Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Healdsburg Hospital D/p Snf during CMS and state inspections, most recent first.
Missing individualized activity care plans: The facility did not develop activity care plans for three sampled residents. Staff used a general activity flow sheet in the eMR, but it did not identify each resident's preferred activities or how personal activity needs would be met. The Nurse Manager and Quality Manager stated the eMR was not set up for activity care plans, and social work progress notes did not replace a care plan. The affected residents had significant neurologic conditions and were unable to complete cognitive assessments.
Incomplete Activity Assessments: The facility failed to complete activity assessments for two residents, including at admission and on required annual/periodic reviews. The MDS Coordinator verified the assessments were not completed, noted family members were involved in care, and stated the SW was responsible for completing the activity assessment with family because the resident population was unable to communicate for the most part.
The facility did not post the required daily staffing information, including the facility name, current date, RN/LPN/LVN/CNA hours worked per shift, and resident census. Instead, staffing assignment sheets were posted showing staff assigned to resident rooms. The Nurse Manager stated the facility only posted staffing assignments and did not know what HPRD was.
The facility failed to label and date food items in the refrigerator and dry storage, risking food-borne illnesses. Observations revealed unlabeled prepared food in the refrigerator and several opened items in dry storage without labels. Kitchen staff acknowledged the lapse in following the facility's policy requiring labeling with received, opened, and use-by dates.
A facility failed to create a person-centered care plan for a resident with a medical condition affecting his eyes, which required specific care to prevent drying. Despite the resident having a gauze dressing and receiving eye drops, the electronic care plan lacked documentation addressing his vision needs, contrary to the facility's policy requiring individualized care plans based on medical and psychosocial needs.
A facility failed to follow professional standards for enteral medication administration for two residents. An LPN did not flush the enteral tubes with the required 15-30 ml of water before and after administering medications, as per facility policy. This was observed during medication administration for residents with complex medical histories, including traumatic brain injury and seizure disorders. The DON confirmed the policy requirements, indicating a deficiency in adherence to established procedures.
Missing individualized activity care plans
Penalty
Summary
The facility failed to develop activity care plans for Residents 7, 9, and 13, who were three of five residents sampled for activities. During a record review and concurrent interview on 7/8/26 at 10:52 a.m., the Nurse Manager navigated to a flow sheet in Resident 13's electronic medical record and stated that the flow sheet was considered the activity care plan. Review of Resident 13's activity flow sheet showed general one-word activity categories, such as music, but did not identify the resident's preferred activities or how the resident's personal activity needs would be met. During an interview on 7/8/26 at 2:07 p.m., the Nurse Manager and Quality Manager stated the eMR was not set up to have activity care plans and that a request would need to be made to the eMR company for a customized activity care plan. The Nurse Manager also verified that the flow sheet used for activity documentation was not individualized to residents' preferred activities and that the social worker's progress notes with preferred activities did not replace a care plan. Resident 7's face sheet showed admission with a primary diagnosis of traumatic brain dysfunction, and the MDS dated 5/5/26 indicated the resident was not able to complete a cognitive assessment. Resident 9's face sheet showed admission with a primary diagnosis of stroke, and the MDS indicated the resident was not able to complete a cognitive assessment. Resident 13's face sheet showed admission with a primary diagnosis of persistent vegetative state, and the MDS indicated the resident was not able to complete a cognitive assessment. The facility policy Person-Centered Care Plan, last revised 10/2024, stated the plan would be comprehensive based on the resident's medical, functional, and psychosocial needs and include person-centered care focused on resident choice, such as choosing activities.
Incomplete Activity Assessments
Penalty
Summary
The facility failed to complete comprehensive activity assessments for two sampled residents, Residents 9 and 13, when the assessments were due and when they were first admitted. During a record review and concurrent interview on 7/8/26 at 1:30 p.m., the MDS Coordinator reviewed Resident 9’s activity assessments dated 3/23/26 and 3/22/25 and verified they had not been completed. The MDS Coordinator also reviewed Resident 9’s admission activity assessment from March 2024 and verified it had not been completed, meaning Resident 9 had never had an activity assessment completed at the facility. The MDS Coordinator stated the social worker was responsible for conducting the activity assessment with the resident’s family because the resident population was unable to communicate for the most part, and stated Resident 9 had two sons involved in her care and the assessments should have been completed. During the same record review and interview, the MDS Coordinator reviewed Resident 13’s activity assessments dated 1/29/26 and 1/28/26 and verified they had not been completed. The MDS Coordinator stated Resident 13 had family involved in her care and the activity assessments should have been completed. The MDS Coordinator also stated the facility had a social worker at the time these assessments were due. During an interview on 7/8/26 at 2:07 p.m., the Nurse Manager stated having a personalized activities plan for the resident population was very important. Facility policy titled Minimum Data Set (MDS) Assessments, last revised 4/2026, stated the facility would submit all required MDS assessments according to MDS guidelines and that interdisciplinary team members other than nursing may complete their sections by the specified due date.
