PLYMOUTH VILLAGE
Non profit - Corporation
48 Beds
HUMANGOOD
Data: November 2025
Trust Grade
70/100
#438 of 1155 in CA
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Plymouth Village in Redlands, California, has a Trust Grade of B, indicating it is a solid choice for families considering nursing home options. It ranks #438 out of 1,155 facilities in California, placing it in the top half, and #33 out of 54 in San Bernardino County, meaning there are only a few better choices locally. The facility is improving, with a decrease in issues from 7 in 2024 to 6 in 2025, and it has no fines recorded, which is a positive sign. However, staffing is a concern with a 47% turnover rate, which is average, and the facility has less RN coverage than 87% of California facilities, meaning residents may not receive as much specialized care as they might need. Specific incidents reported include unsanitary food preparation and storage practices, with dirt and food debris found in kitchen areas, and the use of a dirty laundry basket for clean linens, which could increase infection risk. These findings highlight both positive aspects and areas that need improvement at Plymouth Village.
- Trust Score
- B
- In California
- #438/1155
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 19 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 22 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 37%
No red flags
7 → 6 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 6 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 47%
Near California avg (46%)
Higher turnover may affect care consistency
Chain: HUMANGOOD
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 22 deficiencies on record
Jun 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure dignity was maintained for one of seven reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure dignity was maintained for one of seven residents (Residents 4) reviewed for dining observation when a Licensed Vocational Nurse (LVN 2) was standing over Resident 4 while feeding him lunch on June 16, 2025.
This failure resulted in staff not maintaining Resident 4's individuality and dignity.
Findings:
During a review of Resident 4's admission Record (contains demographic and medical information), undated, the admission Record indicated, Resident 4 was admitted to the facility on [DATE], with diagnoses of Hemiplegia, unspecified affecting right dominant side (weakness on one side of the body), Dysphasia (condition affecting speech) and dysphagia (difficulty swallowing).
During an observation on June 16, 2025, at 12:24 PM, in the second dining room, LVN 2 was standing over Resident 4 while feeding him lunch.
During an interview on June 16, 2025, at 1:00 PM, LVN 2 stated staff are expected to be seated while feeding residents.
During a concurrent interview and record review, on June 16, 2025, at 3:14 PM, with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure (P&P) titled, Assistance with Meals, revised March 2022, it indicated Dining Room Residents: . 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals . The DON stated staff should be engaging and sitting next to residents for a full meal.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe oxygen administration were provided in ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe oxygen administration were provided in accordance with the physician's orders and facility policies and procedures for one of three sampled residents (Resident 12) reviewed for respiratory care when Resident 12's oxygen tubing (a device which delivers oxygen) was not labeled to indicate the date that it was changed.
This failure had the potential for Resident 12 to be at risk of developing a respiratory infection (caused by bacteria, viruses, fungi, or parasite).
Findings:
During a review of Resident 12's clinical record, the admission Record (patient demographics), indicated, Resident 12 was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that makes it hard to breathe), diastolic (congestive) heart failure (a condition where the heart muscle is too stiff to relax properly, preventing the heart from filling with enough blood between beats), and atrial fibrillation (heart rhythm disorder).
During a review of Resident 12's Physician Order, dated February 10, 2025, the Physician Order indicated, Resident 12's had an order for Oxygen Tubing and Humidifier Change when in use every night shift, every Wednesday. The Physician Order also indicated Resident 12 had an order dated March 30, 2025, for Oxygen at 2 LPM (Liters Per Minute) continuously to maintain O2 (Oxygen) sats (saturation- levels) > (greater than) 90% (percent) every shift for COPD.
During a concurrent observation and interview on June 16, 2025, at 10:10 AM, with the Director of Staff Development (DSD), in Resident 12's room, a nasal cannula (device used to deliver supplemental oxygen to a patient through the nose) attached to an oxygen concentrator through the oxygen tubing, was found undated. The DSD stated she was not aware when the tubing was last changed. The DSD further acknowledged the oxygen tubing should have been labeled to know when to change every week.
During a concurrent interview and record review on June 17, 2025, at 3:09 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy)-Prevention of Infection, dated 2001, was reviewed. The P&P indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment, including ventilators, among residents and staff . Infection Copntrol Considerations Related to Oxygen Administration . 7. Change the oxygen cannula and tubing every seven (7) days, or as needed. The DON stated the policy was not followed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medication error rate was less than five perce...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medication error rate was less than five percent. There were two medication errors identified out of 27 opportunities for errors, affecting one of 13 residents (Resident 14), resulting in an overall medication error rate of 7.4 percent when Resident 14's Levothyroxine (replacement hormone for people whose thyroid gland is not working properly) and Hydrocodone-Acetaminophen (medication used to relieve severe pain) were crushed together during medication administration.
These failures had the potential for Resident 14 to have negative health consequences and effectiveness of the medications.
Findings:
During a review of Resident 14's clinical records, the admission Record (contains demographic and medical information) indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included, gastro esophageal reflux (a condition where stomach acid flows back up into the esophagus), hypothyroidism (a condition when the thyroid gland doesn't make enough thyroid hormone) and pain in thoracic spine (middle section of the spine, situated between the neck and the lower back).
During a review of Resident 14's physician's orders, dated June 6, 2025, it indicated Resident 14 had an order for Levothyroxine Sodium Oral Tablet 25 mcg (micrograms- unit of measurement) Give 1 tablet by mouth in the morning for hypothyroidism.
During further review of Resident 14's physician's order, dated June 6, 2025, it indicated, May Crush or pull apart medication unless contraindicated- separate meds [medications]. Evaluate each medication for indications/contraindication for crushing - each must be prepared individually if more than one is to be administered.
During review of Resident 14's physician's order, dated June 9, 2025, indicated Resident 14 had an order for Hydrocodone - Acetaminophen Tablet 5 -325mg (milligrams- unit of measurement). Give 1 tablet by mouth every 8 hours for pain management.
During medication administration observation on June 18, 2025, at 5:48 AM, at the medication cart in front of Resident 14's room, one Licensed Vocational Nurse (LVN 3) verified the information of Resident 14 and then proceeded to take out one tablet of Levothyroxine Sodium 25 mcg and one tablet of Hydrocodone-Acetaminophen 5-325 mg. LVN 3 then combined both medications in one plastic pouch and crush both medications together. LVN 3 placed the crushed medication in a plastic medication cup and mix it with apple sauce and proceeded to give it to Resident 14 to swallow it.
During concurrent interview and record review on June 18, 2025, at 5:51 AM, with the LVN 3, LVN 3 stated mixing all medications is okay if there is an order.
During a concurrent interview and record review, on June 18, 2025, at 7:00 AM, with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure (P&P) titled, Administering Medications, revised April 2019. The P&P indicated, . 4. Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders, including any required time frame. The DON stated facility did not follow the policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the privacy of patient health records for one o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the privacy of patient health records for one of six sampled residents (Resident 14) was maintained when a Licensed Vocation Nurse (LVN 3) left Resident 14's health information on the computer screen, unattended in the hallway, visible for anyone to see.
This failure had the potential for Resident 14's private information to be disclosed without authorization which could lead to Health Insurance Portability and Accountability Act (to protect medical records and other personal information) violations.
Findings:
During a review of Resident 14's clinical records, the admission Record (contains demographic and medical information) indicated, Resident 14 was admitted to the facility on [DATE], with diagnoses which included, gastro esophageal reflux (a condition where stomach acid flows back up into the esophagus), hypothyroidism (a condition when the thyroid gland doesn't make enough thyroid hormone) and pain in thoracic spine (middle section of the spine, situated between the neck and the lower back.
