask properly. |
| Receptionist 1 | Receptionist | Observed with face mask pulled down under chin. |
| Certified Nursing Assistant 1 | CNA | Observed wearing N95 respirator improperly. |
| Certified Nursing Assistant 2 | CNA | Observed wearing N95 respirator improperly. |
| Registered Nurse 1 | RN | Observed not wearing face covering at start of shift. |
Inspection Report
Routine
Citations: 1
Date: Aug 8, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control protocols, particularly related to the use of personal protective equipment (PPE) during a Covid-19 outbreak.
Findings
The facility failed to ensure consistent implementation and proper use of PPE, including improper or absent use of N95 respirators and face masks by staff and visitors, which posed potential health risks due to exposure to respiratory illness.
Citations (1)
Failure to ensure consistent implementation and proper use of personal protective equipment (PPE), including improper wearing or absence of N95 respirators and face masks by staff and visitors.
Report Facts
Date of survey completion: Aug 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Observed not wearing face mask properly |
| Housekeeper 1 | Housekeeper | Observed not wearing face mask properly |
| Receptionist 1 | Receptionist | Observed with face mask pulled down under chin |
| Assistant Director of Nursing/Infection Preventionist | ADON/IP | Interviewed regarding PPE policies and observations |
| Certified Nursing Assistant 1 | CNA | Observed wearing N95 respirator improperly |
| Certified Nursing Assistant 2 | CNA | Observed wearing N95 respirator improperly |
| Registered Nurse 1 | RN | Observed not wearing face mask at start of shift |
| Administrator | ADM | Interviewed about infection prevention coverage during IP leave |
Inspection Report
Annual Inspection
Citations: 5
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements for Country Drive Post Acute nursing home, including resident care, medication management, staffing, and dialysis services.
Findings
The facility was found deficient in providing individualized activities for residents, ensuring proper dialysis care coordination, maintaining adequate nursing staff hours, medication administration accuracy, and proper medication labeling and storage. Deficiencies were generally of minimal harm but affected multiple residents.
Citations (5)
Failed to provide activities for one resident based on assessment and care plan, risking isolation and boredom.
Failed to ensure ongoing and consistent collaboration with dialysis center for one resident, including missing current physician orders and inconsistent dialysis site assessments.
Failed to ensure minimum of 3.5 Direct Care Service Hours Per Patient Day and 2.4 CNA DHPPD on ten weekend days.
Failed to ensure accurate medication administration technique for insulin, resulting in an 8% medication error rate exceeding federal threshold.
Failed to ensure prescription medications were properly labeled and stored; medication refrigerator was operating at 14°F, risking insulin degradation.
Report Facts
Residents sampled: 23
Residents sampled: 29
Residents sampled: 25
Medication error rate: 8
Direct Care Service Hours Per Patient Day (DHPPD): 3.49
Certified Nursing Assistant DHPPD: 2.23
Direct Care Service Hours Per Patient Day (DHPPD): 3.42
Certified Nursing Assistant DHPPD: 2.19
Direct Care Service Hours Per Patient Day (DHPPD): 3.18
Certified Nursing Assistant DHPPD: 1.84
Direct Care Service Hours Per Patient Day (DHPPD): 3.07
Certified Nursing Assistant DHPPD: 1.86
Direct Care Service Hours Per Patient Day (DHPPD): 3.2
Certified Nursing Assistant DHPPD: 2.04
Direct Care Service Hours Per Patient Day (DHPPD): 3.38
Certified Nursing Assistant DHPPD: 1.99
Direct Care Service Hours Per Patient Day (DHPPD): 3.12
Certified Nursing Assistant DHPPD: 1.99
Direct Care Service Hours Per Patient Day (DHPPD): 3.11
Certified Nursing Assistant DHPPD: 1.93
Direct Care Service Hours Per Patient Day (DHPPD): 3.27
Certified Nursing Assistant DHPPD: 2.07
Direct Care Service Hours Per Patient Day (DHPPD): 3.18
Certified Nursing Assistant DHPPD: 1.79
Medication refrigerator temperature: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Named in medication administration error finding and medication labeling observation |
| AD | Activity Director | Named in activity deficiency and care plan absence |
| DON | Director of Nursing | Interviewed regarding importance of activity assessment |
| DSD | Director of Staff Development | Interviewed regarding dialysis communication binder and staffing |
| SDA | Staff Developer Assistant | Interviewed regarding staffing schedules |
| PC | Payroll Coordinator | Provided staffing and census data |
| Nursing supervisor 1 | Nursing Supervisor | Acknowledged medication refrigerator temperature issue |
Inspection Report
Complaint Investigation
Citations: 1
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to prevent and properly manage a pressure ulcer in a resident who was using a leg immobilizer.
