Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Camden Postacute Care, Inc during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain sanitary food storage and labeling practices, including leaving a dented can of grape juice in storage, keeping an open pack of cereal without a date, and storing various produce and frozen items without proper labeling or dating, as confirmed by the Dietary Manager.
Six residents did not have documented evidence that staff discussed, offered, or assisted them in executing advance directives, despite facility policy requiring this. Both the Social Service Director and a Registered Nurse confirmed that this process was not completed for these residents.
Six residents were found to have bed rails installed without documented assessment, attempts at alternatives, informed consent, or risk/benefit review, as required by facility policy. Nursing staff confirmed that these steps were not completed or documented prior to bed rail use, affecting residents with both intact and impaired cognition.
Staff did not consistently use required PPE, such as gowns and gloves, during wound and Foley catheter care for residents on Enhanced Barrier Precautions, and failed to perform proper hand hygiene between glove changes and resident care tasks. Additionally, respiratory and suction equipment was found unlabeled and improperly stored, increasing the risk of cross-contamination.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a board and care facility without the required 30-day written notice to the responsible party or information about appeal rights. The transfer was initiated by a CNA/AA without proper IDT involvement or documentation, and the Social Services Director did not provide written notification or advice regarding the right to appeal, resulting in a violation of the resident's rights.
A resident with severe cognitive impairment and multiple medical conditions was discharged to a board and care facility without proper IDT evaluation, responsible party involvement, or adherence to facility policy. The discharge was initiated by a staff member not authorized for the role, and critical documents were not provided to the receiving facility. The responsible party was not adequately informed or involved, and the resident subsequently eloped multiple times from the new placement.
Several deficiencies were found, including a resident with Parkinson's disease not receiving timely feeding assistance during meals, two residents with urinary catheters left with uncovered drainage bags despite care plan requirements, and staff speaking in a language other than English in the presence of a cognitively intact resident. These actions failed to uphold residents' dignity and respect as outlined in facility policy.
Two residents were found with over-the-counter medications and supplements left unattended at their bedsides, which they self-administered without an IDT assessment or physician order. Nursing staff were aware of the self-administration, but facility records lacked required documentation and authorization for these practices.
Two residents experienced unclean living conditions, including a sticky, soiled privacy curtain and a sticky floor that was not properly mopped. An LVN and the Housekeeping Supervisor confirmed these issues, and the supervisor could not provide documentation of daily or monthly cleaning, relying only on visual checks.
The facility did not complete required PASRR Level I and Level II screenings for two residents with serious mental illness. In one case, a resident with schizoaffective and major depressive disorders did not receive a Level II evaluation due to lack of staff response to the evaluating agency. In another case, a resident with delusional disorder and schizophrenia did not have a new Level I screening after updated diagnoses, as confirmed by staff and documentation review.
A resident with paraplegia, chronic kidney disease, multiple contractures, and several stage 4 pressure ulcers did not have an individualized, person-centered care plan. Instead, all pressure ulcers were combined under the same goals and interventions, despite differing measurements and treatment needs for each site. The facility did not provide relevant policy and procedure documentation.
Two residents' care plans were not updated after significant changes in their conditions: one with dementia did not have care plan revisions to address increased time in bed and the need for a charged cellphone for family contact, and another with ESRD did not have the care plan updated after the hemodialysis schedule increased from three to four times per week. These omissions were confirmed through observation, interviews, and record review.
A resident with hemiplegia and hemiparesis following a stroke was observed smoking unsupervised on the patio, despite clinical records and staff confirming the need for oversight supervision due to the resident's physical limitations. The facility did not provide a policy or procedure for smoking supervision.
The facility did not provide the required number of direct care nursing staff during weekend shifts, as confirmed by review of staffing records and staff interviews. Actual CNA and total DHPPD fell below the facility's policy minimums, affecting all residents in the facility.
The facility did not ensure that a pharmacist's medication regimen review recommendations were reviewed or acted upon for a resident with GERD and chronic pain, and failed to identify or address the lack of required lab monitoring for a resident receiving anticoagulant therapy. Facility policies requiring prompt action and documentation of pharmacist recommendations, as well as protocols for lab monitoring of anticoagulant use, were not followed.