During a concurrent observation and interview on June 18, 2025, at 5:48 AM, with a LVN 3 at the medication cart in front of Resident 14's room, LVN 3 logged into Resident 14's electronic health records in the computer. LVN 3 proceeded to go inside the room to administer Resident 14's medication leaving the computer screen up and unattended. LVN 3 stated he realized he left Resident 14's information open on the computer when he was inside the room. LVN 3 further stated he was not supposed to keep the computer on with Resident 14's information unattended.
During a concurrent interview and record review on June 18, 2025, at 7:00 AM, with the Director of Nursing (DON), the facility policy and procedure (P&P) titled, HIPAA Privacy Policy, dated January 1, 2021, was reviewed. The P&P indicated, 1. Administrative, Technical and Physical Safeguards . [Name of Provider] ensures that appropriate administrative, technical , and physical safeguards are in place to (a) reasonably safeguard PHI from any intentional and unintentional use or disclosure that is in violation of the Privacy Rule; (b) ensure the confidentiality , integrity and availability of e-PHI it creates, receives, maintains or transmits; (c) protect against reasonably anticipated uses or disclosure that violate the Rules; and (d) limit incidental uses and disclosures resulting from otherwise permitted or required uses or disclosures. The DON stated the policy was not followed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices in the kitchen when:
1. The main kitchen floors had accumulatio...
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Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices in the kitchen when:
1. The main kitchen floors had accumulation of food crumbs, black stains, and dirt; the walk-in freezer had food crumbs on the floor, and the walk-in refrigerator floors had multiple cilantro leaves, cauliflower pieces, and multiple moist black and brown residue under the shelf.
2. Food equipment such as the toaster had black grime, white residue, and food crumbs; the mixer was found with multiple reddish-orange splashes on the handle.
3. The edge of the wall under the three-compartment sink had black build up and multiple white residues.
These failures had the potential to cause foodborne illnesses (caused by the ingestion of contaminated food or beverages) in a highly susceptible population of 44 residents who received food from the kitchen.
Findings:
1. During a concurrent observation and interview on June 16, 2025, at 07:48 AM, with the Sous Chef (SC) in the main kitchen, the floors had an accumulation of food crumbs, black stains, and dirt. The walk-in freezer had food crumbs on the floor, and the walk-in refrigerator floors had multiple cilantro leaves, cauliflower pieces, and multiple moist black and brown residue under the shelf. The SC stated the floors are to be cleaned daily.
During an interview on June 16, 2025, at 03:25 PM, with the Director of Dining Services (DDS), the DDS stated the expectation was for kitchen floors and walk in freezers/refrigerators to be maintained clean after each shift.
During a review of the FDA Federal Food Code, dated 2022, under 4-601.11, it indicated, .Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris [scattered pieces of waste or remains] . The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.
2. During a concurrent observation and interview on June 16, 2025, at 7:53 AM, with the SC in the main kitchen, the toaster had black grime, white residue and food crumbs inside and out. The mixer was found with multiple reddish-orange splashes on the handle. The SC stated that equipment should have been cleaned.
During a concurrent interview and record review on June 16, 2025, at 3:10 PM, with the DDS, the facility's policy and procedure (P&P) titled Sanitation and Infection Prevention/Control, revised January 2024, was reviewed. The P&P indicated Written procedures are available, detailing daily and weekly (as needed) cleaning for all areas and equipment in the department . The DDS stated the policy and procedure was not followed.
During a concurrent interview and record review on June 16, 2025, at 3:27PM, with the DDS, the kitchen cleaning checklist titled, Station Cleaning Checklist Dishwasher (19), undated, was reviewed. The cleaning checklist indicated, Fri (Friday) - Deck brush kitchen, pull all equipment and clean under and behind . The DDS stated the checklist should have been followed.
3. During a concurrent observation and interview on June 16, 2025, at 7:57 AM, with the SC, the edge of the wall under the three-compartment sink had black build up and multiple white residues. The SC stated it should be cleaned daily after use.
During an interview on June 16, 2025, at 3:25 PM, with the DDS, the DDS stated the expectation was for the wall to be cleaned and free of buildup.
During a review of the FDA Federal Food Code, dated 2022, under 4-601.11, it indicated, .Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris [scattered pieces of waste or remains] .in addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained when a Laundry Staff used a dirty laundry basket (a basket for holding cl...
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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained when a Laundry Staff used a dirty laundry basket (a basket for holding clothes and linen that have been washed) to transfer washed linens into the dryer machine.
This failure had the potential to cause harm to the 44 residents residing within the facility by increasing the risk of exposure and spread of infection (the process by which an infectious agent (like a virus or bacteria) moves from one source to another, causing illness).
Findings:
During a concurrent observation and interview on June 18, 2025, at 12:10 PM, in the laundry room with the Infection Preventionist (IP), Laundry Supervisor (LS) and Laundry Staff (LS 1) observed a large rectangular blue plastic laundry basket with a lid covered with stained dirty white sheet located near the dryer. LS 1 stated the laundry basket is used to transfer washed linens from the washing machine to the dryer. The LS stated the white sheet on top of the laundry basket are changed every day. LS1 stated the white sheet on the laundry basket are changed once a week. LS1 proceeded to remove the white sheet from the top of the laundry basket to replace it with a clean sheet. Once LS 1 removed the dirty white sheet, the lid was observed dirty and appeared to had items inside the laundry basket. There was a black trash bag, a white trash bag, dirty socks, one individual packet of coffee creamer, a dirty mop, a blue blanket, a few dirty tissue papers and spray bottle, inside the laundry basket. The LS stated, I did not know about this. The IP stated, she had not seen this laundry basket when she was making rounds before.
During an interview on June 18, 2025, at 12:30 PM, with the Director of Buildings and Grounds, the director of Buildings and Grounds stated he expected laundry staff to use a clean laundry basket.
During a concurrent interview and record review on June 18, 2025, at 12:50 PM, with the Director of Nursing (DON) and IP, the facility policy and procedures (P&P) titled, Laundry and Bedding, Soiled, dated September 2022, was reviewed. The P&P indicated, Transport . 4. Linen carts are cleaned and disinfected whenever visibly soiled and according to the established schedule . 6. Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. The IP stated, Laundry staff had received education in handling and transporting linens and she was not sure why a dirty laundry basket was used. The DON acknowledged the policy and stated, the dirty laundry basket should not had been used at all. The DON stated her expectation for staff is to use clean laundry carts all the time.
Apr 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure appropriate treatment and management of a gastro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube, a tube inserted through abdomen that delivers enteral feeding formula and hydration directly to the stomach) was implemented for one of two sampled residents with G-tube (Resident 37), when:
1) The G-tube pump (a machine which helps to deliver the enteral formula to the resident), was off and 1500 cc (cc - unit of volume) of Glucerna (enteral feeding formula) 1.2 cal [calories] was left in the bottle.
This failure resulted in Resident 37 not receiving the calculated amount of enteral feeding formula for the day, as per physician's orders.
2) The order for Glucerna 1.2 cal was not transcribed (written) accurately onto the physician's orders (It was ordered via oral route of administration on April 1, 2024, instead of via G-tube).
This failure has the potential for Resident 37 to receive the enteral feeding formula via the wrong administration route.
Findings:
1) During a review of Resident 37's Face sheet (demographic data sheet), Resident 37 was admitted to the facility on [DATE], with the diagnoses of hemiplegia (paralysis of one side of the body), aphasia (a language disorder that affect a person's ability to communicate) and dysphagia (difficulty swallowing).
During a review of Resident 37's physician orders, dated April 1, 2024, Physician order indicated, Glucerna 1.2 Cal 0.06 gram (gram- unit of weight measurement)1.2 kcal (Kilocalories) /mL(mL - milliliter, unit of measurement) oral liquid ,70 mL /hr (hour) . Notes: 70 ml/hr x (times) 22hrs to provide 1848 calories and 92 gram protein, to equal 1540cc. Off @1000 on@1200.
