Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Napa Community Health Center during CMS and state inspections, most recent first.
Nursing staff failed to identify and document a pressure injury on a resident’s cheek caused by oxygen tubing, and they also failed to notify the MD about another resident’s significant, progressive weight loss. The first resident had multiple chronic conditions and was at risk for skin breakdown, yet the cheek wound was not charted until it was found during observation and later identified as a Stage 2 pressure injury. The second resident, who had CHF and CKD, had declining weights and poor meal intake, but physician notes did not address the loss and staff acknowledged there was no qualified clinical oversight or timely MD notification.
A resident with CHF and CKD experienced progressive weight loss while meal intake remained poor and often below 50%. Staff documented the intake in the EMR but did not report unfinished meals to the LPN, and physician notes only recorded weights without addressing the decline. The consulting RD stopped providing services because of nonpayment, the dietary manager was not yet certified to perform RD duties, and the ADON acknowledged there was no qualified clinical oversight, no physician notification, and no timely intervention for the resident’s ongoing weight loss.
Resident rights were not protected when a census of residents and/or their RP were not informed about their right to vote in a primary election, and the activity calendar did not list the election. Several residents stated staff did not talk to them about voting and they were unable to vote, and no resident rights postings were found throughout the facility. The facility also allowed family members to sign a resident's POLST without legal authority, even though the resident had Alzheimer's disease, dementia, and complete memory impairment, and her POA did not authorize medical decision-making.
Dietary services leadership was not properly qualified when the facility allowed an uncredentialed DM to manage the kitchen. The DM said he had a ServeSafe Manager certificate but did not have a CDM credential, had not completed the required 900 hours, and had not yet registered for the exam. The AADM said the prior CDM left, the current DM was stepping into the role, and he could not make assessments; the prior RD also stated she was contracted through a third party and was told not to return until the bill was paid in full.
Improper Food Storage, Expired Foods, Unsanitary Equipment, and Hair Restraint Failure: Dietary staff stored multiple food items without required dates, kept expired and uncovered foods in the pantry and walk-in refrigerator, used expired cut produce, and left the kitchen floor and blender dirty. The DM acknowledged several items were expired or improperly stored, and he also wore a baseball cap with exposed hair and no beard cover in food prep areas.
Open and Damaged Trash Dumpsters: Trash dumpsters were repeatedly observed open and unattended, and one dumpster had a cracked, broken lid with a gap between the lids. The DM stated dumpsters were expected to be closed when not in active use and that the lids should be intact. Facility policy required outdoor waste containers to have tight fitting covers, be maintained in good repair, and remain closed except during loading.
Failure to submit quarterly PBJ staffing data. A CASPER report showed no staffing information for Q1 for a census of 24 residents. The SSD stated internet issues prevented transmission of the PBJ data, and by the time the connection was restored it was too late to submit. The AADM confirmed PBJ data must be reported quarterly and stated the facility had no PBJ policy.
Clean linen transport was deficient when a housekeeping staff member used a damaged cube truck with a gaping hole to move clean linens outside the laundry room. The cart was exposed to soil and small rocks, and a white blanket was placed over the linens to protect them. An ADON verified the hole exposed the clean linens to possible contamination, and the facility policy required clean linens to be transported in covered carts and protected from dust, moisture, and contamination.
Pest control program not effective after a live cockroach was observed in the beauty shop. An LPN identified the insect as a cockroach, and the MW reported recent cockroach complaints in resident rooms and that traps had captured cockroaches.
Staff were not educated on resident rights and facility responsibilities related to voting. Residents stated they had not voted, the SSD was unaware of the election and had not arranged transportation, the IAD did not know who was responsible for informing residents or asking if they wanted to vote, and the AADM acknowledged the election was not posted on the activity calendar. Surveyors also found resident rights were not posted throughout the facility as required by policy.
A resident with dementia and mild memory impairment had psychotropic medication consents that were not consistently obtained from the proper decision-maker. The record showed one consent for Trazodone was signed by the resident’s son even though he did not have legal authority to make medical decisions, while other consents for Lexapro and Buspirone were signed by the resident. The resident was receiving daily Trazodone, Buspirone, and Lexapro, and the facility’s policy required written informed consent from the resident or representative before psychotropic medication initiation or increase.
The facility failed to ensure ADs and POLSTs were completed for multiple residents. One resident with dementia had no documented AD discussion on the POLST, another resident with Alzheimer’s disease had a POLST signed by a Financial RP whose POA did not authorize medical decisions, and three other residents had no AD or POLST in the chart despite Full Code status or serious diagnoses such as polymyositis, heart failure, COPD, and diabetes. Staff confirmed the missing or invalid documentation during record review.
Hot Water Temperatures Exceeded Safe Limits in Resident Restrooms: Surveyors found hot water in multiple resident-use restrooms above 120 degrees F, with several readings in the 120s and 130s. A resident reported lukewarm cold water and very hot water at the tap, and an MW confirmed the water was above the facility's stated safe range and said he did not know why the temperatures were running high. The facility's temperature log showed consistent 115-degree readings despite surveyor measurements showing higher temperatures.
A resident receiving citalopram for depression did not have a properly documented GDR or behavioral monitoring. The GDR form lacked a dated physician response, and staff interviews confirmed there was no evidence of behavior tracking or documented nonpharmacological interventions, despite the facility policy requiring GDRs with such interventions for residents on psychotropic meds.
Failure to Complete and Share Baseline Care Plans: Licensed nurses did not develop baseline care plans within 48 hours of admission for two residents and did not provide them written copies of the baseline care plan summaries. Both residents were cognitively intact, and the care plans were left unsigned by the resident or staff. The ADON stated the baseline care plan should be completed within 48 hours and that residents should receive and acknowledge receipt of the summary.