Surveyors identified a medication error rate above 5% when two residents received medications not in accordance with physician orders: one received glipizide without regard to meal timing, and another was given hydrocortisone without food. Nursing staff did not follow prescribed administration instructions, resulting in a deficiency.
Two residents were affected when a bottle of lorazepam without a legible expiration date was stored in the medication room, and an unlabeled bottle of normal saline solution was left unattended on a bedside table. Nursing staff confirmed that both medications were not labeled or stored according to facility policy, which requires clear labeling and secure storage of all drugs and biologicals.
The facility was found to have rooms with more than four residents, with one room housing six and another five. Each resident had appropriate furnishings and there were no reported concerns from residents or staff regarding care, privacy, or safety.
Several multi-resident rooms were identified as having less than the required 80 square feet per resident, with some rooms providing as little as 64.68 square feet per individual. Despite this deficiency, interviews and observations indicated that care, privacy, and storage needs were adequately met.
The facility did not complete thorough investigations or document outcomes for alleged abuse by a CNA and physical altercations between residents. Investigation summaries lacked findings on whether the incidents occurred, and the administrator confirmed that required procedures were not followed according to facility policy.
A facility failed to assist a resident in obtaining insurance after their MediCal coverage was discontinued. The resident, admitted with heart failure, malnutrition, pressure ulcers, and sepsis, was not informed about private pay options, nor was a new MediCal application submitted. The facility's policy required admission staff to refer residents for Medicaid coverage assistance, but this was not followed.
A resident with a complex medical history was allowed to leave an LTC facility to visit a 7-Eleven store, contrary to a physician's order for therapeutic therapy. The MDSC confirmed the outing was not therapeutic and lacked documentation of physician notification, highlighting a failure to adhere to professional standards of practice.
The facility failed to protect a resident from sexual abuse when two residents were left unsupervised in the activity room, resulting in one resident touching another's inner thigh. The incident occurred due to a lack of supervision after 6 p.m., and the responsible CNA was on a delayed break.
Failure to Maintain Sanitary Food Storage and Labeling Practices
Penalty
Summary
Surveyors observed multiple failures to maintain sanitary conditions in the facility's kitchen. During a kitchen tour, a can of grape juice with a dent was found in the dry storage room and had not been removed to prevent use, despite facility policy and FDA guidance requiring removal of dented cans to prevent bacterial contamination. Additionally, an open pack of cereal was found without a date indicating when it was opened or its expiration date, which was confirmed by the Dietary Manager as not being properly labeled. Further observations revealed that various fresh produce items stored in refrigerator #2, including tomatoes, carrots, onions, lettuce, and celery, were kept in plastic bags without any labeling or dates indicating when they were delivered to the facility. In freezer #2, a pack of cauliflower and a pack of chopped spinach were also found without opened or expiration dates. These findings were in direct violation of the facility's policy requiring all food items in storage, refrigerators, and freezers to be labeled and dated.
Failure to Offer and Assist with Advance Directives
Penalty
Summary
The facility failed to follow its policy and procedure regarding advance directives (AD) for six of eight sampled residents. For each of these residents, documentation such as the face sheet and POLST forms indicated either that no advance directive was present or that it was not available. Further review of the clinical records for these residents showed no evidence that the facility discussed, offered, or assisted them in executing an advance directive, as required by facility policy. During interviews, both the Social Service Director (SSD) and a Registered Nurse (RN) confirmed that there was no documentation of AD discussions or assistance for these residents. The SSD acknowledged that she had not discussed, offered, or assisted the residents with advance directives, and the RN confirmed that the SSD was responsible for this process but had not completed it. The facility's policy states that staff must offer assistance in establishing advance directives if a resident has not already done so, but this was not carried out for the identified residents.
