Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 Jerold Phelps Comm Hosp Snf during CMS and state inspections, most recent first.
An allegation of financial abuse involving a resident with dementia and Parkinson's disease was not reported to the State Survey Agency within the required two-hour timeframe. Staff became aware of the alleged financial exploitation after the resident contacted her bank and became upset about debits from her account, and the abuse coordinator was notified shortly thereafter. However, the abuse coordinator later stated she did not know if the state agency had been called as required, and state records showed no timely voicemail report from the facility. The formal abuse report form was completed by the DON and faxed to the state several days after the facility first became aware of the allegation, resulting in noncompliance with federal reporting requirements.
The facility's policies and procedures did not specify the required 2-hour timeframe for reporting abuse allegations or the 5-day deadline for submitting investigation summaries to CDPH. The DON confirmed these omissions after being informed by the Chief Quality Officer and a CDPH Surveyor, affecting a census of 8 residents.
A CNA shaved a resident's pubic hair without obtaining consent or consulting with licensed staff, despite the resident's severe cognitive impairment and lack of medical indication for the procedure. The incident was witnessed by another CNA and reported to nursing leadership, revealing a failure to respect the resident's rights and to follow facility protocols.
A resident with severe cognitive impairment and multiple health conditions was subjected to unauthorized shaving of pubic hair by a CNA, which was witnessed by another CNA and later observed by an LN. The incident was not reported to CDPH within the required 2-hour timeframe, and the facility did not submit an investigation summary within 5 business days. Facility policies lacked clear guidance on these reporting requirements, contributing to the deficiency.
The facility failed to develop baseline care plans for six residents within 48 hours of their admission. No baseline care plans signed by the residents or their representatives were found, and the facility's policies did not mention this requirement. Interviews with staff confirmed the lack of baseline care plans and documentation.
The facility failed to develop person-centered comprehensive care plans for five residents, impacting their quality of life and care. Residents with multiple diagnoses, including Dementia, Anxiety Disorder, Depression, and Diabetes, lacked care plans for psychotropic drug use and other critical areas. The facility did not adhere to its policy on resident care planning, leading to these deficiencies.
The Governing Body failed to appoint a California Licensed Nursing Home Administrator (NHA) responsible for the facility's management. The Chief Nursing Officer (CNO) confirmed through a phone call and a verification search that the Administrator did not possess an NHA license.
The facility failed to ensure that medication irregularities noted by the pharmacist during the drug regimen review for two residents were properly documented and communicated. The pharmacist's recommendations to taper Trazodone and lower the dose of Quetiapine were not followed up, and the attending physician did not document any review or action taken. This lack of documentation and communication had the potential to adversely affect the residents' health.
The facility failed to ensure that a resident was informed in advance about the use, risks, and benefits of the psychotropic medication Diazepam, as well as other medication options. The informed consent was obtained only after the medication was administered, contrary to the facility's policy and regulatory requirements.
The facility failed to complete a smoking assessment on admission for a resident to determine their functional capacity to safely smoke with or without assistance and the need for protective devices. The resident was observed smoking outside with a security staff member, and neither the resident nor the Licensed Nurse could confirm if a smoking assessment had been conducted. This failure had the potential to result in inappropriate care and supervision, as well as a fire hazard.
The facility failed to maintain a safe smoking environment and provide necessary protective equipment for a resident who smoked. The resident was not wearing a protective apron, and the blanket proposed for use was unsuitable. The designated smoking area was inconsistently defined, and the facility's smoking policy lacked provisions for smoking assessments and adaptive equipment.
Failure to Timely Report Allegation of Financial Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of financial abuse was reported to the State Survey Agency within two hours of becoming aware of the allegation, as required by regulation and facility policy. The resident involved had dementia associated with Parkinson's disease and had been admitted with these diagnoses. The facility became aware of the alleged financial abuse on 2/19/26 at 3:30 p.m., when the resident called her bank to check her balance and became upset due to debits from her account. The abuse coordinator was notified at 3:49 p.m. that same day. The facility’s short-term care plan documented the resident’s upset related to the debits, and the facility’s policy stated it would promptly prevent, identify, and report suspected abuse, neglect, and exploitation. Despite this, the allegation was not reported to the California Department of Public Health (CDPH) within the required two-hour timeframe. The Chief Nursing Officer, who served as the abuse coordinator, stated she did not know if CDPH was called on 2/19/26 and acknowledged it was her expectation that staff report suspected abuse to CDPH within two hours and that it was her responsibility to verify timely reporting. CDPH records showed no voicemail messages from the facility between 2/19/26 and 2/24/26. CDPH ultimately received a faxed Report of Suspected Dependent Adult/Elder Abuse (SOC 341) on 2/23/26 at 4:49 p.m., which had been completed and dated 2/20/26 by the DON, confirming the resident as an alleged victim of financial abuse, demonstrating that the report was not made within the required reporting window.
