Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
158% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident 1 left the facility premises without staff knowledge, resulting in serious injury and death.
Complaint Details
The complaint investigation was substantiated. Resident 1 left the facility without authorization multiple times, including an incident leading to death. The facility failed to conduct proper elopement evaluations, care planning, and documentation. Immediate jeopardy was declared and later removed after corrective actions.
Findings
The facility failed to provide adequate supervision for Resident 1, who eloped from the facility and was found unresponsive at a bus stop. The resident was resuscitated but later died in an acute care hospital. The facility lacked proper elopement risk evaluation, care planning, and documentation related to Resident 1's wandering behavior.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision to prevent Resident 1 from leaving the premises unattended, resulting in immediate jeopardy to resident health or safety. Resident 1 eloped, was found unresponsive, and later died.
Report Facts
Residents at risk for elopement monitored: 13
Residents evaluated for elopement risk: 65
Residents involved in incident: 1
Date of survey completion: Apr 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator (ADM) | Present during immediate jeopardy declaration and involved in corrective actions. | |
| Director of Nursing (DON) | Present during immediate jeopardy declaration, involved in corrective actions, and interviewed regarding findings. | |
| Regional Clinical Resource Nurse (RCRN) | Present during immediate jeopardy declaration and provided education on elopement. | |
| Assistant Director of Nursing (ADON) | Involved in staff in-service and corrective actions. | |
| Licensed Vocational Nurse (LVN) | Assigned nurse to Resident 1, interviewed about elopement incident. | |
| Certified Nursing Assistant (CNA) | Provided care and observations related to Resident 1's whereabouts. | |
| Social Services Director (SSD) | Interviewed about Resident 1's elopement and facility response. |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 14, 2025
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident dignity, privacy, medication management, infection control, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy with uncovered Foley catheter bags, inadequate protection of resident health information, inaccurate PASARR screening, discrepancies in controlled medication administration records, improper medication storage with food, unsanitary kitchen conditions, and lapses in infection prevention and control practices.
Deficiencies (7)
F 0550: The facility failed to ensure dignity and privacy for two residents when Foley catheter drain bags were left uncovered, potentially affecting psychosocial well-being and health.
F 0583: The facility failed to protect one resident's rights to confidentiality when a nurse left a computer screen with protected health information unattended.
F 0645: The facility failed to ensure accurate PASARR Level 1 screening for one resident, risking inappropriate placement and services.
F 0755: The facility failed to ensure controlled medications were fully accounted for and administered according to physician orders for two residents, resulting in inaccurate medication accountability.
F 0761: The facility failed to follow policy for proper labeling and storage of medications when food was stored on two medication carts, risking cross contamination.
F 0812: The facility failed to maintain sanitary conditions in the kitchen, including use of burned utensils, rusted trays, unclean bug light traps, and failure to check sanitizer test strip expiration dates.
F 0880: The facility failed to implement infection control measures including improper storage of nasal cannula tubing, lack of hand hygiene by staff, missing enhanced barrier precaution signage, improper disinfection of medication bottle caps, and inappropriate handling of Foley catheter bags.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 69
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN D | Registered Nurse | Named in confidentiality breach for leaving computer screen unattended |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including catheter bag privacy, medication discrepancies, and infection control |
| Physical Therapy Assistant | Physical Therapy Assistant | Named for hanging Foley catheter bag on cargo pants pocket |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding dignity and infection control related to Foley catheter bag handling |
| Licensed Vocational Nurse E | Licensed Vocational Nurse | Observed storing food in medication cart and cleaning medication bottle cap improperly |
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen sanitation deficiencies |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 26, 2024
Visit Reason
The inspection was conducted to assess compliance with safety and infection control regulations in the nursing home.
Findings
The facility failed to maintain safe hot water temperatures, exposing residents and staff to burn risks, and failed to implement proper infection control practices related to handling soiled linen and waste, potentially spreading infection.
Deficiencies (2)
F 0689: The facility failed to ensure hot water temperatures at sinks in Rooms AA and BB were within safe limits, measuring 127 F and 130 F respectively, risking burns to residents and staff.
F 0880: The facility failed to implement infection control practices when CNAs placed soiled linen and towels on restroom floors and carried soiled items and trash out of resident rooms into hallways, risking infection spread.
Report Facts
Hot water temperature: 127
Hot water temperature: 130
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 30, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely issue the Notice of Medicare Non-Coverage (NOMNC) to a resident, potentially compromising the resident's right to appeal the discontinuation of Medicare covered services.
Complaint Details
The complaint investigation found that the facility did not timely issue the NOMNC to Resident 1, potentially compromising the resident's right to appeal the discontinuation of Medicare covered services. The social services director and director of nursing confirmed lack of documentation for timely issuance.
Findings
The facility failed to ensure the NOMNC was issued in a timely manner for one of three sampled residents. Documentation showed the NOMNC was signed on the same day Medicare covered services ended, with no evidence of earlier issuance or refusal to sign, limiting the resident's opportunity to appeal.