Failure to Follow Bed Rail Assessment and Consent Procedures
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for six residents. Observations revealed that multiple residents were using partial bed rails on their beds, and interviews with staff confirmed that these bed rails had been installed without proper documentation or assessment. Specifically, there was no evidence that alternatives to bed rails were attempted prior to their use, nor was there documentation of informed consent from the residents or their representatives. Additionally, the required assessment of risks and benefits, including the risk of entrapment, was not completed or documented before the installation of bed rails. Clinical record reviews for the affected residents showed that none had documentation supporting the necessary steps for bed rail use. This included the absence of a bed rail assessment, lack of documentation of alternatives attempted, no record of risk versus benefit discussions, and no informed consent obtained. The residents involved had varying levels of cognitive function, as indicated by their BIMS scores, with some having intact cognition and others having severe cognitive impairment. Despite these differences, the facility did not individualize or document the decision-making process for bed rail use as required by policy. Interviews with nursing staff confirmed the lack of documentation and adherence to policy for all residents observed with bed rails. The facility's policy clearly states that the interdisciplinary team must assess the resident, attempt alternatives, review risks and benefits, obtain informed consent, and assess for entrapment risk prior to bed rail installation. These steps were not followed or documented for the six residents identified, resulting in a failure to ensure that residents and their representatives were fully informed and protected according to facility policy and regulatory standards.
Failure to Adhere to Infection Control Protocols and PPE Use
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols, specifically regarding the use of Enhanced Barrier Precautions (EBP) and personal protective equipment (PPE) during resident care. Staff did not consistently wear gowns and gloves when providing wound care and Foley catheter care to residents who were on EBP, despite signage and the presence of PPE carts. Interviews with staff, including CNAs and LVNs, revealed a lack of compliance and understanding of when PPE was required, even though the Director of Nursing and Director of Staff Development confirmed that PPE should be used during these activities. Residents involved had significant medical histories, including sepsis, MRSA, indwelling catheters, and multiple wounds, increasing their risk for infection. Hand hygiene practices were also not followed as required. During wound treatment observations, an LVN failed to perform hand hygiene between glove changes and after touching various surfaces and supplies, despite acknowledging the need to do so. The facility's policy required hand hygiene to prevent the spread of infection, but this was not consistently implemented during care activities, including wound dressing changes and feeding assistance. Additionally, infection control lapses were observed in the storage and labeling of respiratory and suction equipment. A resident's nebulizer mouthpiece and suction tubing were found unlabeled and improperly stored, in contact with potentially contaminated surfaces and personal items. Staff confirmed these practices were not in line with facility policy, which required proper cleaning, labeling, and storage of such equipment. These failures in infection control practices had the potential to result in cross-contamination and the spread of infection among the facility's residents.
Improper Transfer/Discharge Without Written Notice or Appeal Rights
Penalty
Summary
The facility failed to properly manage the transfer and discharge process for a resident diagnosed with Alzheimer's disease, unspecified dementia, unsteadiness on feet, a history of falls, type 2 diabetes mellitus, hearing loss, psychotic disturbance, mood disturbance, and anxiety. The resident's cognitive status was severely impaired, and the responsible party (RP), identified as the resident's granddaughter, was not provided with the required written notice at least 30 days prior to the transfer. The RP was only verbally informed by the Social Services Director (SSD) of the impending transfer due to an alleged abuse incident, and was not given any written documentation or information about the resident's rights to appeal the transfer or discharge. Record review and interviews revealed that the transfer/discharge notice was completed by a Certified Nursing Assistant/Activity Assistant (CNA/AA) who was previously acting as Social Services (SS), rather than by the SSD or through an interdisciplinary team (IDT) discussion. The CNA/AA admitted to initiating the transfer based on her own opinion that the resident was a danger to others, without documentation or input from a medical doctor or the IDT. The administrator confirmed that the CNA/AA should not have been responsible for the transfer/discharge process and that the SSD should have coordinated the process in accordance with facility policy. Facility policy requires a 30-day written notice to the resident and/or their representative, including the reason for transfer/discharge, effective date, location, and information about the right to appeal. In this case, the required written notice and information about the appeal process were not provided to the RP. The SSD also confirmed that she did not provide written notification or advice regarding the right to appeal. As a result, the transfer/discharge was conducted improperly and in violation of the resident's rights.