Failure to identify and document a pressure injury: A resident with multiple comorbidities, including malnutrition, anticoagulant use, rosacea, CHF, stroke, CKD, and COPD, developed a Stage 2 pressure injury on the left cheek where nasal cannula tubing rested. Staff did not document the skin breakdown in progress notes, shower sheets, the skin log, or the skin assessment, and no physician notification was found. The DON stated the injury was likely caused by the oxygen tubing and had been present for a few days without being charted.
Improper Storage and Disposal of Discontinued Medications: Licensed nurses failed to ensure discontinued prescription meds were properly stored and destroyed. An uncovered cardboard box overflowing with discontinued bubble packs was observed in the med room, along with additional discontinued packs placed on a metal basket near a resident’s tote bag and other storage containers. An overfilled pharmaceutical waste receptacle also contained loose pills that were easily accessible and had not been mixed with an undesirable substance as required by policy.
Expired medications were found in an East medication cart during observation, including calcium with vitamin D, a multivitamin, and acetaminophen suppositories. An LPN confirmed the items were expired and removed them from the cart. The ADON stated nurses were expected to check expiration dates before administration and remove expired medications for disposal, and the facility policy addressed proper disposal of medications that cannot be returned to the dispensing pharmacy.
Unlabeled and Undated Food Stored in Resident Refrigerator. A resident refrigerator contained a half-eaten burrito, drinks, and supplements that were not labeled with a resident name or dated to show when they were placed in storage or when they should be discarded. The DM stated the items were likely one resident's and acknowledged the food was not properly labeled or dated, which was inconsistent with the facility policy for outside food brought in for residents.
A resident with dementia, chronic pain, COPD, and other comorbidities was converted from scheduled hydrocodone-acetaminophen to a fentanyl 25 mcg/hr transdermal patch despite not meeting FDA-defined opioid-tolerant criteria, and without documented risk assessment for advanced age and chronic lung disease. The resident’s actual morphine equivalent (ME) exposure was significantly below the 60 mg/day threshold required for initiating this fentanyl dose. Later, after several days without a patch and variable PRN opioid use, the fentanyl dose was doubled to 50 mcg/hr soon after the resident received Norco and lorazepam 0.5 mg for restlessness and anxiety, contrary to manufacturer titration guidance and the facility’s own policy to avoid or closely monitor opioid–benzodiazepine combinations. The resident subsequently developed acute shortness of breath, hypoxia, somnolence, slow shallow respirations, and pinpoint pupils, required naloxone by EMS, and was diagnosed in the ED with accidental opiate overdose and hypoxia.
A resident became upset during a Bingo activity, threatened another resident, and was escorted away while yelling, which drew the attention of the Administrator and DON. Later, while the resident was nearby in the lobby, the DON approached the nurses’ station in an emotional and aggressive manner, stating that the resident was out of control and needed to be sent out, within earshot of the resident. A confidential witness reported that the DON’s physically and verbally aggressive behavior felt like bullying, and the resident began sobbing. Progress notes documented the resident’s emotional distress, including facial redness, shaking, SOB, and crying, and the resident was sent to the ED for further evaluation. The facility’s policy requires staff to treat all residents with kindness, respect, and dignity.
A resident with dementia, traumatic brain injury, chronic pain, bipolar disorder, and other comorbidities had her fentanyl patch increased and her Seroquel regimen intensified, including a higher scheduled dose and a PRN order, without her representative being informed or providing consent, despite the medical director’s determination that the resident lacked decision-making capacity. Nursing documentation showed the discontinuation of a 25 mcg/hr fentanyl patch and initiation of a 50 mcg/hr patch, as well as increased Seroquel dosing, but no evidence of notification to the family or signed informed consent. The family member later discovered the changes after the resident experienced respiratory distress and appeared overly sedated, and staff interviews confirmed that the representative had not been notified, contrary to facility policies on resident rights, psychotropic medication use, and person-centered care planning.
A resident with dementia, bipolar disorder, anxiety disorder, epilepsy, chronic pain, and prior stroke had a PRN Seroquel 25 mg order for agitation related to anxiety that remained active well beyond the 14-day limit set by facility policy for PRN psychotropic medications. The MAR showed multiple PRN administrations, and observations later noted the resident in a wheelchair with eyes closed, chin on chest, and tongue hanging out. Nursing staff could not locate any documentation that the attending physician or a mental health provider had re-evaluated and documented the continued need for the PRN antipsychotic, and the MD was unsure about the 14-day documentation requirement. The pharmacist reported she had recommended discontinuation of the PRN Seroquel during a medication regimen review. This constituted a failure to prevent potential chemical restraint by not ensuring timely re-evaluation and documentation for continued PRN antipsychotic use.
Annual skills competency assessments were not completed for LNs and CNAs for years, with staff stating the last assessments were around 2022. The DSD, DON, ADON, and a CNA all confirmed the lapse, and the DON stated the missing assessments put residents at risk for injury, trauma, and accidents. Staff were also unfamiliar with TIC, and the DSD, DON, ADON, and a CNA stated they had not received in-service on TIC even though the facility assessment identified residents with PTSD and behavioral/psychosocial care needs.
RN coverage and staffing policy did not meet the current requirement. PBJ staffing data showed multiple days without an RN present for 8 consecutive hours, and the DON verified there were no RNs on those dates. The facility policy still stated that a licensed nurse could be an RN or LVN and did not reflect the requirement for an RN to be on duty 8 consecutive hours a day, 7 days a week.
Improper Disposal of Unused Medications and Controlled Substances: The facility failed to ensure unused and unwanted medications, including controlled substances, were destroyed in a way that rendered them unusable and prevented diversion or accidental exposure. A large box of resident meds in blister packs was found in the med storage room, and staff described inconsistent disposal methods, including placing pills in a dry plastic bin, a red biohazard bag, or a container without a securely attached lid. The DON, ADON, DSD, RPH, and PC all confirmed the process did not make the medications irretrievable.