During an observation on April 25, 2024, at 9:45 AM in Resident 37's room, Resident 37 was lying in bed with the head of the bed elevated. Resident 37's G-tube was connected to the pump. The G-tube pump was turned off. A bottle of Glucerna 1.2 cal was hanging from the pole, the bottle was dated April 25, 2024, the bottle label indicated Start time 2:00AM . Rate 70ml/hr.
During an observation and interview on April 25, 2024, at 9:55 AM with Licensed Vocational Nurse 2 (LVN 2) in Resident 37's room, LVN 2 stated, I never calculate the feeding formula. I just do only visual checks if the bottle has enough. LVN 2 further stated, the formula was supposed to be stopped at 10:00 AM according to doctor's order, but I turned it off at 8:00 AM for his morning routine.
During a concurrent observation and interview on April 25, 2024, at 10:50 AM with the Director of Nursing (DON), the DON inspected the G-tube bottle of Glucerna 1.2 cal on hanging in the pole. The DON stated the bottle has a remaining amount of 1500mL. The DON further stated, I agree that there is a discrepancy of more than 300 ml of formula which was supposed to be infused to the resident (Resident 37) by this time.
During a concurrent interview and record review on April 26, 2024, at 10:30 AM with the DON, the facility's policy and procedure (P&P) titled, Enteral Nutrition, dated January 2024, was reviewed. The P&P indicated, . Nursing . Administer and document enteral nutrition per community protocol. The DON stated, The policy was not followed as there was a discrepancy in formula amount delivered.
2) During a concurrent Interview and record review on April 25, 2024, at 9:50 AM with LVN 2, LVN 2 reviewed Resident 37's physician orders, dated April 1, 2024, it indicated, Glucerna 1.2 Cal 0.06 gram-1.2 kcal/mL oral liquid, 70 cc/hr Oral. LVN 2 stated, it was the first time she noticed the order was written incorrectly (via oral route administration).
During a concurrent interview and record review on April 25, 2024, at 11:00 AM with the DON, the DON reviewed Resident 37's physician's orders dated April 1, 2024. The order indicated Resident 37 to receive Glucerna 1.2 Cal 0.06 gram-1.2 kcal/ml oral liquid, 70 cc/hr via oral route. The DON stated, it was a mistake, the correct route should be via G-tube (enteral).
During a concurrent interview and record review on April 26, 2024, at 10:33 AM with the DON, the facility's policy and procedure (P&P) titled, Enteral tube feeding via Continuous pump, dated November 2018, was reviewed. The P&P indicated, General Guidelines . 3. Check the enteral nutrition label against the order before administration . Check the following information: d. Route of delivery . The DON stated, the policy was not followed as the Route was wrong.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (narcotic medications that are controlled by the government because it ma...
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Based on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (narcotic medications that are controlled by the government because it may be abused or cause addiction) for one of two medication carts (Front Hall medication cart), with seven missing signatures for narcotics count.
This failure had the potential for drug diversion (Illegal distribution of controlled drugs for any illicit use) of controlled medications by the staff.
Findings:
During concurrent interview and record review on April 24, 2024, at 6:30 AM, with the Director of Nursing (DON), the DON reviewed the Front Hall medication cart's narcotics shift count verification signature log (a form used by facility to verify counting of controlled drugs at the change of shift by oncoming and off going licensed nurses), dated March 2024 and April 2024. The log indicated the following:
a. On March 20, 2024, missing signatures on the night shift (NOC) from Signature 1 (incoming nurse) and Signature 2 (outgoing nurse).
b. On March 26, 2024, missing signature on NOC shift from Signature 1.
c. On April 21, 2024, missing signatures on day shift from Signature 1 and Signature 2.
d. On April 23, 2024, missing signatures on NOC from Signature 1 and Signature 2.
The DON acknowledged the missing signatures for the above dates. The DON further stated her expectation is for licensed nurses to count at the beginning and end of shift and sign the sheet. I am not sure what happened.
During interview on April 26, 2024, at 8:39, AM with Licensed Vocational Nurse (LVN 2), LVN 2 stated, We count narcotics together with incoming and outgoing nurse and we sign the sheet. LVN 2 further stated, I forgot to sign the narcotics sheet count verification signature log. It is simply a mistake. LVN 2 stated, We are responsible to count and sign at the beginning and end of each shift.
During concurrent interview and record review on April 26, 2024 at 11:05 AM, with the DON, the facility's provided policy and procedure (P&P), titled Controlled Substances, revised November 2022, was reviewed. The P&P indicated, Dispensing and Reconciling Controlled Substances 3, Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4, The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing . The DON stated, the licensed nurses have been educated to sign the shift confirmation for narcotics counts and it is expected that all licensed nurses count and verify at each shift.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles for one of one resident (Resident 247) when a bubble pack (a card that packages doses of medications within plastic bubbles organized by day and time of the day) containing morphine (medication used to treat pain) had no expiration date ( a date that indicates when medicine is no longer effective) written in the label.
This failure had the potential to result in staff administering an expired medication to Resident 247 which can alter the efficacy (ability to produce desired effects) of the medications and reduce its therapeutic effectiveness.
Findings:
During a concurrent observation and interview on [DATE], at 6:15 AM, with the Director of Nursing (DON), the medication storage Cart 1 located at the front hallway, was inspected. A bubble pack containing Resident 247's Rx# (prescription number) 159536, Morphine Sulfate (MS), 15 milligrams (mg -a unit of measure), tablet (TAB) #10, dated [DATE], was inspected. The bubble pack contained 15 half tablets of morphine; the label did not have an expiration date. The DON stated, it is received by Registered Nurse (RN), RN verifies the medication with label and gets recorded on the narcotic log. The DON further stated, I know this one does not have an expiration date, but we can use all medications within one year of the order date.
During a further interview on [DATE], at 7:54 AM with the DON, the DON stated, Unfortunately, we don't have the one-year use policy. I am going to check with our pharmacy consultant.
During a telephone interview on [DATE], at 9:35 AM with the Pharmacy Consultant (PC), the PC stated he was not aware of Resident 247's Rx# 159536, MS 15 mg, TAB #10, order date [DATE]), had no expiration date. The PC further indicated, the standard for pharmacy is, for medications to have a label with an expiration date either written by hands or generated by computer.
A review of the facility's policy and procedures (P&P) by [name of the pharmacy] policies and procedures titled, Medication Storage and Labeling,[ Undated], indicated, . All prescription medications used in the facility must have a pharmacy label that includes the following information: Expiration date of the effectiveness of the drug dispensed, . State of California Business & Professions Code, Chapter 9, Division 2, 4076 # 9, it indicated, the expiration date of the effectiveness of the drug dispensed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain a sanitary and safe medication storage in one of two medication carts (a cart used in healthcare facilities to store...
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Based on observation, interview, and record review, the facility failed to maintain a sanitary and safe medication storage in one of two medication carts (a cart used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment) when the hearing aids (a small device that fits in or on the ear, worn by a partially deaf person to amplify sound) for four of four residents (Resident 39, 29, 13 and 25) were found inside a medication cart's narcotic drawer.
This failure had the potential for cross contamination and infection (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and jeopardize the health and safety of (Resident 39, 29, 13 and 25).
Findings:
During a concurrent observation and interview on April 24, 2024, at 5:40 AM, with the Director of Nursing (DON), the DON reviewed the Front Hall medication cart. The DON opened the narcotic drawer inside the medication cart. The narcotic drawer contained two small black cases, one small gray case and two clear specimen containers. The DON stated, the three cases and the two specimen containers, contained resident's hearing aids. The DON further stated, They are not new hearing aids. The DON stated, the residents give their hearing aids to the nurse in the evening to keep it locked. When the residents ask for it, the nurse takes out the case from the narcotics drawer, removes the hearing aid from the case and gives the hearing aid to the residents.