Failure to Ensure Safe and Proper Discharge Planning for Cognitively Impaired Resident
Penalty
Summary
The facility administrator failed to provide consistent oversight to ensure that the Social Services Department and interdisciplinary team (IDT) implemented the facility's policy and procedure for safe transfer and discharge of a resident with severe cognitive impairment. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, unsteadiness, history of falls, diabetes, hearing loss, psychotic and mood disturbances, and anxiety, was discharged to a board and care facility without proper IDT evaluation or documentation of a discharge meeting with the responsible party (RP). The responsible party, identified as the resident's granddaughter, was not given adequate notice, was not involved in the discharge planning, and did not receive necessary information such as discharge orders, medication instructions, or the opportunity to collect the resident's personal belongings. The discharge process was initiated by a staff member who was no longer serving in the Social Services Director (SSD) role, but rather as a certified nursing assistant (CNA) and activity assistant (AA). This staff member completed the notice of transfer/discharge without a documented discussion or agreement from the medical doctor or IDT, and based the decision on her own opinion that the resident was a danger to others. The current SSD and the administrator both confirmed that the proper process was not followed, and that the SSD should have been responsible for coordinating the discharge in collaboration with the IDT. Additionally, the facility failed to send critical documents, such as the POLST (physician orders for life-sustaining treatment), to the receiving board and care facility. The responsible party was not notified when the board and care staff assessed the resident, nor was she given the chance to review the new placement prior to discharge. Following the transfer, the resident eloped from the board and care facility multiple times, and the board and care facility had to implement additional safety measures. The facility's actions did not adhere to its own policy requiring a 30-day written notice and proper communication with the resident or responsible party regarding the transfer or discharge.
Failure to Maintain Resident Dignity and Timely Assistance During Care and Meals
Penalty
Summary
Multiple deficiencies were identified regarding the failure to honor residents' rights to dignity, respect, and timely assistance. One resident with Parkinson's disease, who was dependent for eating and required one-on-one feeding assistance, was observed on two separate occasions sitting alone in the dining room without staff assistance while other residents were being helped. Staff interviews confirmed that feeding assistance was delayed, and the facility's policy required immediate assistance for residents needing full help upon meal delivery. Another deficiency involved two residents with urinary catheters whose drainage bags were left uncovered. Observations showed that the catheter bags were not covered with privacy bags as required by the residents' care plans and facility policy. Staff interviews confirmed awareness of the requirement to cover catheter bags for privacy, dignity, and infection control, but this was not done for these residents. Additionally, a resident reported that housekeeping and dietary staff were speaking in a language other than English in her presence while providing care and working in the facility. This was confirmed by direct observation and staff interviews, with staff acknowledging that English should be spoken when residents are present. The facility's policy emphasized the importance of promoting dignity and respect for all residents, including communication practices and privacy measures.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to conduct an interdisciplinary team (IDT) assessment and obtain physician orders for self-administration of medications for two residents. One resident had a bottle of isopropyl alcohol, which he used daily to clean his skin, left unattended on his tray table. This resident had purchased the isopropyl alcohol himself, and nursing staff were aware of his use. Review of his records showed no documentation of an IDT assessment for self-administration or a physician order for the isopropyl alcohol. The resident was cognitively intact and had a diagnosis of a non-pressure chronic ulcer of the left foot. Another resident was found with a bottle of hydrogen peroxide and a bottle of folic acid on his bedside table, both left unattended. The resident reported using the hydrogen peroxide to clean his teeth weekly and taking folic acid daily, with both items brought in by his son. Nursing staff were aware of his self-administration, but records indicated that the IDT had documented 'No' for self-medication administration and there were no physician orders for these items. This resident was also cognitively intact and had a diagnosis of anemia. Facility staff confirmed that medications should not be left at bedside unattended and that required assessments and orders were missing.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for two residents. In one instance, a resident's privacy curtain was observed to be sticky and soiled with brownish dry food particles. This was confirmed by an LVN, who stated that the curtain was dirty and should have been changed by housekeeping or janitorial staff. In another instance, a resident's room had a sticky floor, and the resident reported that housekeeping had only cleaned the room because a state surveyor was present, and that the floor was not properly mopped. The resident expressed dissatisfaction with the cleanliness of her room. The Housekeeping Supervisor stated that both daily cleaning and monthly deep cleaning of resident rooms were the responsibility of housekeeping and janitorial staff, with privacy curtains scheduled to be changed monthly or as needed. However, the supervisor was unable to provide documentation verifying that daily or monthly cleaning had been performed, as he relied solely on visual checks. Additionally, the facility was unable to provide a policy and procedure for cleaning and maintaining resident rooms.