Unlocked medication and treatment carts and an expired tuberculin vial were found in the facility. A Lab cart and two TX carts were left unattended and unlocked, with one containing needles and another containing scissors, creams, lotions, and prescribed topical treatments. In the medication storage room, an open multi-dose tuberculin vial was found without an open date and staff confirmed it had expired and should have been discarded.
Failure to Address Annual Staff Competency Assessments in QAPI: The facility's governing body did not implement its policy for annual skills competency assessments for LNs and CNAs when leadership failed to address the missing assessments in QAPI. Review of QAPI agendas showed the issue was not discussed, and the AA stated she was unaware the assessments were not being completed and that the QAPI policy and procedure was not provided.
Unsafe and Unclean Environment Due to Wheelchair Maintenance and Kitchen Floor Deficiencies: The facility failed to keep resident wheelchairs clean and maintained, with staff stating there was no schedule, no logs, and no recent cleaning of the wheelchairs. A resident said her wheelchair had not been cleaned, another resident was unaware of any cleaning, and staff noted one wheelchair became dirty from food. The facility also had broken, cracked, and missing kitchen floor tiles that the CDM acknowledged needed repair.
Late Medicare Non-Coverage Notices: A resident’s NOMNC and ABN were not issued within the required timeframe before Medicare coverage ended. The SSD and AA verified the notices were signed before the last covered day, but both acknowledged they were issued late and did not meet the 48-hour requirement. The facility did not provide its policy for NOMNC and ABN issuance.
The facility failed to provide required transfer and discharge notices for two residents. One resident was discharged home without evidence that the Ombudsman received the Notice of Transfer and Discharge, and another resident with intracerebral hemorrhage and left-sided weakness was sent to the ED after a change in condition without the required transfer/discharge notice, bed-hold notice, or evidence that the Ombudsman was notified.
A facility failed to complete the BCP within 48 hours for one resident and failed to provide the BCP summary to two residents or their RPs. The ADON acknowledged not knowing the required timeframe and verified the summaries were not given, while the DON confirmed facility policy required timely completion and written summary provision to the resident or RP.
A resident admitted with AFTT and edema had intact skin on baseline and repeated skin checks, but the care plan for skin integrity risk did not include interventions to prevent heel injury. The resident continued wearing shoes with a low heel counter that rubbed the left heel, and staff later confirmed the footwear caused friction and that the resident acquired a left heel wound in the facility. The wound was later documented as a full thickness traumatic wound with slough, and the DON verified the care plan had no interventions to address reopening of the heel wound.
Failure to supervise a resident during lunch in the social dining area led to delayed response to respiratory distress. The resident had dx including acute respiratory failure with hypoxia and dysphagia, with orders and care plan interventions for aspiration precautions, upright positioning, and supervision during meals. Surveyors observed the resident hunched over, drooling, coughing, and stating, "I can't breathe," while several residents were seated at the table without staff supervision. An LPN later acknowledged the lack of supervision, and the DON confirmed residents in social dining should be supervised by facility staff during meals.
A resident with chronic pain and anxiety continued to report moderate to severe pain despite a lidocaine patch, scheduled acetaminophen, and a PRN opioid that was given almost daily and sometimes twice daily. The resident stated the medications were not enough, described pain in the back, knees, and legs, and said staff had not responded to her request for additional patches. The DON confirmed the PRN opioid use should have prompted reevaluation, and the facility’s pain policy called for NPI and reconsideration of the analgesic regimen when analgesic requests were more than occasional.
A resident with bronchitis and COPD had a nebulizer mask found on the floor and urinary drainage bags stored in a drawer in an unsanitary manner. Staff acknowledged the respiratory and urinary supplies were being reused, sometimes rinsed, and stored without dates, with residual urine present and no caps on the tubing. The DON and ADON confirmed the items should be cleaned and stored in a sanitary manner if reused, or discarded.
A resident admitted with asthma and ARF had no documentation showing the COVID vaccine was offered or refused. The ADON and DON both verified the immunization record lacked evidence that the vaccine had been offered, and facility policy required documentation of vaccination education and any refusal.
A facility failed to investigate and report an alleged abuse incident involving a resident who reported physical abuse by a CNA, resulting in a hand discoloration. Despite the facility's policy requiring investigation and reporting, no documentation or investigation summary was provided to the State Department of Health, potentially delaying further investigation.
The facility failed to maintain the final rinse temperature of the dishwasher at the required 180 degrees Fahrenheit, compromising the sanitization of dinnerware and cooking utensils. Dietary staff confirmed the issue had been ongoing for several months, leading to the use of disposable plates and utensils as a temporary measure.
The facility failed to ensure hand hygiene for six residents before meals, did not conduct ongoing infection surveillance, and did not follow physician's orders for changing a resident's oxygen equipment weekly. Staff did not routinely offer hand hygiene, infection control documents were incomplete, and the resident's oxygen equipment was not labeled or changed as required.
The facility failed to consistently perform antibiotic stewardship, leading to potential inappropriate or unnecessary antibiotic treatment. The new Infection Preventionist (IP) had not seen previous documentation except for a folder on Antibiotic Stewardship, and the Director of Nursing (DON) stated that infection control documents could not be located. No antibiotic surveillance tracking was completed from August to December 2023, and the IP had not conducted in-services with staff on antibiotic stewardship.
A resident with dementia and dry eye syndrome had a large, bleeding growth on her nose that was not properly diagnosed or treated by the facility. Despite observations and interviews indicating the growth's consistent increase in size and bleeding, the facility only applied a band-aid and did not pursue further treatment or accurate monitoring. The resident's Responsible Person had declined further diagnosis based on age and perceived lack of pain, but had not seen the current state of the growth.
The facility failed to ensure that a resident received the RNA program as ordered by the physician, resulting in inconsistent delivery of prescribed exercises. Staffing shortages and reassignment of RNA staff to CNA duties contributed to this deficiency, which was confirmed by both the resident and staff.