Deficiencies (1)
F 0582: The facility failed to issue the Notice of Medicare Non-Coverage at least two calendar days before Medicare covered services ended, limiting the resident's ability to appeal the decision. Documentation did not show any prior attempt to issue the notice or resident refusal to sign.
Inspection Report
Deficiencies: 15
Date: Jul 28, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, care, medication management, food safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity, incomplete documentation of advance directives and transfer notices, inaccurate resident assessments, medication administration errors, inadequate activity provision, behavioral health management, pharmaceutical controls, medication storage, food palatability, sanitation, pest control, and infection prevention practices.
Deficiencies (15)
F 0550: The facility failed to ensure the dignity of one resident when a CNA improperly wrapped a sheet around the resident's legs, restricting movement and violating the resident's rights.
F 0578: The facility failed to inform one resident about advance directives, risking inappropriate medical decisions.
F 0623: The facility failed to provide timely notification of transfer and discharge to residents, responsible parties, and the State Long-Term Care Ombudsman for two residents.
F 0641: The facility failed to accurately complete the Minimum Data Set assessment for one resident, omitting a documented fall.
F 0658: The facility failed to provide care and services according to professional standards for three residents, including failure to notify physicians of medication refusals and incorrect insulin administration.
F 0679: The facility failed to provide activities for one resident, negatively affecting the resident's well-being.
F 0740: The facility failed to monitor and manage behavioral health for one resident exhibiting disruptive behavior, causing discomfort to a roommate.
F 0755: The facility failed to ensure controlled medications were fully accounted for and administered according to physician orders for two residents.
F 0757: The facility failed to ensure one resident's medication regimen was free from unnecessary drugs, with prolonged use of metoclopramide without risk/benefit assessment.
F 0761: The facility failed to maintain medication refrigerator temperatures within acceptable range, risking medication effectiveness.
F 0804: The facility failed to ensure food was palatable, with multiple residents complaining of bland food.
F 0812: The facility failed to ensure food was stored and prepared under sanitary conditions, with crusty residue on the ice machine and improper sanitizer testing.
F 0814: The facility failed to properly store refuse, with an overfilled dumpster and open lid, risking pest attraction.
F 0880: The facility failed to perform hand hygiene during wound treatment for one resident, risking infection.
F 0925: The facility failed to maintain an effective pest control program, with live fruit flies observed in the kitchen after recent treatment.
Report Facts
Medication refusals: 20
Insulin units administered: 13
Temperature out-of-range readings: 27
Live fruit flies: 22
Live fruit flies observed: 11
Norco tablets unaccounted: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Failed to notify physician of repeated medication refusals for Resident 7. |
| LVN E | Licensed Vocational Nurse | Administered 13 units of insulin instead of 6 units and notified physician after administration. |
| LVN A | Licensed Vocational Nurse | Failed to perform hand hygiene during wound treatment for Resident 6. |
| DA B | Dietary Aid | Did not check temperature of kitchen surface sanitizer before testing. |
| Director of Nursing | Director of Nursing | Interviewed multiple times confirming findings and deficiencies. |
| Dietary Manager | Dietary Manager | Confirmed presence of crusty residue on ice machine and live fruit flies in kitchen. |
| Regional Clinical Resource Nurse | Regional Clinical Resource Nurse | Assisted in investigation of dignity violation incident. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 28, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the improper use of a sheet wrapped around Resident 317's lower body, potentially violating the resident's right to dignity.
Complaint Details
The complaint was substantiated. The investigation confirmed that Resident 317 had a sheet wrapped and knotted around her lower legs, which was not proper procedure and violated her dignity rights.
Findings
The facility failed to ensure the dignity of Resident 317 when a certified nursing assistant wrapped a sheet around the resident's lower body in a manner that was not proper procedure. The sheet was tied around the resident's legs, which was against the resident's rights and raised concerns about restraint and dignity.
Deficiencies (1)
F 0550: The facility failed to honor the resident's right to a dignified existence and self-determination when CNA G did not use proper technique in modestly covering Resident 317's unclothed lower body by wrapping a sheet around her legs.
Report Facts
Residents Affected: 1
Sampled residents: 17
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA G | Certified Nursing Assistant | Named in the finding for improper sheet wrapping around Resident 317. |
| CNA H | Certified Nursing Assistant | Witnessed the improper sheet wrapping and reported it. |
| ADM I | Administrator | Spoke with CNA G about the incident and recommended retraining. |
| Director of Nursing | Director of Nursing | Interviewed during the investigation and received report from CNA H. |
| Regional Clinical Resource Nurse | Regional Clinical Resource Nurse | Assisted in investigation and recreation of the sheet wrapping. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 11, 2023
Visit Reason
The inspection was conducted in response to a complaint regarding the misappropriation of a resident's property involving unauthorized purchases made on the resident's debit card.