Failure to Complete Required PASRR Screenings for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) Level I and Level II screenings were completed for two residents with serious mental illness (SMI). For one resident, who had diagnoses including schizoaffective disorder and major depressive disorder, the PASRR Level I screening indicated a Level II mental health evaluation was required. However, the Level II evaluation was not completed because facility staff were unresponsive to multiple attempts at communication from the evaluating agency, resulting in the case being closed without the necessary follow-up or resubmission of a new Level I screening. For another resident, who had diagnoses of delusional disorder and schizophrenia, the facility did not complete a new Level I PASRR screening after the resident was diagnosed with SMI. The resident's records showed no evidence of a Level I screening following the updated diagnoses, and staff confirmed that the required screening was not performed. The facility's own policy requires timely submission and follow-up of PASRR documentation, but this was not adhered to in these cases.
Failure to Develop Individualized Care Plans for Pressure Ulcers
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan with measurable objectives, goals, and individualized interventions for a resident with multiple complex medical conditions. During an interview and record review with a registered nurse, it was found that the resident was admitted with diagnoses including paraplegia, chronic kidney disease, multiple contractures, and several stage 4 pressure ulcers at different anatomical sites. The care plan for pressure ulcers grouped all sites together under the same goals and interventions, rather than addressing each ulcer individually. Further review of interdisciplinary team meeting notes revealed that each pressure ulcer had different measurements, treatment changes, and status updates, confirming that individualized care planning was necessary but not implemented. The registered nurse acknowledged that each pressure ulcer site should have been care planned separately to provide person-centered care. The facility did not provide a policy and procedure related to this aspect of care planning.
Failure to Update Care Plans After Changes in Resident Condition
Penalty
Summary
The facility failed to update and revise individualized and comprehensive care plans for two residents following significant changes in their conditions. For one resident with dementia, the care plan was not updated to reflect the resident's increased time spent in bed and the importance of maintaining a fully charged personal cellphone at bedside to support psychosocial well-being and facilitate communication with family members. The care plan also did not address the resident's cultural background or the need for individualized, person-centered care, despite observations and staff interviews indicating these needs. For another resident with end stage renal disease (ESRD) on hemodialysis (HD), the care plan was not revised after the resident's HD schedule increased from three to four times per week. The care plan continued to reflect the previous schedule and did not account for the change in treatment frequency, as confirmed by the DON during record review. The facility's policy required care plans to be reviewed and updated every 90 days or when there is a change in resident status or condition, but this was not followed in these cases.
Failure to Provide Required Supervision During Resident Smoking
Penalty
Summary
A resident with a history of muscle weakness, hemiplegia, hemiparesis following a stroke, and type 2 diabetes mellitus was observed smoking on the facility patio without wearing a smoking apron and without staff supervision. The resident stated that staff only provided supervision when handing over and lighting cigarettes, but not during the actual smoking period. Facility staff, including an Activity Assistant, confirmed that the resident requires oversight supervision while smoking for safety reasons. A review of the resident's clinical records and smoking safety assessments indicated that the interdisciplinary team determined the resident could smoke only with oversight supervision due to their physical limitations and medical diagnoses. The Director of Nursing confirmed that staff are expected to supervise residents during scheduled smoking times. The facility was unable to provide a policy and procedure regarding smoking supervision.
Insufficient Nursing Staff on Weekend Shifts
Penalty
Summary
The facility failed to provide sufficient direct care nursing staff to meet the needs of all residents for 24 hours a day during the weekend. Review of the facility's census and direct care service hours per patient day (DHPPD) forms showed that on two consecutive weekend days, the actual CNA DHPPD was below the required 2.4, and the total DHPPD (including CNAs and licensed nurses) was below the required 3.5. The Director of Staff Development confirmed that staffing levels did not meet the facility's own policy requirements on both days. Interviews with staff and review of facility policy further confirmed that the minimum staffing standards were not met, potentially affecting the care, health, and well-being of all 55 residents in the facility. No specific residents or their medical conditions were mentioned in relation to the deficiency, but the findings were based on record review and staff interviews confirming the shortfall in required staffing levels.
