Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on interview and record review, the facility failed to ensure one resident (Resident 1) of three
sampled residents was treated with respect and dignity when Certified Nursing Assistant A (CNA A) shaved
Resident 1's pubic hair without Resident 1's consent. This failure had the potential to cause risks like cuts,
infections, and skin irritations to Resident 1.
Findings:
A review of Resident 1's Minimum Data Set (MDS- is a standardized assessment tool that measures health
status in nursing home residents) dated 1/26/25, indicated Resident 1:
-had a Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify
memory, orientation, and judgement status of the resident) score was 5 which indicated he had severe
cognitive (the mental process involved in knowing, learning, and understanding things) impairment;
- was dependent on staff for toileting hygiene;
- has dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive
disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements),
anxiety (a group of mental health conditions characterized by excessive worry, fear, and avoidance
behaviors that significantly interfere with daily life), and depression (a mood disorder characterized by
persistent sadness and loss of interest or pleasure in daily activities).
During an interview on 4/17/25 at 11:25 a.m., Licensed Nurse B (LN B) stated she observed Resident 1's
pubic area was shaved sloppily (in a careless, untidy, or messy way). LN B stated she submitted a report
regarding the incident on 4/3/25. LN B stated she also reported her observation to the Director of Nursing
(DON) on 4/4/25.
During an interview on 4/17/25 at 12:15 p.m., LN C stated she reported what happened to Resident 1 to
the DON on 4/4/25. The LN C stated she had been questioned by Human Resources (HR) about Resident
1. The LN C notified HR Resident 1 was unable to give consent to whomever shaved him, and there was no
reason for him to be shaved because he was not scheduled to have surgery. The LN C stated she felt
Resident 1 had been abused.
During an interview on 4/19/25 at 2 p.m., CNA D stated on 3/29/25, she witnessed CNA A shave Resident
1's pubic hair using Resident 1's personal beard shaver. The CNA D stated she and CNA A both worked
the 7 a.m. to 7:30 p.m. shift on 3/29/25. The CNA D stated she was confused as to why CNA A
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
555516
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555516
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jerold Phelps Comm Hosp Snf
733 Cedar Street
Garberville, CA 95542
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
shaved Resident 1's pubic hair because Resident 1 had not asked for it and CNA A had not given a reason
why she did it. The CNA D stated Resident 1 looked agitated but had not asked CNA A to stop. The CNA D
stated on 4/3/25 at around 5 p.m., she received a phone call from CNA A asking her not to tell anybody she
had shaved Resident 1's pubic area. The CNA D stated she reported for work on 4/5/25 and informed LN C
what CNA A did to Resident 1.
Residents Affected - Few
During an interview on 4/20/25 at 10:30 a.m., CNA A confirmed she worked with CNA D to provide
incontinent care to Resident 1 on 3/29/25. CNA A stated she observed Resident 1 was hurting as she
cleaned him from front to back because he had long pubic hair. The CNA A acknowledged she used
Resident 1's own personal shaving equipment to shave his pubic hair. The CNA A stated Resident 1 was
fine when she started shaving his pubic hair but Resident 1's body language looked like he was
uncomfortable with the shaving, so she stopped right away. The CNA A stated the incident was investigated
by the DON and a person from HR The CNA A stated she signed a document which indicated she
understood she had committed a violation.
During an interview on 4/21/25 at 1:07 p.m., the DON stated it was her expectation CNAs would not
unilaterally act without discussing and checking with licensed nurses when providing care that is not
included in a resident's plan of care.
A review of an undated facility document titled Statement of Patient Rights indicated, Patients of this facility
have the right to .Considerate and respectful care, and to be comfortable. You have the right to respect for
your cultural, psychosocial, spiritual, and personal values, beliefs, and preferences .receive as much
information about any proposed .procedure as you may need in order to give informed consent or to refuse
a course of treatment.