The facility failed to ensure that resident meals were served with the appropriate dietary consistency. Licensed staff reviewed meal tray cards and dietary orders but did not check the actual food consistency before serving it to residents. Unlicensed staff were observed delivering meal trays without the required checks when the responsible licensed staff member was on a break. Interviews revealed a lack of formal documentation or training on this task, and the DON was unaware of the issue.
The facility failed to ensure a safe and functional kitchen environment due to unrepaired cracks and missing tiles on the floor. Cracked tiles were observed in front of the dry good storage, by the washing sinks, the exit door, and another dry good storage entrance. The Certified Dietary Manager acknowledged the non-compliance.
The facility failed to perform annual performance reviews for two CNAs. The Director of Staff Development acknowledged the reviews were behind due to a three-day work schedule, with 2023 reviews not yet completed for all unlicensed staff. Human Resource files confirmed the absence of reviews for 2023 and 2024.
Failure to identify pressure injury and report significant weight loss
Penalty
Summary
Nursing staff failed to assess, prevent, and identify a pressure injury on a resident’s left cheek. The resident was admitted with multiple chronic conditions including long-term anticoagulant use, protein-calorie malnutrition, rosacea, congestive heart failure, stroke, coronary artery disease, chronic venous thrombosis, chronic kidney disease, and COPD. Her care plan identified her as at risk for impaired skin integrity because of her history of pressure ulcers and rosacea, and staff were expected to monitor her skin and notify licensed nurses of any breakdown. During observation, she was found sitting in bed with oxygen tubing lying across both cheeks, and a scabbed wound was seen on the left cheek under the tubing. There was no padding, dressing, or gauze in place to protect the skin from the tubing. Record review showed no documented evidence of a pressure injury in the days before the observation and no documented change-of-condition notification to the physician about a facial skin concern. The Assistant Director of Nursing stated that if a CNA identified a new skin issue, the CNA was expected to notify the licensed nurse, who would assess, document, notify the physician, and request treatment orders. The ADON reviewed the chart and confirmed there were no skin issues documented on shower sheets, in the skin log, or on the most recent skin assessment. When the ADON and DON assessed the left cheek, they determined it was a Stage 2 pressure injury and stated it was likely caused by the oxygen tubing. The DON stated the injury had been present for a few days and had not been charted. Nursing staff also failed to notify the physician when another resident experienced significant and progressive weight loss. This resident was admitted with acute on chronic systolic and diastolic heart failure and chronic kidney disease, and her care plan identified her as at risk for nutritional complications. Her plan directed staff to monitor meal intake, weigh her monthly, and notify licensed staff when intake was below 50%. Her weights declined from 123 pounds to 104.6 pounds over six months, and meal records showed frequent intake at 50% or less. The quarterly nutrition assessment documented that she consumed only 58% of meals and had a 10.67% weight loss over six months, yet physician progress notes contained only weight entries without assessment or orders addressing the loss. Staff interviews showed the RD was no longer providing services, the DON had left, the MD had departed, and the DM was not yet certified. The ADON acknowledged the resident had significant and progressive weight loss and that there had been no qualified clinical oversight, no physician notification, and no timely intervention. The resident stated she was unhappy and concerned about being too thin.
Failure to Address Resident Weight Loss
Penalty
Summary
The facility failed to ensure that Resident 8 received necessary care and services to address continued weight loss. Resident 8 was admitted with acute on chronic systolic and diastolic heart failure and chronic kidney failure, and the care plan identified her as being at risk for nutritional complications related to nutritional deficiency. The care plan directed staff to administer ondansetron before meals, weigh the resident monthly, monitor meal intake, notify licensed staff when intake was below 50%, document food substitutes, and provide a calorie- and protein-dense supplement. Resident 8’s documented weights showed a steady decline from 118.2 lbs. on admission to 104.6 lbs. by the end of the review period. Meal records from early May through early June showed 21 of 87 meals at 50% or less consumed, with some meals refused or not recorded because the resident was unavailable. The resident also stated that the food was often too spicy, did not taste good, and gave her a stomachache. A nursing assistant stated that Resident 8 often picked at meals and rarely finished them, but did not report unfinished meals to the licensed nurse because the intake was documented in the EMR. Physician documentation did not address the ongoing weight loss. Progress notes from late December through mid-March only recorded weight data without comment, and no additional physician documentation was found until a new physician began providing care in June, with no note addressing the resident’s current weight loss. The nutritional assessment documented that the resident’s intake was insufficient to meet estimated caloric needs, and quarterly assessments showed declining intake and significant weight loss. The consulting RD reported she had stopped providing services to the facility because of nonpayment, and the dietary manager stated he was not yet certified to perform RD duties. The ADON stated the DON, MD, and RD were no longer providing oversight, resulting in no qualified clinical oversight, no physician notification, and no timely intervention for the resident’s ongoing significant weight loss.
Resident Rights and Informed Consent Failures
Penalty
Summary
The facility failed to ensure resident rights were exercised when a census of 24 residents and/or their responsible parties were not informed about their right to vote in the California primary election. During the resident council meeting, residents in attendance stated they had not voted. Interviews with the Social Services Designee and Interim Activities Director showed staff were unaware of the election, did not know who was responsible for informing residents, and acknowledged residents had not received election information from the Activities Department. The Assistant Administrator stated past elections had been posted on the activity calendar, but the June 2026 calendar did not list the election as an offered activity. Multiple residents stated the facility did not talk to them about voting and they were not able to vote, and an observation found no posted copies of resident rights throughout the facility as required by the facility policy. The facility also failed to ensure Resident 22's final wishes were followed when family members signed her POLST without legal authority to do so. Resident 22 was admitted with Alzheimer's disease and dementia, and her MDS indicated complete memory impairment. Her POLST, prepared in March 2019, showed her financial RP signed the form, but the signature was not dated and the relationship to Resident 22 was not completed. The POLST also stated the financial RP had consent to sign based on an advance directive dated September 2017. Review of Resident 22's Uniform Statutory Form Power of Attorney showed it did not authorize anyone to make medical or other healthcare decisions. During interview, the Social Services Designee stated the POLST was not correct and that the signer did not have consent based on the POA. The facility's informed consent policy required consent from the legally authorized representative when the resident lacked decision-making capacity and required documentation supporting incapacity and surrogate authority to be maintained in the medical record.