Complaint Details
The complaint was substantiated. Resident 1 reported unauthorized purchases totaling around $400 over several months. The facility investigation confirmed the Activities Director made purchases without the resident's authorization and accepted gifts from the resident, violating policy.
Findings
The facility failed to protect one resident from financial exploitation by an Activities Director who made unauthorized purchases using the resident's debit card. The Activities Director was suspended and given a written reprimand for violating facility policy by accepting gifts from the resident.
Deficiencies (1)
F 0602: The facility failed to protect a resident from wrongful use of her belongings by allowing unauthorized purchases on her debit card. The Activities Director accepted gifts from the resident, violating facility policy.
Report Facts
Unauthorized purchase amount: 400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding Resident 1's complaint and facility policies | |
| Activities Director | Employee who made unauthorized purchases and accepted gifts from Resident 1 | |
| Administrator | Interviewed about the complaint investigation and disciplinary actions |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Feb 8, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to maintain the water circulating system in safe operating condition, resulting in residents being unable to shower regularly due to no warm or hot water.
Complaint Details
The complaint was substantiated. The facility was aware of low water temperatures for about a month, causing residents to receive fewer showers than scheduled.
Findings
The facility failed to maintain adequate water temperatures in residents' rooms and shower rooms, with water temperatures significantly below the required 100 to 120 Fahrenheit range. Several residents reported fewer showers than scheduled due to cold water, confirmed by interviews and review of Activities of Daily Living records.
Deficiencies (1)
F 0908: The facility failed to maintain the water circulating system in safe operating condition for 60 residents, resulting in no warm or hot water in shower rooms or residents' rooms. Water temperatures ranged from 82 to 91.4 Fahrenheit, below the required 100 to 120 Fahrenheit.
Report Facts
Residents affected: 60
Resident 1 showers: 5
Resident 2 showers: 6
Resident 4 showers: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator (ADM) | Confirmed water temperatures and stated the water circulating system should be repaired promptly |
| Director of Nursing | Director of Nursing (DON) | Reviewed resident assessments and confirmed cognition intact; stated some residents received fewer showers due to lack of hot water |
| Janitor | Janitor (JN) | Measured water temperatures and confirmed facility awareness of low water temperature |
Inspection Report
Annual Inspection
Capacity: 75
Deficiencies: 12
Date: Jun 26, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with healthcare regulations and standards at Windsor Skyline Care Center.
Findings
The facility was found deficient in multiple areas including resident dignity during meal assistance, failure to provide required notices to Medicare residents, incomplete restorative nursing services, inadequate accident prevention measures, improper IV site care, incomplete dialysis communication records, medication management issues, unsafe food storage, and infection control lapses.
Deficiencies (12)
F 0550: Facility failed to promote resident dignity when CNAs stood while assisting with meals for four residents, potentially decreasing residents' self-esteem.
F 0582: Facility failed to provide Notice of Medicare Non-Coverage to two discharged residents, potentially preventing timely appeals.
F 0688: Facility failed to provide restorative nursing assistant services as ordered for two residents, risking decline in functional abilities.
F 0689: Facility failed to prevent accidents by not providing bolster in bed, not completing neurological assessments after falls, and allowing fire hazards in residents' rooms.
F 0694: Facility failed to ensure proper care of IV site dressing and accurate measurement of arm circumference and catheter length for one resident, risking IV complications.
F 0698: Facility failed to complete dialysis communication records for one resident, risking undetected dialysis complications.
F 0757: Facility failed to ensure adequate behavioral and adverse effect monitoring for Seroquel use in one resident, risking adverse drug reactions.
F 0758: Facility failed to limit Alprazolam use to 14 days for one resident, risking adverse drug reactions.
F 0761: Facility failed to ensure medications were properly labeled, unused narcotics disposed of timely, and discontinued narcotics secured, risking medication errors and diversion.
F 0810: Facility failed to provide a plateguard during lunch for one resident, potentially affecting self-feeding ability.
F 0812: Facility failed to store, prepare, and distribute food safely due to torn, dirty refrigerator/freezer gaskets, rusted racks, and freezer burn on food, risking foodborne illness.
F 0880: Facility failed to implement infection control by storing used lancets in an unlocked freezer in an unlocked biohazardous waste area, risking infectious disease exposure.
Report Facts
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 75
Lancets found: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN J | Licensed Vocational Nurse | Confirmed lack of behavioral and adverse effect monitoring for Seroquel and Alprazolam duration issue |
| RN B | Registered Nurse | Interviewed regarding IV site care and measurements for Resident 66 |
| ADON | Associate Director of Nursing | Confirmed multiple findings including medication labeling, narcotics handling, infection control, and IV site care |
| CNA E | Certified Nursing Assistant | Observed standing while assisting meals and acknowledged fire hazards in residents' rooms |
| CNA G | Certified Nursing Assistant | Observed standing while assisting meals and confirmed alarm device issues |
| CNA F | Certified Nursing Assistant | Observed standing while assisting meals |
| CNA H | Certified Nursing Assistant | Observed not using plateguard during meal for Resident 61 |
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