Above average — CMS composite of the measures below.
A standard survey is most likely before around July 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 Marysville Post-acute during CMS and state inspections, most recent first.
The facility failed to follow wound care protocols by providing wound care without a physician's order, inconsistently documenting and assessing wounds, and not completing required change of condition documentation for a resident with significant medical needs. Additionally, three residents with pressure wounds were not repositioned every two hours as required, with documentation and resident interviews confirming infrequent repositioning.
A resident with quadriplegia and a stage 4 pressure wound was discharged without proper wound care education provided to the caregiver and without arrangements for home health services. Documentation did not show that wound care instructions or supplies were given, and staff interviews confirmed the caregiver did not receive necessary training. The resident required multiple ER visits after discharge due to wound complications.
A resident with quadriplegia and a history of cervical spine fusion developed a stage 4 pressure ulcer on the coccyx during their stay. The discharge MDS failed to document this physician-diagnosed wound, instead only listing unstageable pressure injuries present at admission. The MDS Coordinator confirmed the omission, resulting in an inaccurate assessment at discharge.
A resident with COPD and intact cognition was allowed to self-administer a nebulizer treatment without an assessment of their ability to do so, while being denied the right to self-administer their inhaler. Staff interviews and record reviews confirmed that the facility did not evaluate or document the resident's capacity for self-administration, as required by policy, and did not permit residents to keep or self-administer medications.
A resident with severe cognitive impairment had an MDS assessment inaccurately coded to indicate both the presence of unhealed pressure ulcers and daily use of bed rails as a restraint, despite documentation and staff clarification that contradicted these entries. The errors were confirmed by the MDS Coordinator, and facility leadership emphasized the need for accurate, section-by-section review of MDS assessments.
A resident was treated disrespectfully by a Marketing Director, causing distress, and there was a failure in handling the resident's POLST, leading to unwanted medical intervention. The resident, with multiple health issues, was considering hospice but had not decided, and the POLST was not signed by the provider, resulting in confusion during a medical emergency.
A resident's POLST indicating selective treatment and DNR was not signed by a medical provider, leading EMTs to consider the resident full code during a transfer. This resulted in the resident being intubated and sent to the ICU, contrary to their wishes. The absence of the physician and nurse practitioner delayed the signing of the POLST, and staff interviews highlighted concerns about the handling of the resident's care preferences.
A resident with Huntington's disease and high fall risk experienced 14 falls in 50 days due to inadequate supervision at an LTC facility. Despite recommendations for one-on-one supervision, the facility failed to update the care plan, resulting in avoidable falls and injuries. Staff and family highlighted the lack of supervision, and the facility did not act on external offers for assistance.
Two residents in the facility were not provided with adequate incontinent care, leading to potential skin breakdown and loss of dignity. One resident, requiring substantial assistance, reported being left wet for extended periods, including overnight. Another resident, dependent on staff for toilet hygiene, was left wet throughout the night due to staff's unfamiliarity with her medical equipment. Staff interviews confirmed that registry CNAs often failed to adhere to the facility's policy of rounding every two hours.
A resident, admitted with multiple diagnoses and requiring assistance with daily activities, reported that a CNA made her wait 30 minutes for bathroom assistance, causing her to wet herself. Despite a prior complaint and a promise that the CNA would not assist her again, the CNA was assigned to her care, leading to the resident's anger and a recognized dignity issue.
Failure to Follow Wound Care Protocols and Repositioning Requirements
Penalty
Summary
The facility failed to follow its wound prevention, maintenance, and wound care policies and procedures for three residents. For one resident with quadriplegia, diabetes, and muscle weakness, wound care was provided without a physician's order, despite facility policy requiring such an order. The resident was admitted with no documented open wounds, but a dressing was changed by a nurse without an order, and the nurse stated that no order was needed. The Director of Nursing later confirmed that a physician's order was required and not present at the time of the dressing change. Skin assessments for this resident were inconsistent and did not accurately reflect the condition or location of the wound. Documentation was found to be copied and pasted across multiple assessments, and the wound was not properly staged or described. When an open area was identified, it was not documented as a change of condition, and the required change of condition documentation was not completed. The discharge summary also failed to include a review or assessment of a newly diagnosed stage 4 pressure ulcer or the treatment plan initiated by the wound physician. Additionally, the facility did not ensure that three residents, all with significant mobility impairments and pressure wounds, were repositioned every two hours as required by policy and physician orders. Instead, documentation showed that repositioning was only recorded once per shift. Interviews with staff and residents confirmed that repositioning was not performed or documented every two hours, and residents reported not being offered repositioning as frequently as required.