Dietary Manager Lacked Required Qualifications
Penalty
Summary
The facility's Administration failed to ensure the Dietary Manager had the required qualifications to manage the kitchen. During an interview, the Dietary Manager stated he had worked at the facility for six years and had been in the Dietary Manager role for about three months after the previous Dietary Manager resigned. He stated he had a ServeSafe Manager certificate but did not have a Certified Dietary Manager certification, and he said he was qualified to take the Certified Dietary Manager exam but had not yet registered or received a test date. He also stated, "I have not done the 900 hours," and said he was not a nutritionist. The Assistant Administrator stated the previous CDM left because she did not want to work for the new owner and that the facility could not hire a new one because the new owner wanted to make that decision. The Assistant Administrator said the current Dietary Manager was "qualified; he just hasn't taken the test," but also stated he could not make assessments. The previous RD stated she had been contracted through a third-party company, that the previous CDM left the facility, and that her last day at the facility was after she was instructed not to return until the bill was paid in full. The facility's job description for Director of Food & Nutrition Services stated the position required a certified food protection manager who had shown proficiency through passing a test in an accredited program.
Improper Food Storage, Expired Foods, Unsanitary Equipment, and Hair Restraint Failure
Penalty
Summary
The facility failed to store food in a sanitary manner in the dietary department. During observation of the dry pantry, multiple boxes were either missing received dates or had unclear/misdated information, including two cans of cranberry sauce labeled only with 11/15 and no year. The Dietary Manager stated he inspected food and made sure items were not expired, but acknowledged that not all boxes had delivery stickers with received dates and that he could not determine when some items were received or when they needed to be discarded. The facility’s Dry Goods Storage Guide stated unopened canned foods had a shelf life of 12 months. In the food pantry, several clear plastic bags of sliced bread and bread rolls were found without received or use-by dates, and a white cardboard box containing red potatoes had a stain from spilled liquid on its lid. The potatoes had sprouts growing out of them. The facility representative stated the bread should have been dated and that the potatoes were not good. The Dietary Manager stated he had been told the bread vendor would label and rotate the bread, but that the facility should have been doing it as well. He also stated he was unaware fresh produce had to be labeled. The facility’s policies and storage guides required open food items to have open and use-by dates, bread to be good for 5 days, and fresh fruits or vegetables to be dated and stored within the stated time limits. In the walk-in refrigerator, several food items were stored without received dates, including fresh vegetables and fruit. Multiple prepared foods were also found beyond their use-by dates or left uncovered, including gelatin trays without covers, cut garlic labeled with a use-by date that had already passed, and a container of tuna salad labeled with a use-by date that had already passed. The Dietary Manager acknowledged that cut fruit should be good for 5 days, that food beyond expiration increases the risk for foodborne illness, and that the uncovered gelatin should have been covered. Additional findings included multiple spices on the spice shelf that were undated or expired, cut carrots that were expired and still planned for use, a dirty kitchen floor, a blender with a gooey substance on it that had not been cleaned after use, and the Dietary Manager wearing a baseball cap with exposed hair and no beard cover during kitchen and food prep observations. The DM acknowledged the spice containers were not properly dated, the tarragon was expired, the carrots were expired, the blender had not been cleaned, and his hair and beard were not fully covered.
Open and Damaged Trash Dumpsters
Penalty
Summary
The facility failed to ensure trash was stored in a sanitary manner when trash dumpsters were observed left open for a census of 24 residents. During an observation on 6/2/26 at 5:41 a.m., Trash Dumpster 1 was open with no one in attendance, and Trash Dumpster 2 had a four-inch gap between the lids; the lid was also cracked and broken. In a concurrent observation and interview on 6/2/26 at 10:34 a.m., the Dietary Manager stated, "Someone forgot to close this," as he closed Trash Dumpster 1, and stated the dumpsters were expected to be closed when not in active use and that the lids should be intact. During multiple later observations on 6/2/26, 6/3/26, 6/4/26, and 6/5/26, Trash Dumpster 1 was repeatedly observed open and unattended. The facility policy titled, General Waste (Garbage) Disposal, dated 6/4/26, stated outdoor waste containers shall have tight fitting covers, be maintained in good repair, and remain closed except during loading.
Failure to Submit Quarterly PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate PBJ staffing information to CMS on a quarterly basis based on payroll and other verifiable and auditable data for a census of 24 residents. A CASPER report showed there was no staffing information for Q1 (1/26 through 3/26). During interview, the SSD stated she was responsible for submitting the PBJ data and reported that internet-related issues prevented transmission of the first quarter data, and by the time the connection was established it was too late to submit. The AADM stated PBJ staffing information had to be reported quarterly, acknowledged the facility attempted to submit the data but encountered technical difficulties, and stated there was no facility policy regarding PBJ.
Clean Linen Transport Not Protected From Contamination
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when laundry staff failed to prevent the development and transmission of communicable diseases and infections for a census of 24 residents. During a concurrent observation and interview on 6/5/26 at 9:04 a.m., Housekeeping Staff 1 stated the person who usually did the laundry was on leave and showed a gray container labeled cube truck that was being used to transport clean linen to the clean linen storage inside the facility. The container had a gaping hole on one side and was sitting outside the laundry room over pavement with soil and small rocks within a foot of it. Housekeeping Staff 1 acknowledged the container had clean linen inside it and had a white blanket on top to protect the linen from getting dirty. A second clean linen container was also observed with a hole on one side, although it did not contain clean linens at the time. During a concurrent observation and interview at 9:33 a.m., the ADON observed the container with clean linens inside, noted it was exposed outside the laundry room, and verified the hole exposed the residents' clean linens to pathogens that could contaminate the linens and could possibly affect the residents. The facility's policy titled Infection Control and Laundry Services, dated 6/1/26, stated clean linens are to be transported in covered carts and protected from dust, moisture, and contamination.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to maintain an effective pest control program when a live cockroach was observed inside the facility's beauty shop during a concurrent observation and interview with LN 1, who stated, "I think it is a cockroach" and that residents can get an infection if cockroaches are in the facility. During an interview, the MW stated there had been complaints of cockroaches in one room three weeks earlier and another room one week earlier, and that traps were set and checked weekly. The MW also stated that when he last checked the two traps placed in one room, a cockroach was found in each trap. The facility's Pest Control policy stated that the facility shall maintain an effective pest control program and keep the building free from insects and rodents.