Complaint Details
The investigation was triggered by a complaint regarding the development of a pressure ulcer in Resident 1. The complaint was substantiated as the facility failed to monitor and intervene appropriately to prevent the ulcer.
Findings
The facility failed to ensure proper monitoring and interventions to prevent pressure ulcers for one resident, resulting in a facility-acquired, unstageable pressure ulcer on the right lower leg. Documentation and skin checks under the immobilizer were inadequate, and the care plan was not updated to reflect the risk or presence of the ulcer.
Citations (1)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in actual harm to a resident with a device-related pressure ulcer on the right lower leg.
Report Facts
Residents Affected: 3
Pressure ulcer measurement: 10
Pressure ulcer measurement: 3
Braden Scale score: 13
BIMS score: 10
Inspection Report
Citations: 1
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards related to pressure ulcer prevention and treatment at Country Drive Post Acute facility.
Findings
The facility failed to ensure proper monitoring and interventions to prevent pressure ulcers for one sampled resident, resulting in a facility-acquired, unstageable pressure ulcer on the right lower leg caused by an immobilizer. Documentation and skin checks under the immobilizer were inadequate, and the care plan was not updated accordingly.
Citations (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, specifically inadequate monitoring of skin under immobilizer leading to unstageable pressure ulcer.
Report Facts
Residents Affected: 3
Residents Affected: Few
Pressure ulcer measurement: 10
Pressure ulcer measurement: 3
Braden Scale score: 13
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) 1 | Stated no wound measurement was done when pressure ulcer was discovered | |
| Director of Nursing (DON) | Unable to show skin checks under immobilizer were performed; stated skin should be checked at least once every shift | |
| Registered Nurse (RN) 1 | Stated skin checks under immobilizer would be documented in treatment administration record | |
| Certified Nursing Assistant (CNA) 1 | Stated only licensed nurses would check skin under immobilizer |
Inspection Report
Annual Inspection
Citations: 1
Date: Jul 25, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulations regarding medication management and resident care.
Findings
The facility failed to ensure adequate monitoring of adverse effects for one resident administered buspirone, an anti-anxiety medication. The deficiency had minimal harm potential and affected a few residents.
Citations (1)
F 0757: The facility failed to ensure Resident 1 was administered buspirone with adequate monitoring of adverse effects. This failure could delay management of adverse effects and lead to unnecessary medication use.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding medication administration record and monitoring of adverse effects for Resident 1 |
Inspection Report
Citations: 1
Date: Jul 25, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding medication management, specifically ensuring that residents' drug regimens are free from unnecessary drugs.
Findings
The facility failed to ensure adequate monitoring of adverse effects for Resident 1 who was administered buspirone, an anti-anxiety medication, rather than an antipsychotic. This failure had the potential to delay management of adverse effects and unnecessary medication use. The facility's policy requires monitoring and documentation of medication effects, including adverse effects, which was not properly followed.
Citations (1)
Failure to ensure Resident 1 was administered buspirone with adequate monitoring of adverse effects from the medication.
Report Facts
Medication dosage: 5
Date of survey completion: Jul 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding medication administration record and monitoring for Resident 1 |
Inspection Report
Routine
Citations: 9
Date: May 18, 2023
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations, focusing on care planning, treatment, medication administration, dialysis care, medication error rates, and food service sanitation.