Failure to Include Timely Abuse Reporting Requirements in Facility Policies
Penalty
Summary
The facility failed to ensure that its policies and procedures regarding resident abuse included the requirement to report allegations of abuse to the California Department of Public Health (CDPH) within 2 hours of awareness and to submit an investigation summary within 5 business days. A review of the facility's policies titled 'Abuse and Neglect Investigation' and 'Abuse Reporting Requirements' revealed that neither document specified these mandatory reporting timeframes. During an interview, the Director of Nursing (DON) acknowledged the omission of these requirements in the facility's policies and stated that she became aware of the 2-hour and 5-day reporting requirements only after being informed by the Chief Quality Officer and a CDPH Surveyor. These failures affected a census of 8 residents, as the facility's policies did not align with state reporting requirements for abuse allegations.
Resident Shaved Without Consent by CNA
Penalty
Summary
A Certified Nursing Assistant (CNA) shaved a resident's pubic hair without obtaining the resident's consent or consulting with licensed nursing staff. The resident involved had severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 5, and was dependent on staff for toileting hygiene. The resident also had diagnoses of dementia, Parkinson's disease, anxiety, and depression. The CNA used the resident's personal beard shaver to perform the shaving during incontinent care, despite the resident not requesting this care and not being scheduled for any procedure that would require shaving. Another CNA witnessed the incident and later reported it to a licensed nurse, who then informed the Director of Nursing (DON) and Human Resources (HR). Interviews with staff confirmed that the CNA did not provide a reason for shaving the resident and that the resident appeared agitated during the incident. The facility's policies and job descriptions require CNAs to act under the supervision of licensed nurses and to respect residents' rights to informed consent and dignified care. The incident was reported internally, and the CNA acknowledged understanding that a violation had occurred. The failure to obtain consent and to follow proper procedures resulted in the resident not being treated with respect and dignity, as required by facility policy and patient rights.
Failure to Timely Report and Investigate Suspected Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with severe cognitive impairment, dementia, Parkinson's disease, anxiety, and depression. A Certified Nursing Assistant (CNA) was observed by another CNA shaving the resident's pubic hair without medical reason or consent, using the resident's personal beard shaver. The resident appeared agitated during the incident, and the CNA who witnessed the event did not immediately report it. The incident was later observed by a Licensed Nurse (LN), who noticed the resident's pubic area was shaved in a sloppy manner and the skin was red. The LN submitted an incident report to Human Resources and informed the Director of Nursing (DON) the following day. Despite multiple staff members becoming aware of the incident, the facility did not report the suspected abuse to the California Department of Public Health (CDPH) within the required 2-hour timeframe from the time of awareness. The facility's policies and procedures did not specify the 2-hour reporting requirement, and staff interviews revealed a lack of clarity regarding the appropriate steps to take when abuse is suspected. The DON later acknowledged that staff are mandated reporters and should have reported the suspicion of abuse immediately or within 2 hours, but this was not reflected in the facility's written policies. Additionally, the facility failed to submit a summary of the investigation to CDPH within 5 business days, as required. The facility's policies did not include this 5-day reporting requirement, and the DON confirmed that a 5-day follow-up report was not provided. The lack of timely reporting and incomplete policy guidance contributed to the deficiency identified by surveyors.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan for six residents within 48 hours of their admission. This deficiency was identified during a review of records and interviews with facility staff. Specifically, no baseline care plans signed by the residents or their representatives were found among the facility documents. The Chief Nursing Officer (CNO) confirmed that there were no baseline care plans developed within the required timeframe and that there were no records of any care plans signed by new residents or their Resident Representatives (RR). The facility's policies on admission documentation and resident care planning did not mention the requirement to develop a baseline care plan within 48 hours of admission. During interviews, Licensed Nurse K stated that new residents signed documents in an admission packet but was unaware if a care plan was developed within 48 hours of admission. The CNO also consulted with Health Information Management (HIM), who were unable to find any documentation for the six residents indicating they received and signed for a baseline care plan. The regulatory Health and Safety Code S483.21 requires the facility to develop and implement a baseline care plan within 48 hours of a resident's admission, including initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. The facility must also provide the resident and their representative with a summary of the baseline care plan, which was not done in these cases.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for five residents, which had the potential to negatively impact their quality of life and care. Resident 1, who was admitted with multiple diagnoses including Hypertension, Anxiety Disorder, Depression, Type 2 Diabetes, and Parkinson's Disease, did not have a care plan for the use of psychotropic drugs Sertraline and Trazodone. Similarly, Resident 3, diagnosed with Dementia, Anxiety Disorder, Depression, Bipolar Disorder, Diabetes, and Hyperlipidemia, lacked a care plan for the psychotropic drug Risperidone. Resident 5, admitted with Coronary Artery Disease, Hypertension, and Dementia, had no individualized care plans until they were developed on 2/29/24, after the issue was identified by the Chief Nursing Officer (CNO). Resident 4, admitted with conditions such as debility, cachexia, Dementia, malnutrition, and adult failure to thrive, had care areas like cognitive loss/dementia and psychotropic drug use triggered during the admission assessment, but no corresponding care plans were found. Additionally, Resident 57, who smokes after meals and was observed being administered Diazepam, did not have care plans for smoking or Diazepam use. The Health Information Manager (HIM) and the CNO acknowledged that the care plans provided for Resident 57 were completed the night before the surveyors' review. The facility's policy on resident care planning indicates that nurses gather data upon admission, input it into the electronic medical record (EMR) system, and complete weekly summaries to generate data for the Minimum Data Set (MDS). The MDS is supposed to auto-populate appropriate plans of care, which are then reviewed monthly by the Director of Nursing (DON). However, the facility failed to adhere to this policy, resulting in the absence of comprehensive care plans for the residents mentioned above.