Failure to Educate Staff on Resident Rights and Voting Access
Penalty
Summary
The facility failed to ensure staff members were educated on residents' rights and the facility's responsibilities to support residents in exercising those rights, including the ability and option to vote. During the Resident Council meeting, residents in attendance stated they had not voted the previous day. The Social Services Designee stated none of the residents came to ask for transportation to vote and that she was not following the election or aware of the California Primary election. The Interim Activities Director stated she did not know who was responsible for informing residents about an upcoming election, acknowledged residents had not received election information from the Activities Department, stated residents were not asked if they wanted to vote, and stated no vote-by-mail ballots were received for residents. The Assistant Administrator stated past elections were posted on the activity calendar, but acknowledged the California election was not posted on the June 2026 activity calendar and was not aware whether activity staff asked residents if they wanted to participate. A review of the activity calendar showed the June 2, 2026 California primary election was not listed as an offered activity. Observation of the facility found no posted copies of resident rights throughout the building as required by the facility's policy. The Assistant Administrator stated resident rights copies may be in a binder and acknowledged she had not read the policy requirements and that resident rights were not posted throughout the facility.
Informed Consent Not Properly Obtained for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for one resident when the resident’s Responsible Party did not have legal authorization to provide consent. Resident 3 was admitted in February 2021 with a diagnosis of unspecified dementia, and a Minimum Data Set dated 3/10/26 indicated mild memory impairment. The record showed informed consent for psychotropic medication Trazodone dated 3/19/25 was signed by the resident’s son on 3/24/25, even though the Social Services Designee stated the son did not have consent to make medical decisions for the resident and that the resident was the Responsible Party. The record also showed informed consent for psychotropic medications Lexapro dated 6/20/25 and Buspirone dated 10/7/25 were signed by the resident. The resident’s order summary for May 2026 indicated ongoing orders and daily administration of Trazodone, Buspirone, and Lexapro. The facility’s policy stated written informed consent shall be obtained from the resident or representative prior to initiation or increase of a psychotherapeutic or antipsychotic medication.
Failure to Formulate ADs and POLSTs for Multiple Residents
Penalty
Summary
The facility failed to ensure Advance Directives (AD) and Physician Orders for Life-Sustaining Treatment (POLST) were formulated for five residents. Resident 3 was admitted with unspecified dementia and had mild memory impairment on the MDS, but her POLST contained no documentation of a discussion with her regarding AD. Resident 22 was admitted with Alzheimer’s disease and dementia and had complete memory impairment on the MDS; her POLST was signed by her Financial RP without dating or identifying the relationship to the resident, and the document in the chart showed that the Financial RP’s POA did not authorize medical or healthcare decision-making. The Social Services Designee reviewed these records and stated that Resident 3’s AD conversation had not been documented and that Resident 22’s Financial RP did not have the power to make medical decisions, making the DNR not valid. Resident 5 had a physician order showing Full Code status, but no AD or POLST was found in the chart. Resident 7 was admitted with acute on chronic systolic heart failure, and her POLST had no documentation of a discussion regarding AD; the Medical Record Supervisor confirmed there was no evidence of a POLST or AD in Resident 5’s chart and no evidence of an AD in Resident 7’s chart. Resident 6 had chronic obstructive lung disease and diabetes, had a physician order summary showing Full Code status, and the chart contained no POLST or AD. The Assistant Director of Nursing stated that without an AD the facility would not know who the decision maker was and could not provide proper care, and the Medical Record Supervisor confirmed there was no POLST or AD in Resident 6’s chart and that she had already called the resident’s daughter to request the documents.
Hot Water Temperatures Exceeded Safe Limits in Resident Restrooms
Penalty
Summary
The facility did not maintain hot water temperatures within safe regulatory limits in multiple resident-use restrooms. During observation and interview, Resident 8 stated she was bothered by not having any cold water in her restroom, and when the cold-water tap was turned on the water was lukewarm. When the hot-water tap was turned on, the water became too hot to safely hold hands under, and a calibrated thermometer measured the hot water at 128.5 degrees F. Surveyors measured hot water temperatures in multiple resident-use restrooms and found readings above 120 degrees F in most of the rooms checked, including 124.9 F, 128.5 F, 122.4 F, 124 F, 120.1 F, 129.3 F, 129.3 F, 122.6 F, 124 F, 123.8 F, and 127.6 F. A maintenance worker confirmed lukewarm water from the cold-water tap in Resident 8's restroom and measured the hot water at 123.1 degrees F. He stated the hot water temperature should be between 115 and 120 degrees F and acknowledged temperatures above 120 degrees F had the potential to scald residents. He also stated he was unsure why the water temperature was running above 120 degrees F. The maintenance worker reported checking water temperatures Monday through Friday and recording them in a maintenance binder, but the facility's Room Water Temperature log from 5/1/26 through 6/2/26 showed consistent documented temperatures of 115 degrees F with only one-to-two-degree variances, despite surveyor measurements showing higher temperatures in the same resident restroom on multiple occasions. The maintenance worker stated he had not calibrated his thermometer since starting his position about one and a half years earlier and did not know how or how often calibration was required. The facility policy stated tap water shall be kept within a temperature range to prevent scalding and that water heaters serving resident areas shall be set to no more than 120 degrees F.