Failure to Provide Wound Care Education and Home Health Coordination at Discharge
Penalty
Summary
The facility failed to ensure that discharge planning needs were met for a resident with significant medical needs, specifically regarding wound care. The resident, who had quadriplegia and was unable to perform self-care for a stage 4 pressure wound on the coccyx, was discharged without adequate instruction or education provided to his caregiver on how to perform wound care as ordered by the physician. Documentation did not indicate that the caregiver received wound care education, nor was there evidence of a return demonstration to confirm competency. The discharge summary also lacked instructions on wound care and did not mention the presence of the stage 4 wound. Additionally, the resident was discharged without arrangements for home health services, which would have included nursing support for wound care, assessments, and education. Although the discharge planning care plan indicated that the resident would be assessed for discharge needs and provided with education, there was no documentation that home health services were offered or coordinated. The social services documentation noted that the resident would need to follow up with a primary care physician but did not include referrals for home health or information on obtaining wound care supplies. Interviews with staff confirmed that the resident was unable to perform his own wound care and that the caregiver should have received education, which was not documented. The resident and caregiver both reported not receiving wound care instructions or supplies at discharge, and the resident subsequently required multiple emergency room visits due to wound complications. The facility's failure to provide necessary education and coordinate post-discharge care did not meet the resident's needs or preferences for a safe and effective discharge.
Inaccurate Discharge MDS Fails to Reflect Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure the accuracy of the discharge Minimum Data Set (MDS) for a resident who was admitted with quadriplegia, cervical spine fusion, and bacteremia. Upon admission, the resident was noted to have skin discoloration and an old pressure scar, but no open wounds. Shortly after admission, documentation indicated the development of an open area on the coccyx, and a wound physician later diagnosed a stage 4 pressure ulcer at that site following surgical debridement. Despite this diagnosis, the discharge MDS did not reflect the presence of the stage 4 pressure ulcer, instead only documenting two unstageable pressure injuries that were present upon admission. The MDS Coordinator confirmed during interviews and record reviews that the discharge MDS should have included the stage 4 pressure ulcer but did not, resulting in an inaccurate assessment of the resident's skin condition at discharge.
Failure to Assess and Permit Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications before allowing the resident to self-administer a nebulizer treatment unsupervised and denying the resident the right to self-administer their inhaler. The resident, who had a history of COPD, diabetes, respiratory failure with hypoxia, and muscle weakness, expressed a desire to self-administer medications. Despite having intact cognition and no functional limitations in their upper or lower extremities, as indicated by a BIMS score of 13 and the MDS assessment, the facility did not evaluate or document the resident's capacity for self-administration as required by facility policy. Observations revealed the resident was left alone during nebulizer treatments, and interviews with staff confirmed that the facility did not permit residents to keep or self-administer medications, regardless of individual requests or abilities. The care plan and physician orders did not address self-administration, and staff reported that all medications were to be administered by nurses, with supervision during administration. The facility's policy required an assessment of mental and physical abilities before permitting self-administration, but this was not completed for the resident in question.
Inaccurate MDS Coding for Pressure Ulcers and Restraints
Penalty
Summary
The facility failed to ensure the accuracy of a resident's Minimum Data Set (MDS) assessment regarding pressure ulcers and the use of restraints. Specifically, the MDS for a resident with severe cognitive impairment was coded to indicate the presence of one or more unhealed pressure ulcers/injuries, but the detailed sections for each type of pressure ulcer were marked as not present. Additionally, the MDS indicated that bed rails were used daily as a restraint, although facility staff clarified that the side rails were used for mobility and should not have been coded as a restraint. These discrepancies were identified through interviews, record reviews, and examination of facility policy and CMS guidelines. The resident involved had a history of dementia, hypertension, depression, and anxiety, and required assistance with bed mobility. The care plan documented the use of one-quarter length bilateral bed rails for mobility and noted a pressure ulcer to the left heel after the MDS assessment reference date. The MDS Coordinator acknowledged the errors in coding both the pressure ulcer and restraint sections, and the DON and Administrator both stated that MDS assessments are expected to be accurate and thoroughly reviewed before submission.
Resident's Rights and POLST Handling Deficiency
Penalty
Summary
The facility failed to ensure a resident's right to be treated with dignity and respect was upheld. The Marketing Director (MD) spoke to the resident in a disrespectful manner, stating, "What the hell are you doing. We would've never brought you back if we knew you weren't going on hospice. Nobody wants you here," which caused the resident to become tearful. This interaction occurred in the presence of a hospice nurse, who intervened by taking the phone away from the resident. The resident had been admitted with multiple health issues, including morbid obesity, obstructive sleep apnea, and depression, and was considering hospice care but had not yet decided to proceed with it. Additionally, there was a failure in handling the resident's Physician Orders for Life-Sustaining Treatment (POLST). The resident had expressed a desire for selective treatment rather than full CPR, but the POLST was not signed by the medical provider, leading to confusion during a medical emergency. The resident was intubated and transferred to the ICU, contrary to his wishes. Interviews with staff revealed a lack of professionalism and support in assisting the resident with his POLST, and the Director of Nursing confirmed that the resident had the right to refuse hospice care as he was oriented and of sound mind.