Failure to Follow Consultant Pharmacist Recommendations and Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a thorough monthly drug regimen review (MRR) and that recommendations were appropriately followed for two residents. For one resident with diagnoses including gastroesophageal reflux disease (GERD) and chronic pain, the consultant pharmacist identified issues with medication forms and dosing frequencies during the MRR. However, there was no evidence that nursing staff reviewed or acted upon these recommendations, as indicated by the absence of signatures or documentation on the MRR and confirmed by interviews with nursing staff and the Director of Nursing (DON). For another resident with a history of atrial fibrillation and pulmonary embolism who was receiving anticoagulant therapy (rivaroxaban), the facility did not order baseline or periodic laboratory work to monitor kidney function and blood levels, despite this being an intervention listed in the resident's care plan. The MRR reports for this resident did not address the lack of laboratory monitoring, and both the DON and the consultant pharmacist confirmed that this oversight occurred. The consultant pharmacist acknowledged that baseline and periodic blood work should have been recommended but was not identified during the monthly review. Facility policies required that consultant pharmacist findings be communicated to the DON or designee and that recommendations be acted upon and documented within 72 hours. Additionally, the facility's anticoagulation protocol specified that appropriate lab testing should be ordered to monitor anticoagulant therapy. These policies were not followed, resulting in missed medication clarifications and lack of necessary laboratory monitoring for residents receiving high-risk medications.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
A medication error rate of 5.56% was identified during a medication pass, with two errors observed out of 36 opportunities involving two residents. For one resident with type 2 diabetes mellitus, a registered nurse administered glipizide 2.5 mg as ordered, but failed to ensure it was given 30 minutes prior to meals as specified in the physician's order. The medication was administered in the afternoon without confirmation of the timing in relation to meals. For another resident with a BIMS score indicating cognitive intactness and a diagnosis of low cortisol, a licensed vocational nurse administered hydrocortisone 5 mg without food, contrary to the physician's order to give the medication with food. The nurse assumed the resident had eaten a snack earlier, but the resident confirmed no food was consumed during the relevant time frame. The facility's policy requires medications to be administered according to physician orders, but this was not followed in these instances.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for two residents. In one instance, a bottle of oral liquid lorazepam, a controlled medication prescribed for anxiety, was found in the medication storage room without a legible expiration date. The medication had last been administered to the resident several months prior, and both nursing staff and the Director of Nursing acknowledged that the expiration date was unclear and should have been clarified with the pharmacy before use. Facility policy requires that each prescription medication label include an expiration date. In another instance, an unlabeled bottle of normal saline solution (NSS) was found unattended on a resident's bedside table. The resident, who was cognitively intact, reported that staff left the NSS for use in flushing a Foley catheter and for wound treatment. A nurse confirmed that the NSS should have been labeled and stored in the treatment cart, not left at the bedside. Facility policy states that any medications found at the bedside not authorized for bedside storage must be reported and given to the charge nurse.
Resident Room Overcapacity
Penalty
Summary
The facility failed to ensure that resident rooms accommodated no more than four residents, as required. During an observation, one room was found to have six beds and six residents, while another had five beds and five residents. Both rooms provided each resident with a bed, privacy curtain, nightstand, and closet, and there were no obstructions to closets, bathrooms, or exits. Interviews with residents, a CNA, and an LVN confirmed the presence of more than four residents in these rooms, though no concerns regarding care, privacy, or safety were identified by those interviewed.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
Multiple multi-resident rooms were found to be less than the required 80 square feet per resident, with specific rooms ranging from 64.68 to 78 square feet per resident. This was identified through observation, interviews with staff and residents, and record review. The facility administrator confirmed that the rooms listed did not meet the minimum space requirement. Despite the space deficiency, no care or privacy issues were observed, and both staff and residents reported that nursing care and services were not impacted. Closet and storage spaces were also found to be sufficient for residents' needs.