During observation on April 24, 2024 at 6:10 AM, in the hallway, Resident 39 asked the Licensed Vocational Nurse (LVN 3), for his hearing aid. LVN 3, opened the narcotic drawer pulled out one black case from the narcotic drawer and removed the hearing aid. LVN 3 proceed to give the hearing aids to the Resident 39, without using gloves. LVN 3 stated, I only hand it to the residents out of the box. I don't clean it.
During an interview on April 26, 2024, at 8:00 AM, with the DON. The DON stated, Unfortunately, we don't have a policy to store hearing aids inside narcotics drawer.
During a concurrent interview and observation on April 26, 2024, at 8:28 AM with the Infection Preventionist (IP) and LVN 2, the LVN 2, opened the narcotic drawer inside the Front Hall medication cart. The IP counted two small black cases, one small gray case and two clear specimen containers containing hearing aids. The IP was not able to provide a policy regarding storage of resident's hearing aids. The IP stated, there is no policy regarding storage of hearing aids.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to implement a process to routinely evaluate contracted nursing staff on their skill levels (range of tasks and duties to be performed) and de...
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Based on interview and record review, the facility failed to implement a process to routinely evaluate contracted nursing staff on their skill levels (range of tasks and duties to be performed) and develop individualized competency-based training (a process to acquire skills and knowledge to be able to perform a task to a specified standard) for 10 of 10 contracted staff (one Licensed Vocational Nurse [LVN 1], and nine Certified Nursing Assistants [CNA 1, 2, 3, 4, 5, 6, 7, 8 and 9]).
This failure had the potential to compromise the services and types of care necessary to safely meet the resident's needs.
Findings:
During an interview and record review on April 25, 2024, at 2:30 PM, with the Director of Nursing (DON), the DON reviewed the document titled, Orientation Checklist dated March 20, 2020, the checklist indicated, Skills-C.N.A . Ambulation . Bed making .Body Mechanics . Position in Bed .Charting and Reporting .Bladder Training . Foley Catheter Cares . Vital Signs . The DON stated the facility used the checklist for contracted nursing staff. DON was not able to provide documented evidence of the Orientation Checklist for LVN 1, CNA 1 and 2 to demonstrate that each of the contracted nursing staff have been validated for their skills. The DON stated she is not able to provide a documented competency checklist for any contracted staff that have been assigned to the facility today.
During a concurrent interview and record review on April 25, 2024, at 2:49 PM, with the Director of Staffing Development (DSD), in the presence of the DON, the electronic files from Clipboard Health (staffing record) were reviewed. The DSD stated there were three (3) contracted nursing staff currently working at the facility (LVN 1, CNA 1 and 2). The DSD stated, the ,facility uses a buddy system for the contracted CNA's to validate their competencies and skills. The DSD further stated, the contracted RN's (Registered Nurses) and LVN's are assigned to a core staff member to be supervised throughout their shift. Both, the DON and DSD were not able to provide documented evidence of the competencies or skills set checklist for the contracted nursing staff were completed and reviewed.
During a review of the staffing assignment for the month of April 2024, contracted nursing staff worked in the facility for the following dates, shifts, and assignments:
1. LVN 1 - April 25, 2024, 7:00 AM - 3:00 PM Shift, as a treatment nurse
2. CNA 1 - April 25, 2024, 7:00 AM - 3:00 PM Shift, Rooms 31A - 34A
3. CNA 2 - April 25, 2024, 7:00 AM - 3:00 PM Shift, Rooms 40A - 43B
4. CNA 3 - April 22, 2024, 3:00 PM - 11:00 PM Shift, Rooms 44A - 47B, 40A & 40B
5. CNA 4 - April 21, 2024, 11:00 PM - 7:00 AM Shift, Rooms 30 - 37B
6. CNA 5 - April 21, 2024, 11:00 PM - 7:00 AM Shift, Rooms 40 - 47B
7. CNA 6 - April 19, 2024, 3:00 AM - 11:00 PM Shift, Rooms 20A - 22B, 30A & 30B
8. CNA 7 - April 15, 2024, 7:00 AM - 3:00 PM Shift, Rooms 44A - 47B
9. CNA 8 - April 7, 2024, 11:00 PM - 7:00 AM Shift, Rooms 30A - 37
10. CNA 8 - April 5, 2024, 11:00 PM - 7:00 AM Shift, Rooms 30A - 37B
11. CNA 9 - April 1, 2024, 7:00 AM - 3:00 PM Shift, Rooms 40A - 43A
During a concurrent interview and record review on April 26, 2024, at 8:26 AM, with the DSD, the DSD reviewed the electronic files from Clipboard Health, for CNA 3, 4, 5, 6, 7, 8 and 9. The DSD stated , there was no documented Orientation Checklist on file for CNA 3, 4, 5, 6, 7, 8 and 9.
During an interview on April 26, 2024, at 10:02 AM with CNA 2, CNA 2 stated, during her first day of work, she was oriented to fire exits, rooms and resident assignments. CNA 2 further stated, she does not recall any checklist that was signed or given to her during her orientation. When asked ,if the facility provided any written documentation on completing competency training, she stated she does not recall any checklist that was signed or given to her during her orientation.
During an interview with the DON on April 25, 2024, at 4:40 PM, the DON was not able to provide a policy and procedure regarding contracted nursing staff to validate their competencies and skills. The DON stated, We do not have any policy and procedure for contracted staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to store food by methods that conserve nutritive value, flavor, and appearance, when four bags of raw chicken had freezer burn (f...
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Based on observation, interview and record review, the facility failed to store food by methods that conserve nutritive value, flavor, and appearance, when four bags of raw chicken had freezer burn (frozen foods are exposed to cold, dry air, which causes them to dehydrate as the outer layers lose moisture. One of the most commonly recognized signs of freezer burn is the formation of ice crystals on the outside of food, making it appear frost bitten). This had the potential for the chicken to not be palatable when cooked and served to 40 of 41 medically compromised residents who received food from the kitchen.
Findings:
During an observation on April 22, 2024 at 9:00 a.m., inside the walk-in freezer, there were four bags of frozen chicken that had ice build-up and the bags had a lot of air that was keeping the bags expanded.
During an interview with the Food Service Director on April 24, 2024, at 12:03 p.m., She stated that no food in the freezer should have any ice build-up or freezer burn.
During a review of the facility policy titled Production, Purchasing, Storage, dated January 2023, indicated, All food, non-food items and supplies use in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen when:
1. Floors under equipment in multiple areas of the kitchen had a build up of black grime, o...
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Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen when:
1. Floors under equipment in multiple areas of the kitchen had a build up of black grime, old food, crumbs, and trash, this had the potential for microorganism growth that could be inadvertently transferred to food and for pests to be attracted.
2. Two convection (fans to circulate air around food to create an evenly heated environment) ovens, two ranges, a grill top, a food warmer box (appliance that holds already cooked foods at ideal temperatures until they are ready to be served) and 4 waffle irons, had a buildup of black grime, and yellow crusted grime. This had the potential for microorganism growth that could be inadvertently transferred to food and for pests to be attracted.
3. Two buckets used as funnels to drain cooking liquid from a large steam kettle (used to cook large quantities of liquid-based foods) were crusted with old food. This had the potential for microorganism growth that could be inadvertently transferred to food and for pests to be attracted.
These failures had the potential to cause food borne illness to 40 of 41 medically compromised residents who received food from the kitchen.