Failure to Maintain Valid POLST Leads to Resident Intubation
Penalty
Summary
The facility failed to implement resident-directed care consistent with preferences and rights for a resident when it did not maintain a valid copy of the Physician Orders for Life-Sustaining Treatment (POLST) in the resident's medical record during a transfer via ambulance. The POLST, which indicated selective treatment and a Do Not Resuscitate (DNR) order, was not signed by the medical provider, leading emergency medical technicians to consider the resident as full code. This resulted in the resident being intubated and transferred to the ICU, contrary to their documented wishes. The deficiency was compounded by the absence of the physician and nurse practitioner from the facility on key dates, which delayed the signing of the POLST. Interviews with staff and the resident's power of attorney revealed concerns about the lack of timely medical provider signatures and the inappropriate handling of the resident's care preferences. The Director of Nursing acknowledged that backdating documentation was inappropriate and that the resident's intubation was against their wishes.
Inadequate Supervision Leads to Multiple Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident identified as high risk for falls. This resident, who had Huntington's disease, muscle weakness, and was on high-risk medications, experienced 14 falls over a 50-day period. Despite multiple falls and recommendations for increased supervision, the Interdisciplinary Team (IDT) did not revise the resident's fall care plan to include necessary interventions such as one-on-one supervision. The resident's falls were often unwitnessed, and the facility's response was inadequate, as evidenced by repeated recommendations for one-on-one supervision that were not implemented. The IDT's interventions were limited to medication adjustments and therapy evaluations, which did not effectively address the resident's fall risk. The facility's policy required a resident-centered fall prevention plan, but the care plan was not updated to reflect the resident's needs, leading to avoidable falls and injuries. Interviews with staff and family members highlighted the lack of supervision and the facility's inability to provide one-on-one care. The resident's family and a social worker from a Huntington's disease clinic offered assistance and recommendations, but the facility did not act on these offers. The Director of Nursing acknowledged the facility's staffing limitations and the resident's need for supervision, but no effective measures were taken to prevent further falls.
Inadequate Incontinent Care for Residents
Penalty
Summary
The facility failed to provide adequate incontinent care for two residents, resulting in potential skin breakdown and a loss of dignity. Resident 1, who was admitted with conditions including rhabdomyolysis, spondylosis, and a history of stroke, was rated as requiring substantial assistance for toilet hygiene. On multiple occasions, Resident 1 reported being left wet for extended periods, including a specific instance where she waited 20 minutes for assistance after pressing the call light. She also reported being left wet overnight on several occasions, with her sheets becoming wet and uncomfortable. Resident 2, admitted with conditions such as leg cellulitis, diabetes, and congestive heart failure, was rated as dependent for toilet hygiene. She reported being left wet throughout the night, with no CNA attending to her until the morning. Resident 2 had a large cast on her foot, which she believed intimidated newer or registry CNAs, leading them to avoid changing her. Both residents' reports were corroborated by staff interviews and observations, indicating a pattern of neglect in providing timely incontinent care. Interviews with staff, including a CNA and an LVN, revealed that the facility's policy required CNAs to round on residents every two hours. However, registry CNAs, who were not directly supervised by the facility, often failed to adhere to this policy. The Director of Staff Development confirmed that a registry CNA assigned to Resident 1 had not documented any care provided, and there were previous reports of residents not being changed. The facility's policy emphasized the need for appropriate care and services for residents unable to perform activities of daily living independently, including toileting every two hours and as needed.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that Resident 2 was treated with dignity and respect during direct patient care. Resident 2, who was admitted with diagnoses including injury of the lower spine and pelvis, COPD, difficulty walking, chronic pain, heart disease, and a history of falls, was cognitively intact and made her own decisions. The resident's care plan indicated she needed assistance with activities of daily living due to limited physical mobility and a history of falls. On one occasion, Resident 2 reported that CNA F made her wait for 30 minutes to get help to the bathroom, resulting in the resident wetting herself. This incident caused Resident 2 to become angry, and she expressed that she did not want to see CNA F again. Despite a prior complaint and a promise that CNA F would not assist Resident 2 again, CNA F was assigned to her care. Licensed Nurse A confirmed that CNA F was not supposed to return to Resident 2's room and mentioned a possible language barrier. The Assistant Director of Nursing and the Director of Nursing both acknowledged the dignity issue and confirmed that CNA F was not to be assigned to Resident 2. The incident was recognized as a failure to honor the resident's right to dignity and respect, as outlined in the facility's policies.
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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 Marysville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgeview Post Acute | 2.1 mi | ★★★★★ | 23 | 0 |
| Yuba City Post Acute | 2.2 mi | ★★★★★ | 24 | 0 |
| Fountains, The | 2.7 mi | ★★★★★ | 1 | 0 |
| River Valley Care Center | 8.6 mi | ★★★★★ | 1 | 0 |
| Gridley Post Acute | 15.9 mi | ★★★★★ | 0 | 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 June 2026) and official state health department websites.