Findings
The facility was found deficient in multiple areas including failure to develop baseline care plans within 48 hours of admission, incomplete care plan revisions, inadequate fingernail care, lack of physician orders for oxygen administration, incomplete dialysis communication records, improper use of psychotropic medication without adequate diagnosis, medication errors including omissions and incomplete administration via G-tube, and poor sanitation in the dietary three compartment sink.
Citations (9)
Failed to develop a baseline care plan for one of six residents within 48 hours of admission.
Failed to review and revise a comprehensive plan of care within 7 days of assessment for one resident.
Failed to ensure one resident had clean and groomed fingernails.
Failed to obtain a physician's order for oxygen administration for one resident.
Failed to complete dialysis communication records for three residents.
Failed to document adequate indication and diagnosis for use of psychotropic medication (Seroquel) for one resident.
Medication error rate exceeded 5% with three medication omissions for one resident.
Failed to ensure one resident was free from significant medication errors; incomplete administration of medications via G-tube.
Failed to maintain cleanliness of the three compartment sink in dietary services, risking cross contamination.
Report Facts
Medication error rate: 8.33
Medication omissions: 3
Dialysis frequency: 3
Medication dosages: 50
Medication dosages: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in medication error findings related to incomplete medication administration via G-tube and medication omissions |
| DON | Director of Nursing | Interviewed regarding care plan deficiencies, medication administration expectations, and medication errors |
| AD | Assistant Director of Nursing | Interviewed regarding baseline care plan and psychotropic medication use |
| RN 1 | Registered Nurse | Interviewed regarding dialysis communication record deficiencies |
| CNA 1 | Certified Nursing Assistant | Interviewed regarding fingernail care for Resident 251 |
| LVN 3 | Licensed Vocational Nurse | Interviewed regarding oxygen order absence and fingernail care |
| SSA | Social Services Assistant | Interviewed regarding care conferences and social service needs |
| SSD | Social Services Director | Interviewed regarding care conferences and social service needs |
| DS | Dietary Supervisor | Interviewed regarding dietary sanitation deficiencies |
| ADON | Assistant Director of Nursing | Interviewed regarding psychotropic medication use and monitoring |
Inspection Report
Routine
Citations: 14
Date: Mar 21, 2019
Visit Reason
Routine inspection of Country Drive Post Acute nursing facility to assess compliance with regulatory standards and resident care.
Findings
The facility had multiple deficiencies including failure to ensure resident dignity during meals, incomplete Medicare coverage notices, inadequate care plans for pain and range of motion, medication administration errors, insufficient staffing during meals, pharmaceutical service issues, food safety violations, infection control lapses, and equipment maintenance problems.
Citations (14)
F0550: Facility staff assisted residents with meals while standing, interrupting dignity and respect during care.
F0582: Facility failed to provide complete Skilled Nursing Facility Advance Beneficiary Notices to Medicare residents, lacking signatures and cost information.
F0656: Facility failed to develop a care plan for pain for a resident with chronic pain, risking unmet pain relief needs.
F0684: Phosphate binders were not administered as ordered to dialysis-dependent residents, resulting in elevated phosphorus levels.
F0688: Facility failed to provide range of motion exercises or timely restorative nursing aide services for residents with limited mobility.
F0697: Facility failed to provide timely pain medication doses and did not follow pain management plan for residents.
F0725: Facility failed to provide adequate nursing staff to assist dependent residents with eating during lunch.
F0726: Three licensed nursing staff lacked required competency skills checks and annual performance evaluations.
F0755: Multiple medications were expired or unlabeled, controlled substances were unaccounted, and medication cart was left unsecured.
F0804: Facility failed to ensure food was served at safe and appetizing temperatures; multiple food safety violations including personal items in food storage and broken equipment.
F0809: Facility failed to offer therapeutic bedtime snacks to six residents, risking hunger and hypoglycemia.
F0812: Facility failed to store, prepare, and serve food in accordance with professional standards including unlabeled food, worn chopping boards, uncovered beard in food area, and broken refrigerator thermometer.