Failure to Complete and Document Abuse and Incident Investigations
Penalty
Summary
The facility failed to conduct thorough investigations and provide clear outcomes for six residents involved in alleged abuse and physical altercations. Specifically, the 5-day investigation summaries for incidents involving alleged abuse by a CNA toward two residents, as well as physical altercations between two separate pairs of residents, did not indicate whether the facility determined if the alleged events occurred. The administrator acknowledged that the 5-day follow-up investigations were not completed according to the facility's abuse policy and procedure, and that he was unable to verify if the allegations were substantiated. Record reviews and interviews confirmed that the facility's investigation documentation lacked required findings and did not follow the established policy, which mandates thorough investigation, documentation, and reporting of all abuse allegations. The policy also requires that findings be reported to the appropriate authorities within five working days. The absence of documented outcomes for these incidents compromised the facility's ability to determine the circumstances surrounding the events.
Failure to Assist Resident with Insurance Coverage
Penalty
Summary
The facility failed to assist a resident with obtaining insurance coverage after their MediCal insurance was discontinued. The resident, who was admitted with diagnoses including heart failure, malnutrition, pressure ulcers, and sepsis, was removed from MediCal on July 31, 2024. The facility administrator confirmed that there was no discussion of private pay options with the resident and that the facility did not apply for MediCal on behalf of the resident. The social services staff indicated that the previous business office manager was responsible for completing the MediCal redetermination and would contact her to obtain necessary documents from the family. The facility's policy and procedure for admissions stated that admission staff should refer residents to the Social Service Director for Medicaid coverage and that the Medicaid application could be completed during the admission process.
Failure to Follow Physician's Order for Therapeutic Therapy
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident when a Licensed Vocational Nurse (LVN) did not adhere to a physician's order regarding therapeutic therapy. The resident, who had a complex medical history including chronic obstructive pulmonary disease, neuralgia, neuritis, hypertensive heart, and chronic kidney disease with heart failure, was allowed to leave the facility to go to a 7-Eleven store. This action was not in line with the physician's order, which specified that the resident could go out on pass for therapeutic therapy. During an interview and record review, the Minimum Data Set Coordinator (MDSC) confirmed that the resident signed the facility's Out on Therapeutic Pass/Leave of Absence Log to leave the premises. The MDSC stated that the resident became verbally and physically aggressive, prompting the decision to let her go out that night, and claimed to have notified the physician. However, there was no documentation in the progress notes to confirm that the physician was notified. The MDSC acknowledged that the resident's outing to the 7-Eleven store did not qualify as therapeutic therapy and was against the physician's order.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure that Resident 1 was free from sexual abuse when Resident 1 and Resident 2 were left alone in the activity room, resulting in Resident 2 touching Resident 1's inner thigh. Resident 1, who has severe cognitive impairment with a BIMS score of 0, was admitted with diagnoses including vascular dementia and cognitive communication deficit. Resident 2, who also has dementia and a BIMS score of 5, was observed by Resident 3 with his hands inside Resident 1's pants. Resident 3 immediately called RN A, who confirmed the incident upon arrival at the activity room. Interviews with staff revealed that the activity room lacked supervision after 6 p.m. On the evening of the incident, CNA C, who was responsible for Resident 1, was on a delayed break and had asked other CNAs to watch her assigned residents. The facility's policy on abuse, dated 7/2025, mandates the prohibition of abuse, including sexual abuse, and requires staff to prevent such occurrences. However, the lack of supervision in the activity room after 6 p.m. contributed to the incident involving Resident 1 and Resident 2.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Campbell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Childrens Hc Org No Ca -pediatric Hospital D/p Snf | 0.9 mi | ★★★★★ | 0 | 0 |
| Baywood Post Acute | 0.9 mi | ★★★★★ | 0 | 0 |
| Plum Tree Care Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Woodlands Healthcare Center | 1.4 mi | ★★★★★ | 2 | 0 |
| Stonebrook Health And Rehabilitation | 1.9 mi | ★★★★★ | 26 | 0 |
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