Findings:
1. During an observation on April 22, 2024, at 8:41 a.m. in the kitchen, there was a build-up of crumbs under the stainless-steel counter-top and behind and under the industrial mixer. under the reach-in refrigerator and freezer there was a build-up of trash and crumbs.
During an observation in the dry storage area on April 22, 2024, at 8:45 a.m., there was food crumbs, liquid spills and a tomato that had fallen on the floor and turned moldy (type of fungus that causes food spoilage) under the shelves on the floor.
During an observation in the walk-in refrigerator on April 22, 2024, at 8:55 a.m., there was food and trash and spills under the shelves on the floor.
During an observation in the walk-in freezer on April 22, 2024, at 9:00 a.m., there was old food and trash on the floor under the shelves.
During an observation in the mop closet on April 22, 2024, at 9:04 a.m., there was crumbs and trash on the floor.
During an observation and concurrent interview with the Executive Chef, on April 22, 2024, at 9:09 a.m., at the front cooking line the floors under the equipment and under the stainless-steel countertop had a build-up of old food and trash. The Executive chef stated that the floor under the equipment should be clean.
During an interview with the Food Service Director on April 24, 2024, at 12:03 p.m., She stated that the floor underneath equipment should be kept clean and there shouldn't be any old food on the floor. She stated that they would need to add those areas that were identified to their cleaning list.
During a review of the facility policy titled Sanitation and Infection Prevention/Control, dated January 2024, indicated Nonfood contact surfaces of equipment .shall be cleaned as often as is necessary. Kitchen floors will be swept and mopped at a minimum daily or as needed.
During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated C) Nonfood- contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. Section 4-602.13 indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.
2. During an observation in the kitchen on April 22, 2024, at 8:41 a.m., the convection oven near the handwashing sink had black grime build-up and the inside of the doors had yellow crusted build-up.
During an observation in the kitchen on April 22, 2024, at 9:09 a.m., the convection oven near the steam kettle was crusted with black grime and had yellow build-up on the inside of the doors.
During an observation in the kitchen on April 22, 2024, at 9:12 a.m., two range ovens had black grime build-up and food crumbs inside the ovens. Next to the ovens was a rack with storing waffle irons that had food crumbs, grease, and a white powdery substance. The grill next to the rack, used to grill hamburgers, was crusted with black grime and the stainless steel was crusted with black grime.
During an interview with the Food Service Director, on April 24, 24, at 12:03 p.m., she stated the equipment should be kept clean and should be added to their cleaning list for deep cleaning.
During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Nonfood-Contact Surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.
3. During an observation in the kitchen on April 22, 2024, at 9:06 a.m., under the grill top near the steam kettle there were two white buckets that were being used as funnels to drain water from the steam kettle into the floor drain so that water does not go all over the floor. The buckets were crusted with old food.
During an interview with the Food Service Director, on April 24, 24, at 12:03 p.m., she stated the buckets being used as funnels should be kept clean, should have no food in them.
During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Nonfood-Contact Surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.
Mar 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 17) w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 17) was provided reasonable accommodation of needs, when Resident 17's hearing deficit was not addressed by the facility. This failure resulted in Resident 17 not receiving an adequate hearing assessment and Resident 17 potentially failing to achieve her highest level of functioning, dignity, and well-being.
Findings:
During a concurrent observation and interview on March 7, 2023, at 8:02 AM, with Resident 17, in Resident 17's room, Resident 17 was observed to be hard of hearing. Resident 17 asked surveyor to repeat what was said because she could not hear. Surveyor repeated what was said multiple times, and spoke louder, slower, and closer to Resident 17's ear. Resident 17 stated she would have to talk to her son about getting hearing aids.
During an interview on March 8, 2023, at 9:48 AM, in Resident 17's room, with Registered Nurse 1(RN 1), RN 1 stated Resident 17 had difficulty hearing since she was admitted .
During an interview on March 9, 2023, at 7:53 AM, in Resident 17's room with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated Resident 17 had a hearing deficit and does not wear hearing aids.
During an interview on March 9, 2023, at 2:13 PM, with the Social Services Director (SSD), the SSD stated she was not aware that the Resident 17 had a hearing deficit. The SSD further stated if a hearing deficit was communicated to the SSD, the SSD would contact the physician, contact the family, and schedule an appointment for a hearing exam.
During a record review of the Face Sheet, (contains admission and demographic information) dated March 10, 2023, the Face Sheet showed Resident 17 was admitted on [DATE], with a diagnosis of Alzheimer's Disease (the most common cause of dementia - an impaired ability to think, remember, or make decisions), depression, and cachexia (weakness and wasting of the body due to severe chronic illness).
During a record review titled, Clinical Note Report, dated January 24, 2023, at 15:01 (3:01 PM), indicated .she (Resident 17) is HOH (hard of hearing) no hearing aids .
During a concurrent interview and record review on March 10, 2023, at 8:57 AM, with Director of Nursing (DON), the DON reviewed the Minimum Data Set (MDS - Computerized Assessment Instrument) dated January 31, 2023, which indicated in Section B - Hearing, Speech, and Vision Resident 17 had adequate hearing, without difficulty in normal conversation or social interaction. The DON also reviewed Resident 17's, Clinical Note Entry dated January 24, 2023, at 3:01 PM, which indicated .resident is HOH(Hard of hearing) with no hearing aids . The DON stated there was a discrepancy in the two observations and there was a gap in Resident 17's care.
During an interview on March 10, 2023, at 11:25 AM, with Resident 17, Resident 17 stated she still could not hear. Resident 17 acknowledged that at times staff must raise their voice because of her hearing deficit. Resident 17 stated she had notified the staff members that she had difficulty with hearing. Resident 17 stated she hoped she was not becoming deaf and would like to have her ears checked by a physician.
During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs dated March 2021, the P&P indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The document further indicated, .2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 28) was provided a safe, clean, comfortable, and homelike environment when Re...
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Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 28) was provided a safe, clean, comfortable, and homelike environment when Resident 28's wheelchair was not found in good repair. This failure had the potential to result in discomfort for Resident 28, which could have negatively impacted the resident's quality of life.
Findings:
During a concurrent observation and interview on March 7, 2023, at 10:40 AM, with Resident 28, in Resident 28's room, the vinyl fabric (a durable, waterproof, man-made synthetic leather) lining of Resident 28's wheelchair was observed to be torn on both sides of the backrest, where it connected to the wheelchair frame. The exposed fabric was partially covered with dirty, peeling, paper medical tape. Resident 28 stated, the wheelchair was provided to him by the facility and had been torn since he was admitted in October 2021.
During a concurrent observation and interview on March 10, 2023, at 9:51 AM, with the Infection Preventionist (IP), in the IP's office, Resident 28's wheelchair was observed. The IP stated the wheelchair needs to have an easily wipeable surface and due to the rips in the vinyl and exposed fabric, it would not be easily wipeable. The IP further stated it was a risk for infection.
During an interview on March 9, 2023, at 10:38 AM, with the Director of Nursing (DON), the DON stated, they did not have a process to track maintenance and inspections of resident's wheelchairs in the facility. The DON further stated Resident 28's wheelchair condition was not maintained to the appropriate standard and could have been a safety and infection risk.
During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised February 2021, the P&P indicated, .2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include a. clean, sanitary, and orderly environment .
During a review of the facility's P&P titled, Medical Equipment Management Plan, revised May 2022, the P&P indicated, Objective: To provide a safe environment through proper selection, use, testing, and maintenance of Medical Equipment .The [Director of Building and Grounds] establishes and maintains a current, accurate and separate inventory of all equipment included in a program of planned inspections or maintenance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess a resident with a hearing deficit w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess a resident with a hearing deficit when one of three sampled residents (Resident 17), Minimum Data Set (MDS -a federally mandated assessment for residents in nursing homes) who was known by the staff to have a hearing deficit.