A review of a facility document titled Job Description: Certified Nursing Assistant dated 6/19/2019,
indicated, The Certified Nursing Assistant (CNA) employs intellectual, interpersonal, and technical skills to
perform basic resident/patient care, under the supervision of the RN (Registered Nurse) or LVN (Licensed
Vocational Nurse) . Adheres to all facility policies and procedures .Assists with problem solving and
resolution in collaboration with the [LVN], Resource [RN] and [DON] within the Skilled Nursing Facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555516
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555516
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jerold Phelps Comm Hosp Snf
733 Cedar Street
Garberville, CA 95542
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to ensure their policy regarding resident abuse
indicated the person responsible for investigating abuse allegations was to submit allegations of resident
abuse within 2 hours of being made aware and submit an investigation summary within 5 business days to
the California Department of Public Health (CDPH). These failures decreased the facility's potential to
protect a census of 8 residents from abuse and take appropriate corrective action.
Residents Affected - Many
Findings:
A review of the facility ' s policy and procedure (P&P) titled Abuse and Neglect Investigation printed on
4/17/25 was conducted on 4/28/25. Upon review, the P&P did not indicate the facility was to report
allegations of resident abuse within 2 hours of the facility ' s awareness to CDPH nor did it indicate a
summary of the investigation was to be submitted to CDPH within 5 business days.
On 4/28/25 at 10:13 a.m., the CDPH Surveyor requested a copy of the facility ' s P&Ps regarding reporting
allegations of abuse to CDPH. The documents were received by CDPH on 4/28/25 at 3:39 p.m.
A review of the facility ' s undated P&P titled Abuse Reporting Requirements showed no documented
evidence the facility was to report allegations of resident abuse within 2 hours of the facility ' s awareness to
CDPH.
In an interview on 5/6/25 at 10:54 a.m., the Director of Nursing (DON) acknowledged neither the P&Ps
titled Abuse and Neglect Investigation and Abuse Reporting Requirements indicated the facility was to
report allegations of resident abuse within 2 hours of the facility ' s awareness to CDPH and the
investigation summary was to be submitted to CDPH within 5 business days. The DON stated she was
notified of the 2-hour reporting timeframe by the facility ' s Chief Quality Officer and was notified of the 5
day investigation summary timeframe from the CDPH Surveyor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555516
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555516
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jerold Phelps Comm Hosp Snf
733 Cedar Street
Garberville, CA 95542
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on interviews and record reviews, the facility failed to ensure:
1. An allegation of abuse was reported to the California Department of Public Health (CDPH) within 2 hours
of awareness of the allegation for one resident (Resident 1) of three sampled residents when Certified
Nursing Assistant D (CNA D) and Licensed Nurse E (LN E) did not report when CNA A shaved Resident 1 '
s pubic hair without medical reason and without consent; and,
2. The facility submitted the investigation summary within 5 business days to CDPH.
These failures decreased the facility's potential to protect Resident 1 and other residents from abuse and
take appropriate corrective action. Cross reference F607.
Findings:
1. A review of Resident 1's Minimum Dats Set (MDS- is a standardized assessment tool that measures
health status in nursing home residents) dated 1/26/25, indicated Resident 1:
-had a Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify
memory, orientation, and judgement status of the resident) score was 5 which indicated he had severe
cognitive (the mental process involved in knowing, learning, and understanding things) impairment.
- was dependent on staff for toileting hygiene;
- has dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive
disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements),
anxiety (a group of mental health conditions characterized by excessive worry, fear, and avoidance
behaviors that significantly interfere with daily life), and depression (a mood disorder characterized by
persistent sadness and loss of interest or pleasure in daily activities).
A review of a document titled Report of Suspected Dependent Adult/Elder Abuse faxed to the CDPH on
4/7/25 at 2:03 p.m., from the facility indicated, Date Completed .4/5/2025 .Received report from nursing
staff that another staff member unilaterally clipped a [Resident 1's] pubic hair without consulting others. The
employee [CNA A] in question was placed on administrative leave pending completion of investigation and
follow up action.
During an interview on 4/17/25 at 11:25 a.m., LN B stated she observed Resident 1's pubic area was
shaved sloppily (in a careless, untidy, or messy way) on 4/3/25. The LN B confirmed she submitted an
incident report regarding her observation of Resident 1's pubic area on 4/3/25 at approximately 6 p.m. to
the facility's Human Resources (HR) department. LN B stated she also reported her observation to the
Director of Nursing (DON) on 4/4/25.