Missing Required Daily Staffing Postings
Penalty
Summary
The facility did not ensure the posted daily staffing information included the required elements of the facility name, current date, total number and actual hours worked by RN, LPN/LVN, and CNA staff directly responsible for resident care per shift, and resident census. During an observation on 7/7/26 at 11:35 a.m., staffing assignment sheets were posted at the nursing station and showed licensed and unlicensed staff assigned to specific resident rooms. During an interview on 7/7/26 at 11:50 a.m., the Nurse Manager stated the facility did not publicly post the required hours per resident, only the staffing assignment, and stated she did not know what Hours Per Resident Day (HPRD) was.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to ensure proper food storage practices, which could lead to food-borne illnesses. During an observation, it was noted that two bowls of prepared food in the walk-in refrigerator were not labeled. Additionally, several food items in the dry storage area, including oatmeal, Nilla wafers, tortilla chips, pasta, and pancake mix, were opened and lacked labels indicating the date they were opened or a use-by date. This lack of labeling could result in the rapid growth of pathogenic microorganisms, posing a risk to the residents. Interviews with kitchen staff revealed that the facility's policy required food items to be labeled with a received date, an opened date, and a use-by date. However, this policy was not followed, as evidenced by the unlabeled items found during the survey. Kitchen Staff E and D acknowledged the labeling requirements and the failure to adhere to them, indicating a lapse in following the facility's food and supply storage policy dated June 2023.
Failure to Develop Individualized Care Plan for Resident's Eye Care
Penalty
Summary
The facility failed to develop a person-centered individualized care plan for a resident, identified as Resident 7, which had the potential to impact the care provided to the resident's eyes. During an observation, it was noted that Resident 7 had his right eye covered with a gauze dressing due to a medical condition that caused swelling, preventing the eyelids from closing. This condition required the use of eye drops and a dressing to prevent the eye from drying out. However, upon review of the electronic care plan, it was found that there was no individualized care plan addressing Resident 7's vision needs. The facility's policy on Person-Centered Care Plans, dated August 2024, mandates that a care plan should be written for each resident based on their medical, functional, and psychosocial needs, which was not adhered to in this case.
Failure to Properly Flush Enteral Tubes During Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of medications through enteral tubes for two residents, Resident 16 and Resident 5. During observations, it was noted that Licensed Nurse A did not flush the enteral tubes with the required amount of water before and after administering medications. Specifically, the nurse flushed the tubes with only approximately 5 ml of water between each medication, contrary to the facility's policy which mandates a flush of 15-30 ml of warm water before and after medication administration. Resident 16, who had a history of traumatic brain injury, fecal incontinence, and gastroesophageal reflux disease, was administered several medications through an enteral tube without the proper flushing protocol. Similarly, Resident 5, diagnosed with traumatic brain injury, seizure disorder, and pneumonia, also received medications through an enteral tube without the required flushing before and after the administration. This oversight in following the established protocol could potentially lead to blockages in the enteral tubes, affecting the timely delivery of critical medications. The Director of Nursing confirmed that the facility's policy requires flushing the feeding tube with at least 15-30 ml of warm water before and after medication administration. The failure to comply with this policy was observed during the medication administration process for both residents, highlighting a deficiency in the facility's adherence to its own procedures for enteral medication administration.
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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 Healdsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbol Healthcare Center Of Santa Rosa | 12.6 mi | ★★★★★ | 20 | 0 |
| Cloverdale Healthcare Center | 14.4 mi | ★★★★★ | 5 | 0 |
| Blue Oak Post-acute | 15.3 mi | ★★★★★ | 36 | 0 |
| Park View Post Acute | 15.8 mi | ★★★★★ | 12 | 0 |
| Northvine Postacute Care | 16.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.