This failure had the potential to cause Resident 17 to receive inadequate care at the facility and adversely affect Resident 17's quality of life and ability to function since the time of admission.
Findings:
During a concurrent observation and interview on March 7, 2023, at 8:02 AM, with Resident 17, in Resident 17's room, Resident 17 was observed to be hard of hearing. Resident 17 requested surveyor to repeat what was said because she could not hear. Surveyor repeated what was said multiple times, while spoken louder, slower, and closer to Resident 17's ear. Resident 17 stated she would have to talk to her son about getting hearing aids.
During an observation on March 7, 2023, at 9:48 AM, in Resident 17's room, the Administrator asked Resident 17 how she was doing. Resident 17 stated she could not hear what the Administrator said to her. After the Administrator repeated what was said in a louder tone, Resident 17 stated that she could still not hear what was being said to her. The Administrator did not clarify what was being told to her and exited the room.
During a concurrent observation and interview on March 8, 2023, at 9:48 AM, in Resident 17's room, with Registered Nurse 1 (RN 1) explained to Resident 17 she was going to begin performing wound care on the Resident's heels. Resident 17 stated she couldn't hear. RN 1 repeated what was said louder and closer to Resident 17's ear. Resident 17 stated she was in a lot of pain, yelped when gently touched, and requested RN 1 to perform wound care when resident was not in as much pain. RN 1 agreed to come back when Resident 17 was ready for wound care. When asked if Resident 17 has always had difficulty hearing, RN 1 stated her hearing has been like that since she was admitted .
During a concurrent observation and interview on March 9, 2023, at 7:53 AM, in Resident 17's room, a Certified Nurse Assistant 1 (CNA 1) assisted Resident 17 in getting ready to eat breakfast. CNA 1 told Resident 17 after breakfast CNA 1 would assist Resident 17 in getting dressed. Resident 17 stated she could not hear what CNA 1 said. CNA 1 increased her volume and spoke closer to Resident 17's ear and repeated what was said. Resident verbalized she understood the words after breakfast . but did not hear what was said after. CNA 1 reiterated what was said once more and spoke loudly and distinctly. Resident 17 smiled, agreed to care, and thanked CNA 1. When asked if Resident 17 has hearing aids, CNA stated Resident 17 does not wear hearing aids. CNA 1 further stated Resident 17 cannot hear because staff was wearing a face mask.
During a concurrent interview and record review on March 9, 2023, at 2:33 PM, with RN 1 (whose additional role is to do MDS assessments) RN 1 stated Resident 17 was certainly hard of hearing. RN 1 reviewed Resident 17's MDS assessment dated [DATE], which indicated in Section B - Hearing, Speech, and Vision, Resident 17's hearing was documented as 0. Adequate - no difficulty in normal conversation, social interaction, listening to TV.
During a record review of the Face Sheet, (contains admission and demographic information) dated March 10, 2023, the Face Sheet showed Resident 17 was admitted on [DATE], with a diagnosis of Alzheimer's Disease (the most common cause of dementia - an impaired ability to think, remember, or make decisions), depression, and cachexia (weakness and wasting of the body due to severe chronic illness).
During another record review with RN 1, titled, Clinical Note Report, dated January 24, 2023, at 15:01 (3:01 PM), indicated .she is HOH (hard of hearing) no hearing aids . RN 1 stated based on the two assessments, Resident 17's hearing deficit was not captured on the MDS.
During a concurrent interview and record review on March 10, 2023, at 8:57 AM, with the Director of Nursing (DON), the DON reviewed the MDS dated [DATE], which indicated in Section B - Hearing Speech, and Vision, Resident 17 had 0. Adequate - no difficulty in normal conversation, social interaction, listening to TV. The DON also reviewed Resident 17's record titled, Clinical Note Entry dated January 24, 2023, at 3:01 PM, which indicated .resident is HOH with no hearing aids . The DON stated there was a discrepancy in the two observations and there was a gap in Resident 17's care.
During an interview on March 10, 2023, at 11:25 AM, with Resident 17, Resident 17 stated she still could not hear. Resident 17 acknowledged that at times staff must raise their voice because of her hearing deficit. Resident 17 stated she had notified the staff members that she had difficulty with hearing. Resident 17 stated she hoped she was not becoming deaf and would like to have her ears checked by a physician.
During a review of the facility's policy and procedure (P&P), titled, Charting and Documentation, dated July 2017, the P&P indicated, The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P further indicated, 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for two of four sam...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for two of four sampled residents (Resident 9 and Resident 28) receiving anticoagulant (blood thinner) medication.
This failure had the potential to cause adverse health outcomes such as bleeding and hemorrhage (profuse discharge of blood from a ruptured blood vessel) which may lead to hospitalization and/or death.
Findings:
1. During an interview on March 7, 2023, at 11:16 AM, with Resident 9's responsible party (RP), RP stated Resident 9 is taking Xarelto (anticoagulant medication to prevent blood clots), and Resident 9 would get bruises whenever her blood is drawn for laboratory work. RP further stated after Resident 9's recent stroke, communication became harder because Resident 9 did not talk as much.
During a review of Resident 9's medical record, the Face Sheet, (contains admission and demographic information) dated March 10, 2023, the Face Sheet indicated Resident 9 was admitted on [DATE], with diagnoses that included aphasia (disorder that affects communication) following cerebral infarction (stroke caused by a blood clot), cardiac arrythmia (irregular heartbeat), and dementia (impaired ability to remember, think, or make decisions).
During a review of Resident 9's record titled, Medications, a physician ordered Xarelto 20 mg (milligram - unit of measurement) tablet Every 1 Day on February 26, 2023.
During a concurrent interview and record review on March 10, 2023, at 8:40 AM, with the Director of Nursing (DON), the DON reviewed Resident 9's care plan, and verified there was no care plan in place for anticoagulant medication and/or Xarelto. The DON further stated a care plan for anticoagulant medications is important because it explains the risks and benefits of a blood thinner, what signs and symptoms to be cautious for, when to notify a physician, and how to intervene if those signs and symptoms were present.
During a review of the facility's policy and procedure (P&P), titled, Care Plan, Comprehensive Person Centered, dated March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P further indicated, 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .
2. During a review of the History & Physical (H&P) for Resident 28, dated November 21, 2022, the H&P indicated, Resident 28 was admitted on [DATE], with a diagnoses that included Alzheimer's dementia (a progressive loss of intellectual functioning, impairment of memory and personality change), hypertension (blood pressure is higher than normal), atrial fibrillation (an irregular heart rhythm that can lead to blood clots in the heart), and heart failure (long term weakness of the heart muscle).
During a review of Physician Orders for Resident 28, dated March 10, 2023, the Physician Orders indicated, an order for Eliquis (an anticoagulant medication to prevent serious blood clots) 5 mg (milligram-unit of measurement) tablet two times daily, dated November 23, 2022.
During a review of Resident 28's clinical record, the record indicated there was no care plan developed for anticoagulant use.
During a concurrent interview and record review on March 9, 2023, at 10:23 AM, with the DON, Resident 28's medical record was reviewed. The DON reviewed and verified Resident 28's care plan documentation and stated there was no care plan in place for Resident 28's anticoagulant use. The DON agreed that there should be one, so staff would know about things to monitor for a resident who is at risk for bleeding.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, .7. The comprehensive, person-centered care plan: e. reflects currently recognized standards of practice for problem areas and conditions .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of practice for urinary...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of practice for urinary catheter (flexible tube used to empty the bladder and collect urine in a drainage bag) care for one of three sampled residents (Resident 28), when Resident 28 was instructed to hold his catheter during a urinary catheter irrigation (a sterile procedure to flush the urinary catheter to keep it clear and working properly) procedure.