Failure to Appoint Licensed Nursing Home Administrator
Penalty
Summary
The Governing Body failed to appoint a California Licensed Nursing Home Administrator (NHA) responsible for the management of the facility. During an interview, the Chief Nursing Officer (CNO) was unable to provide a copy of the Administrator's license and confirmed through a phone call with the Administrator that he did not possess an NHA license. The Administrator also confirmed in a separate interview that he did not have a license. A verification search through the California Department of Public Health (CDPH) confirmed the absence of an NHA license for the Administrator.
Failure to Document and Address Medication Irregularities
Penalty
Summary
The facility failed to ensure that irregularities noted by the pharmacist during the drug regimen review (DRR) for two residents were properly documented and communicated to the attending physician, medical director, and Director of Nursing (DON). Specifically, the pharmacist recommended tapering Trazodone for one resident and lowering the dose of Quetiapine for another resident. However, there was no documentation or follow-up on these recommendations, and the pharmacist did not provide a separate, written report of the irregularities as required by the facility's policies and procedures. Additionally, the attending physician did not document any review or action taken regarding the identified irregularities in the residents' medical records. During interviews, the Pharmacy Tech and Pharmacy Consultant confirmed the process of monthly DRR and acknowledged the need for improved documentation and communication. The pharmacist's recommendations were recorded in an Excel spreadsheet, but this method lacked the necessary detail and formal reporting required to ensure proper follow-up and action. The failure to document and address these medication irregularities had the potential to result in adverse effects on the residents' health and well-being.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident 57 was informed in advance by the physician or other practitioner about the use, risks, and benefits of the psychotropic medication Diazepam, as well as other medication options. This deficiency was observed during a medication administration on 2/29/24, when Licensed Nurse H administered a 5 mg tablet of Diazepam to Resident 57 without prior informed consent. The informed consent was only obtained later on the same day, as confirmed by the Chief Nursing Officer (CNO) during a record review and interview on 3/1/24. The facility's policy, dated 3/30/23, requires that informed consent be obtained and documented by the physician before initiating the administration of psychoactive drugs. Additionally, Title 22 CCR Section 72528(c) mandates that facility staff verify the presence of such documentation in the patient's health record prior to starting the therapy. The failure to adhere to these protocols deprived Resident 57 of her right to be fully informed about her medication and treatment options, which is essential for making an informed decision about her care.
Failure to Complete Smoking Assessment on Admission
Penalty
Summary
The facility failed to complete a smoking assessment on admission for one of six residents to determine the resident's functional capacity to safely smoke with or without assistance and the need for protective devices. This deficiency was identified during an observation and interview where the resident was seen smoking outside the facility with a security staff member. The resident had a portable ashtray positioned by the right side of her wheelchair and stated she smoked after meals outside the facility. When asked, the Licensed Nurse (LN) could not provide the smoking assessment and referred to the Health Information Management (HIM)/Information Technician (IT) to print out the document from the facility's electronic medical records. The resident herself could not confirm if she had undergone a smoking assessment for safety purposes. A review of the facility's policy on resident assessment indicated that a comprehensive assessment of the resident's needs should be made by the interdisciplinary team within fourteen or eight days of the resident's admission. This assessment is intended to describe the resident's capability to perform daily life functions and identify significant impairments in functional capacity. The information derived from the comprehensive assessment enables staff to plan care that allows the resident to reach their highest practicable level of functioning, including determining the resident's need for staff assistance and assistive devices or equipment to maintain or improve functional abilities. However, in this case, the facility failed to adhere to its policy, resulting in the potential for inappropriate care and supervision, as well as a fire hazard to both the resident and the facility.
Failure to Provide Safe Smoking Environment and Protective Equipment
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and provide necessary assistive devices to a resident who smoked. During observations and interviews, it was noted that the resident smoked outside the facility with a portable ashtray positioned by her wheelchair. The resident's cigarettes and lighter were kept in a locked medication room, and she was accompanied by staff during smoke breaks. However, the resident was not wearing a protective apron during these breaks, and the staff could not provide a smoking assessment for the resident. Additionally, the blanket proposed as a protective apron was found to be unsuitable for preventing cigarette burns. The designated smoking area was observed to be inconsistently defined, with discrepancies in its distance from the building and emergency exit door. The facility's smoking policy required a written order for smoking and designated smoking areas but did not include the need for a smoking assessment or adaptive equipment. Interviews with staff and a customer service representative confirmed that the blanket intended for use as a protective apron was not appropriate for this purpose. The facility's failure to provide a safe smoking environment and necessary protective equipment posed a risk of cigarette burns and fire hazards.
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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 Garberville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fortuna Rehabilitation And Wellness Center, Lp | 38.4 mi | — | 31 | 0 |
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