Failure to Document GDR and Behavioral Monitoring for Psychotropic Medication
Penalty
Summary
The medical and nursing staff failed to ensure that a resident receiving a psychotropic medication had a gradual dose reduction (GDR) and behavioral interventions documented. The resident was admitted with diagnoses including polymyositis and major depressive disorder and was receiving citalopram hydrobromide 10 mg by mouth daily for depression. Her care plan directed staff to document moods, behaviors, and medication side effects every shift, and the medication record showed a GDR was completed, but the GDR form did not include a physician response, and the physician signature was not dated or timed. During interviews, the PharmD stated GDRs must occur at least every six months and expressed concern that nursing staff were sending forms to the physician without behavior monitoring or attempts at dose reduction. The ADON stated GDRs were performed three times a year and confirmed the resident's returned GDR form lacked a physician indication to continue or taper citalopram, was not dated, and had no evidence of behavior monitoring. The ADON identified expected behavior monitoring for citalopram as including increased confusion, increased weakness, crying, agitation, and suicidal thoughts. The facility policy stated residents on psychotropic medications receive GDRs coupled with non-pharmacological interventions in an effort to discontinue these medications.
Failure to Complete and Share Baseline Care Plans
Penalty
Summary
Licensed nurses failed to develop a baseline care plan within 48 hours of admission and failed to provide written copies of the baseline care plan summaries to two residents, Resident 14 and Resident 16, out of three sampled residents. Resident 14 was admitted on 5/14/26, was her own RP, and had an MDS dated 5/20/26 showing a BIMS score of 15, indicating no cognitive impairment. Resident 16 was admitted on 5/22/26, was her own RP, and had an MDS showing a BIMS score of 14, also indicating no cognitive impairment. The baseline care plan provided for each resident was not signed by the resident or any staff member. During interviews, Resident 14 stated on 6/4/26 that she did not receive a copy of her baseline care plan summary and did not remember signing it, and she stated she did not know how the facility would provide care for her. Resident 16 stated on 6/5/26 that she was not provided a copy of her baseline care plan summary and said she yelled at staff because she wanted to know what was going on. The ADON stated the baseline care plan should be developed within 48 hours of admission, that an unsigned plan would be incomplete, and that residents should receive a copy of the summary and acknowledge receipt by signing it. The facility policy stated a baseline plan of care to meet immediate health and safety needs is developed within 48 hours of admission and that the resident and/or representative are provided a written summary.
Failure to Identify and Document a Pressure Injury
Penalty
Summary
Nursing staff failed to assess, prevent, and identify a facility-acquired pressure injury on a resident’s left cheek. The resident was admitted with multiple chronic conditions including long-term anticoagulant use, protein-calorie malnutrition, rosacea, congestive heart failure, cerebral infarction, coronary artery disease, chronic embolism and thrombosis of deep veins in the left leg, chronic kidney disease, and COPD. Her MDS indicated mild memory impairment, and her care plan identified her as at risk for impaired skin integrity due to a history of pressure ulcers and rosacea. The care plan directed staff to complete Braden scale assessments, monitor skin, keep skin clean and dry, reduce friction and shear, and have CNAs immediately notify licensed nurses of any skin breakdown. During observation, the resident was in bed with a nasal cannula in place, and the tubing lay across both cheeks and behind both ears. A scabbed wound was seen on the left cheek just below the tubing, and there was no padding, dressing, or gauze on the cheeks or ears to prevent pressure injury from the cannula. Review of the chart showed no documented pressure injuries in progress notes between 5/24/26 and 6/1/26, and no documented change-of-condition notification to the physician regarding a skin concern on the face during that period. The ADON stated that if a CNA identified a new skin issue, the CNA was expected to notify the licensed nurse, who would then assess, document, notify the physician, and request treatment orders. The ADON reviewed the chart and confirmed there were no skin issues identified on shower sheets, no new skin issues on the skin assessment, and no new skin issues in the skin log. During a concurrent assessment, the ADON determined the left cheek wound was a Stage 2 pressure injury and stated it was likely from the oxygen tubing. The DON stated the injury was not new and had been present for a few days, and that no one had charted it.
Improper Storage and Disposal of Discontinued Medications
Penalty
Summary
Licensed nurses failed to ensure expired and discontinued prescription medications were properly stored and disposed of in the medication room. During observation with the ADON, an uncovered cardboard box overflowing with discontinued residents’ prescription bubble packs was found in front of shelves holding other prescription medications and medical supplies. In addition, six discontinued bubble packs were observed on a metal basket on the opposite side of the room, positioned between a resident’s tote bag containing medication brought in by the resident and stacked white container baskets. A pharmaceutical waste receptacle was also observed overfilled, leaving dry, whole, loose pills easily accessible to anyone with access to the container, and no undesirable substance had been added to inactivate the pills. The ADON stated discontinued medications were supposed to be stored in the box until destroyed and said the current storage system was dangerous because anyone with access to the room could take the medications and possibly give them to other patients. The DSD confirmed medication destruction had not been done for a period after the DON left, and the facility policy required medications to be mixed with an undesirable substance before disposal.
Expired Medications Left in Medication Cart
Penalty
Summary
Licensed nurses failed to ensure expired medications were properly stored when expired multivitamins and pain medication remained in one of two medication carts. During a concurrent observation of the East medication cart and interview with the Licensed Nurse, the cart contained one bottle of calcium 600 mg with Vitamin D expired on 6/26, one bottle of Daily Vite multivitamin expired on 5/26, and four acetaminophen 650 mg suppositories expired on [DATE]. The Licensed Nurse confirmed the medications were expired and removed them from the cart. During interview, the Assistant Director of Nursing stated licensed nurses were expected to check medication expiration dates before administration and remove expired medication from the cart for disposal, and stated expired medication may cause harm to a resident or may be ineffective because it is expired. The facility policy on discarding and destroying medications stated medications that cannot be returned to the dispensing pharmacy are disposed of in accordance with federal, state, and local regulations.