This failure had the potential to result in a urinary tract infection (UTI - an infection in any part of the urinary system) due to improper handling of the urinary catheter, which could have caused the resident harm.
Findings:
During a review of the Face Sheet (contains admission and demographic information) for Resident 28, dated March 10, 2023, the Face Sheet indicated, Resident 28 was admitted on [DATE], with a diagnosis of, but not limited to, benign prostatic hypertrophy (BPH-a condition causing slowing or blockage of the urine stream out of the bladder), and obstructive and reflux uropathy (urine cannot drain out of the bladder).
During a concurrent observation and interview on March 7, 2023, at 11:00 AM, with Resident 28, in Resident 28's room, Resident 28's urinary catheter was observed to have cloudy urine and white sediment build up in the line. Resident 28 stated, he has had his urinary catheter changed approximately 19 times since his admission and he would frequently complain of abdominal pain when the line would get clogged. Resident 28 further stated, his line would get irrigated twice a day by nursing staff.
During a review of the Physician Orders for Resident 28, on March 10, 2023, the Physicians Orders indicated, an order for acetic acid (a medication used to cleanse the inside of the bladder to prevent infection and calcium build up for people with long term catheter use) 0.25% (percent strength) irrigation solution two times daily for catheter sediment, dated February 6, 2023.
During an interview on March 7, 2023, at 3:08 PM, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she had performed the catheter irrigation for Resident 28 that afternoon but had not performed an acetic acid flush for urinary catheters in her career.
During a concurrent observation and interview on March 7, 2023, at 3:17 PM, with the MDS (Minimum data set - a computerized assessment tool) Nurse and Resident 28, in Resident 28's room, Resident 28 described to the MDS Nurse that LVN 2 performed his catheter irrigation but instructed the resident to assist with the procedure by holding the catheter during the flush and manipulate it by pinching the flexible tube while LVN 2 performed the procedure. Resident 28 further stated he has never had to hold his catheter during an irrigation before but did as he was instructed. The MDS Nurse stated it was not a standard practice to have residents assist with their catheter care, since it is to be an aseptic (sterile) procedure.
During an interview on March 8, 2023, at 7:55 AM, with Resident 28, Resident 28 stated he did not feel it was his job to hold the catheter line during catheter care and he did not feel comfortable doing that.
During an interview on March 9, 2023, at 10:23 AM, with the Director of Nursing (DON), the DON stated, it was not the normal process for the residents to hold the catheter themselves during catheter irrigation. The DON further stated, the risk of the resident touching a catheter during an aseptic procedure is an increased risk of infection for an already compromised resident.
During an interview on March 10, 2023, at 9:51 AM, with the Infection Preventionist (IP), the IP stated it was their expectation that licensed staff do not have the residents hold their own catheter during catheter irrigation. The IP stated, LVN 2 should have asked another LVN to assist, someone licensed and trained in the procedure. The IP further stated the risk of the resident manipulating the catheter during irrigation is risk for entry of infection.
During a review of the facility's policies and procedures (P&P) titled, Catheter Care, Urinary, revised September 2014, the P&P indicated, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections .General Guidelines: 2. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the accurate administration of prescribed drug...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the accurate administration of prescribed drugs and biologicals, when a medication was not administered as ordered by the physician for one of seven sampled residents (Resident 17).
This failure resulted in Resident 17 receiving a doubled dosage of an ordered laxative medication which resulted in a medication error and had the potential to cause adverse drug effects to the resident.
Findings:
During a review of the Face Sheet (contains admission and demographic information) for Resident 17, the Face Sheet indicated, Resident 17 was admitted on [DATE], with a diagnosis of Alzheimer's disease (the most common cause of dementia - an impaired ability to think, remember, or make decisions), encounter for palliative care (specialized medical care for people living with a serious illness), bed confinement, and pressure ulcer of sacral region- stage 4 (full thickness damage to the skin and underlying soft tissue of the lower back, just above the tailbone, with exposed fat, muscle, or bone).
During an observation on March 9, 2023, at 10:00 AM, in Resident 17's room, Licensed Vocational Nurse 1 (LVN 1) was observed performing medication pass for Resident 17. LVN 1 administered two tablets of Senna Plus (a combination laxative and stool softener) 8.6mg- 50mg (milligram-unit of measurement) by mouth. The medication bubble packaging (presorted monthly supply of prescriptions for daily dispensing) came with two tablets in each bubble and was labeled for Resident 17, with the following indication: Senna 8.6mg-50mg two tablets twice daily.
During a review of the Medication Administration Record (MAR) for Resident 17, dated March 2023, the MAR indicated, Resident 17 had a physician order for Senna Plus 8.6mg-50mg tablet (1 tablet) two times daily for bowel management hold for loose stools.
During a concurrent interview and record review on March 9, 2023, at 10:10 AM, with LVN 1, LVN 1 reviewed the MAR for Resident 17 and stated, the order for Resident 17's Senna Plus came from hospice. LVN 1 reviewed the [Hospice] Plan of Care for Resident 17, dated January 24, 2023, and the hospice order for medications indicated, Senna Plus 50mg-8.6mg tablet 1 tablets orally 2 times a day for bowel management. LVN 1 stated the wrong dose of Senna was given to Resident 17.
During an interview on March 9, 2023, at 10:45 AM, with the Director of Nursing (DON), the DON stated, nurses should be monitoring for medication discrepancies at all points, when a medication is ordered, loaded into the medication cart, and when it is pulled to be administered to a resident. The DON further stated LVN 1 should have followed the physician's order.
During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised April 2019, the P&P indicated, Policy Statement: Medications are administered in a safe and timely manner . 4. Medications are administered in accordance with prescriber orders . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.
During a review of the facility's P&P titled, Medication Ordering and Receiving from Pharmacy, dated October 2012, the P&P indicated, .B. 1). A licensed nurse: c. Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to observe infection prevention and control measures for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to observe infection prevention and control measures for two of two sampled residents (residents 28 and 30) when:
1. Resident 28's wheelchair was ripped.
2. Resident 30's toothbrush and hair comb were found in a shared bathroom sink, unlabeled.
These failed practices had the potential for the spread of infection and placing residents' health and safety at risk of a highly susceptible population of 39 residents.
Findings:
1. During a concurrent observation and interview on March 7, 2023, at 10:40 AM, with Resident 28, in Resident 28's room, the vinyl fabric (a durable, waterproof, man-made synthetic leather) lining of Resident 28's wheelchair was observed to be torn on both sides of the backrest where it connected to the wheelchair frame. The exposed fabric was partially covered with dirty, peeling, paper medical tape. Resident 28 stated the wheelchair was provided to him by the facility and had been torn since he was admitted in October 2021.
During an interview on March 9, 2023, at 10:38 AM, with the Director of Nursing (DON), the DON stated Resident 28's wheelchair condition was not maintained to the appropriate standard and could have been a safety and infection risk.
During a concurrent observation and interview on March 10, 2023, at 9:51 AM, with the Infection Preventionist (IP), in the IP's office, Resident 28's wheelchair was observed. The IP stated the wheelchair needs to have an easily wipeable surface and due to the rips in the vinyl and exposed fabric, it would not be easily wipeable. The IP further stated it was a risk for infection.
During an interview on March 10, 2023, at 11:20 AM, with Environmental Services 1 (EVS 1), EVS 1 stated a torn wheelchair surface with exposed fabric could not be properly sanitized.
During a review of the facility's policy and procedure (P&P) titled, Standard Precautions, revised October 2018, the P&P indicated, .6. a. Environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces are appropriately cleaned.