During an interview on 4/19/25 at 2 p.m., CNA D stated on 3/29/25, she witnessed CNA A shave Resident
1's pubic hair using Resident 1's personal beard shaver. The CNA D stated she and CNA A both worked
the 7 a.m. to 7:30 p.m. shift on 3/29/25. CNA D stated she was confused as to why CNA A shaved Resident
1's pubic hair because Resident 1 had not asked for it and CNA A had not given a reason why
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555516
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555516
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jerold Phelps Comm Hosp Snf
733 Cedar Street
Garberville, CA 95542
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
she did it. CNA D stated Resident 1 looked agitated while CNA A shaved him but had not asked CNA A to
stop. CNA D stated on 4/3/25 at around 5 p.m., she received a phone call from CNA A asking her not to tell
anybody she had shaved Resident 1's pubic area. CNA D stated she reported for work on 4/5/25 and
informed LN C what CNA A did to Resident 1.
During an interview on 4/20/25 at 8:29 p.m., LN E stated CNA D reported to her CNA A shaved Resident
1's pubic hair on 3/29/25. LN E stated she did not know what to do so she reported this to the oncoming
nurse, whose name she could not recall. LN E stated she had worked at other facilities and knew that
things like shaving were care planned. LN E stated she had observed Resident 1's pubic area after the
incident and noticed it was shaved at the center, but there was pubic hair on the sides, and it was not
completely shaven. LN E stated the skin was a little red. LN E stated she asked CNA A why she shaved
Resident 1's pubic hair and CNA A replied it was for hygiene, and did not elaborate or explain the reason
further. LN E stated CNA A did not ask her if she could shave Resident 1's pubic hair.
On 4/28/25 a review of the facility ' s policy and procedure (P&P) titled Abuse and Neglect Investigation
printed on 4/17/25 was conducted. Upon review, the P&P did not indicate the facility was to report
allegations of resident abuse within 2 hours of the facility ' s awareness to CDPH.
On 4/28/25 at 10:13 a.m., the CDPH Surveyor requested a copy of the facility ' s P&Ps regarding reporting
allegations of abuse to CDPH. The documents were received by CDPH on 4/28/25 at 3:39 p.m.
A review of the facility ' s undated P&P titled Abuse Reporting Requirements showed no documented
evidence the facility was to report allegations of resident abuse within 2 hours of the facility ' s awareness to
CDPH.
During an interview on 5/1/25, at 1:25 p.m., the DON stated facility staff were expected to report suspected
abuse as required. The DON stated CNA D and LN E were mandated reporters of elder abuse and should
have reported the allegation as soon as they were aware but no later than 2 hours of becoming aware of
the suspicion of abuse on 3/29/25. The DON stated it was her understanding that the reporting
requirements on a suspected abuse allegation was to report it immediately or not later than 2 hours.
In an interview on 5/6/25 at 10:54 a.m., the DON acknowledged neither the P&Ps titled Abuse and Neglect
Investigation and Abuse Reporting Requirements indicated the facility was to report allegations of resident
abuse within 2 hours of the facility ' s awareness to CDPH. The DON stated she was notified of the 2-hour
reporting timeframe by the facility ' s Chief Quality Officer.
2. During an interview on 4/21/25, at 1:07 p.m., the DON stated she did not provide a 5-day follow-up report
to CDPH.
On 4/28/25 a review of the facility ' s policy and procedure (P&P) titled Abuse and Neglect Investigation
printed on 4/17/25 was conducted. Upon review, the P&P did not indicate the facility was to submit a
summary of the investigation to CDPH within 5 business days.
In an interview on 5/6/25 at 10:54 a.m., the DON acknowledged the P&Ps titled Abuse and Neglect
Investigation and Abuse Reporting Requirements did not indicate the investigation summary was to be
submitted to CDPH within 5 business days. The DON stated she was notified of the 5-day investigation
summary timeframe from the CDPH Surveyor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555516
If continuation sheet
Page 5 of 5
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
FAQ · About this visit
Common questions about this visit
What happened during the April 17, 2025 survey of JEROLD PHELPS COMM HOSP SNF?
This was a inspection survey of JEROLD PHELPS COMM HOSP SNF on April 17, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at JEROLD PHELPS COMM HOSP SNF on April 17, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.