F0880: Facility failed to implement infection prevention and control procedures during wound care, urinary catheter care, meal assistance, and laundry handling.
F0908: Facility failed to keep essential laundry equipment safe; lint screens on dryers were full, risking fire hazard.
Report Facts
Medication error rate: 11.11
Missed phosphate binder doses: 15
Missed phosphate binder doses: 12
Missed phosphate binder doses: 9
Missed phosphate binder doses: 3
Missed phosphate binder doses: 6
Missed phosphate binder doses: 8
Dependent dining residents waiting: 6
Residents not offered bedtime snacks: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 7 | Licensed Vocational Nurse | Named in dignity failure during meal assistance and medication storage observation. |
| CNA 1 | Certified Nursing Assistant | Named in dignity failure during meal assistance and hand hygiene lapses. |
| LVN 2 | Licensed Vocational Nurse | Named in infection control failure during wound care. |
| DS | Dietary Supervisor | Named in food safety and food temperature deficiencies. |
| DON | Director of Nursing | Named in multiple interviews regarding medication errors, staffing, and infection control. |
| DSD | Director of Staff Development / Infection Prevention Nurse | Named in staff competency and infection control deficiencies. |
| RP | Registered Pharmacist | Named in failure to identify medication regimen irregularities. |
Inspection Report
Routine
Citations: 14
Date: Mar 18, 2019
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, medication management, infection control, food service, and staffing.
Findings
The facility was found deficient in multiple areas including dignity and respect during meal assistance, incomplete Medicare non-coverage notices, lack of pain care plans, medication administration errors, inadequate staffing during meals, insufficient staff competency checks, pharmaceutical service deficiencies, food safety and storage issues, infection control breaches, and equipment maintenance.
Citations (14)
Facility staff assisted residents with meals while standing, failing to ensure dignity and respect.
Facility failed to inform residents of Medicare non-coverage charges properly with incomplete or unsigned notices.
Failed to develop a care plan for pain for a resident, risking unmet pain relief needs.
Phosphate binders were not administered as ordered to dialysis-dependent residents, risking elevated phosphorus levels.
Failed to provide range of motion exercises to residents with limited mobility, risking worsening contractures.
Pain medications were not administered timely or as requested, risking inadequate pain management.
Inadequate nursing staff to assist dependent residents with eating during lunch, risking choking and distress.
Licensed staff lacked competency skills checks and annual performance evaluations.
Multiple medication management issues including expired medications, controlled substance discrepancies, unsecured medication carts, and unlabeled resident medications.
Food served at unappetizing temperatures, with some items cold.
Facility failed to provide therapeutic bedtime snacks to residents, risking hunger and hypoglycemia.
Food storage and kitchen sanitation deficiencies including unlabeled open food, worn chopping boards, personal items stored in food areas, lack of air gap in sink, uncovered beard in food service area, and broken refrigerator thermometer.
Infection control breaches including improper hand hygiene, contaminated urinary drainage bag handling, and improper wound care technique.
Laundry dryers had lint screens full of lint, risking fire hazard.
Report Facts
Medication error rate: 11.11
Missed phosphate binder doses for Resident 37: 36
Missed phosphate binder doses for Resident 76: 17
Dependent dining residents waiting for assistance: 6
Residents not offered bedtime snacks: 6
Lint screen cleaning missed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 7 | Licensed Vocational Nurse | Named in dignity and respect deficiency related to meal assistance while standing. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, pain management, medication errors. |
| CNA 1 | Certified Nursing Assistant | Named in infection control deficiency for failure to perform hand hygiene while feeding residents. |
| Director of Staff Development | Director of Staff Development | Interviewed regarding staff competency and infection control. |
| RN 4 | Registered Nurse | Named in medication administration deficiency related to phosphate binders. |
| RN 2 | Registered Nurse | Named in pain management deficiency. |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding food temperature and personal items in kitchen. |
| Housekeeping Aide | Housekeeping Aide | Named in infection control deficiency for placing linen on clean linen cart after dropping on floor. |
Viewing
Loading inspection reports...