2.During a review of Resident 30's clinical record, the face sheet (contains demographic and medical information) indicated Resident 30 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (the most common cause of dementia - an impaired ability to think, remember, or make decisions) and generalized anxiety disorder (persistent worrying).
During a concurrent observation and interview with Certified Nursing Assistant 5 (CNA 5), on March 9, 2023, at 7:54 AM, in the shared bathroom of Resident 30 and 186, a comb and a wet toothbrush was on the bathroom sink. It did not have a label to indicate who it belonged to. CNA 5 stated, I thinks it's Resident 30's, I will go ahead and write her name.
During an interview on March 9, 2023 at 8:00 AM, with Certified Nursing Assistant 5 (CNA 5), in Resident 30's shared bathroom, CAN 5 stated, Resident 30 should have a new set of toothbrush and comb because it was just lying on the bathroom sink with no label.
During an interview with Licensed Vocational Nurse 5, (LVN 5), on March 10, 2023, at 10:39 AM, she stated, resident belongings should be labeled with their initials or full names to prevent cross contamination, it's an infection control issue.
During an interview with the Administrator, on March 10, 2023, at 10:49 AM, he stated, it's their practice to separate and label the residents belongings with their name and/or initials. We don't have a policy but it's common sense, it's sanitary and infection control practice.
A review of the facility's policy and procedure (P&P) titled, Admitting the Resident: Role of the Nursing Assistant, revised September 2013, the P&P indicated, Purpose. The purposes of this procedure are to assist the resident to his/her room and to help alleviate concerns and answer questions that the resident and family may have. Steps in the procedure: .11. Write the resident's name on the appropriate articles (i.e., water pitcher, cup, urinal, denture cup, etc.) .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a safe environment for all residents in the facility, when an open gap on the dining room floor was present.
This fai...
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Based on observation, interview, and record review, the facility failed to ensure a safe environment for all residents in the facility, when an open gap on the dining room floor was present.
This failure had the potential to impose a tripping hazard for the residents and could have contributed to resident falls with injuries.
Findings:
During an observation on March 7, 2023, at 11:00 AM, an open gap in the flooring of the dining room floor was observed, measuring approximately six inches long and one inch wide.
An interview on March 7, 2023, at 11:00 AM, with the Administrator, the Administrator stated, he didn't know why the gap in the flooring was there. The Administrator stated, he will get it fixed immediately.
During an interview on March 8, 2023, at 12:08 PM, with Maintenance, Maintenance stated, he didn't know how long the open gap had been there. Maintenance stated the gap in the floor may have been there for a few months, due to the build-up of dirt around it.
During an interview on March 9, 2023, at 10:53 AM, with the Administrator, the Administrator stated, housekeeping was responsible for mopping the floor, and they never reported about the open gap in the flooring of the dining area.
During a review of the facility's policy and procedure titled Slips and Falls dated September 13, 2018, the P&P included the following: Policy: This community implements the following procedures to minimize the risk of slips, trips, and falls. Procedure 5. Keep aisles and passageways clear and in good repair, with no obstruction across or in aisles that could create hazard .18. Eliminate uneven floor surfaces.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen environment when:
1) The two ice machines that provide ice for 37 of 38 residents of the facility...
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Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen environment when:
1) The two ice machines that provide ice for 37 of 38 residents of the facility, were not clean to sight and touch. Ice machine 1 had a yellowish build-up in the ice chute (where ice is dispensed and travels from the ice maker to enter the ice bin). Ice machine 2 had a brownish build-up. This had the potential to contaminate the ice and cause foodborne illness.
2) The walk-in freezer that provides storage of food for 37 of 38 residents had liquid food spills, food crumbs and trash on the floor. This had the potential for microorganism growth and to attract pests.
3) The cabinet below the steam table (appliance that keeps food warm after it's been prepared and cooked) in the dining room that services meals for 37 of 38 residents had food crumbs and a rusty liquid spill. This had the potential for microorganism growth and to attract pests.
Findings:
1. During an observation of Ice Machine 1, on March 7, 2023, at 9:00 AM, in the beverage area of the dining room, a yellowish-brown residue was noted in the ice chute.
During an interview on March 7, 2023, at 9:05 AM, with Registered Dietician 1 (RD 1), she stated the ice machine bin is cleaned monthly by staff and quarterly they have a contract company come in and clean the area that was observed to have the build-up (the internal components where the ice is made and dispensed). RD1 observed the yellowish residue that was removed with a paper towel and stated they would need to change the cleaning schedule from quarterly to monthly.
During an observation of Ice Machine 2 and concurrent interview with Maintenance on March 7, 2023, at 10:18 AM, in the kitchen, a brown residue was noted on the ice chute. The Maintenance acknowledged the build-up and stated it should not be there.
During an interview on March 9, 2023, at 2:11 PM with RD 2 she stated her expectation is that the ice machines in the dining room and the kitchen are to not have any build-up.
During a record review of the Health Center Ice Machine Monthly Cleaning Log 2023, indicated, the date for last internal cleaning is January 18, 2023.
During record review of the main kitchen Ice Machine Monthly Cleaning Log dated 2023 indicated, the date for last internal cleaning is January 18, 2023.
During a record review of FDA Federal Food Code 2022, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensil, (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. In addition, 4-602.11 indicates, (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. Also ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.
2. During observation on March 7, 2023, at 8:15 AM, in the kitchen walk-in freezer, there was some sliced potato lying on the ground at entry, a dark pink/purple spill was noted on the floor of the freezer under the shelving, there was crumbs and some trash on the floor of the freezer.
During an interview on March 7, 2023, at 8:15 AM, RD1 and RD2 were shown the spillage. RD1 stated they ran out of the specific cleanser that will clean a walk-in freezer and it is currently unavailable from the company that provides it.
During an interview on March 9, 2023, at 2:11 PM with RD 2 she stated, it is her expectation that the walk-in freezer floor to be kept clean.
During a record review of the Food Code, 2022, the Food Code indicated, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, Food residue, and other debris and the Equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.
3. During an observation on March 7, 2023, at 8:46 AM, in the dining area, where food from the main kitchen is kept warm and plated then distributed to residents, the cabinet below steam table had crumbs on the floor, and a leakage of fluid and brown/rust colored staining to the floor of the cabinet.
During an interview on March 7, 2023, at 8:46 AM, RD 1 acknowledged that it was dirty.
During an interview on March 9, 2023, at 2:11 PM with RD 2, she stated that her expectation is the cabinet needs to be kept clean.
During a record review of the Food Code, 2022, the Food Code indicated, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris and the Equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most California facilities.
Concerns
- • 22 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Plymouth Village's CMS Rating?
CMS assigns PLYMOUTH VILLAGE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within California, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Plymouth Village Staffed?
CMS rates PLYMOUTH VILLAGE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 47%, compared to the California average of 46%.
What Have Inspectors Found at Plymouth Village?
State health inspectors documented 22 deficiencies at PLYMOUTH VILLAGE during 2023 to 2025. These included: 22 with potential for harm.
Who Owns and Operates Plymouth Village?
PLYMOUTH VILLAGE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by HUMANGOOD, a chain that manages multiple nursing homes. With 48 certified beds and approximately 41 residents (about 85% occupancy), it is a smaller facility located in REDLANDS, California.
How Does Plymouth Village Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, PLYMOUTH VILLAGE's overall rating (4 stars) is above the state average of 3.2, staff turnover (47%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Plymouth Village?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Plymouth Village Safe?
Based on CMS inspection data, PLYMOUTH VILLAGE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Plymouth Village Stick Around?
PLYMOUTH VILLAGE has a staff turnover rate of 47%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Plymouth Village Ever Fined?
PLYMOUTH VILLAGE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Plymouth Village on Any Federal Watch List?
PLYMOUTH VILLAGE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.