Unlabeled and Undated Food Stored in Resident Refrigerator
Penalty
Summary
The facility failed to store food in a safe and sanitary manner in the resident refrigerator for a census of 24 when food was found unlabeled and undated. During an observation of the resident refrigerator with the Dietary Manager, a bowl containing a half-eaten burrito and bottles of drinks and supplements were found without a resident name to identify whose food it was and without dates to show when the items were placed in the refrigerator or when they were expected to be discarded. The Dietary Manager stated the items were likely a resident's who treated the resident refrigerator as her own personal refrigerator and acknowledged that it was not good to have the items in the resident refrigerator unlabeled and undated. The facility policy required food or beverages brought in from an outside source to be labeled with the resident's name, room number, and current date, and cooked or prepared food stored in resident-designated refrigerators to be dated when accepted for storage and discarded after 72 hours/3 days.
Failure to Follow FDA Fentanyl Patch Dosing Guidelines Resulting in Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to follow FDA Black Box Warnings and manufacturer dosing specifications for a fentanyl transdermal patch in an elderly resident with COPD and multiple comorbidities. The resident, in her late 70s, had diagnoses including dementia, chronic pain, vertebral compression fractures, bipolar disorder, anxiety disorder, COPD, and cerebral infarction. Prior to fentanyl initiation, the resident was receiving hydrocodone-acetaminophen (Norco) 5-325 mg on a scheduled basis, with a regimen that allowed for up to five tablets per day, but the MAR showed multiple instances where doses were refused or held due to sedation. Based on the consultant pharmacist’s review and morphine equivalent (ME) calculations, the resident’s actual opioid exposure at the time fentanyl was started was approximately 20–25 mg ME per day, below the FDA-defined threshold of at least 60 mg oral morphine daily for at least one week to qualify as opioid-tolerant. The record contained no documented justification for switching from Norco to a fentanyl patch or any risk assessment addressing the resident’s advanced age, COPD, and sub-threshold opioid exposure in relation to the FDA Black Box Warning and manufacturer guidance. On 11/26/25, an order was written for a fentanyl (Duragesic) 25 mcg/hr transdermal patch to be applied every 72 hours for chronic pain, and Norco was changed to PRN two days later. The consultant pharmacist later confirmed that, according to the Duragesic dosing guidelines, a 25 mcg/hr starting dose should only be used in patients already receiving at least 60 mg oral morphine equivalents daily for a minimum of seven days, which this resident did not meet. The facility’s own pain management policy stated that pain medications should be selected based on pertinent treatment guidelines, that the lowest possible effective opioid dose should be used with ongoing monitoring, and that combining opioids and benzodiazepines should be avoided or closely monitored for respiratory depression. Despite these standards and the resident’s COPD and geriatric status, the fentanyl patch was initiated without documentation that the resident was opioid-tolerant as defined by the FDA labeling, and without a documented risk assessment. Subsequently, the resident’s fentanyl dose was increased from 25 mcg/hr to 50 mcg/hr on 1/30/26, after a period in late January when the 25 mcg/hr patch had been removed and not replaced for several days due to unavailability. During January, the resident’s PRN Norco use ranged from one to three tablets per day, with nine days of no Norco administration, and pain scores varied from 0 to 9. On 1/29/26, nursing documentation showed the resident was restless and unable to be consoled, leading to a new order for lorazepam 0.5 mg for anxiety, which was administered at 5:20 p.m., following a Norco dose at 4:00 p.m. The next day, the fentanyl patch dose was doubled to 50 mcg/hr. The consultant pharmacist verified that, at the time of this dose increase, the resident was receiving only 5–15 mg of supplementary morphine equivalents per day, far below the 45 mg ME per day that the manufacturer’s titration guidelines associate with a 12.5 mcg/hr increase, and that lorazepam and Norco had been administered shortly before the fentanyl dose escalation, creating a potential for respiratory depression. On 2/1/26, nursing notes documented that the resident began screaming for help and reported, “I can’t breathe, I can’t talk, I can’t swallow.” The nurse applied supplemental oxygen, but the resident’s oxygen saturation dropped to 77%, and her temperature was 100.1°F. The medical director was notified and ordered transfer to the emergency department. ED triage documentation indicated shortness of breath, slow shallow respirations, pinpoint pupils, and a positive response to naloxone administered by EMS, with the fentanyl patch removed by EMS. The ED history and physical described somnolence presumed due to opioid overdose and shortness of breath, and the ED physician’s note characterized the event as an iatrogenic occurrence requiring re-evaluation of the resident’s pain management strategy. The ED diagnoses included accidental or unintentional opiate overdose and hypoxia. Throughout interviews, the consultant pharmacist confirmed that both the initial fentanyl dose and the subsequent dose increase did not meet FDA and manufacturer criteria for opioid tolerance and dose titration, while the medical director stated he believed he had followed fentanyl dosing guidelines but could not identify the cause of the resident’s respiratory distress.
Failure to Treat a Resident With Dignity and Respect During Behavioral Incident
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to be treated with kindness, respect, and dignity. A confidential witness (CW) reported that during an activities session in January 2026, a resident became upset during Bingo after observing another resident not covering a called number. According to a progress note dated 1/9/26 at 3:34 p.m., the resident stated that if someone did not know how to play, they should not be playing, and was informed by staff that assistance is provided to all residents. As the staff member removed the resident from the table, the resident threatened to slap another resident and threw two Bingo chips against the wall while being escorted down the hall, yelling loudly enough to draw the attention of the Administrator and the DON, who then took over the situation. The CW stated that later that afternoon, while at the nurses’ station, they observed the DON approach the nurses’ station in a very emotional and aggressive manner, saying that the resident was out of control and that something needed to be done, including that the resident needed to be sent out. This interaction occurred within earshot of the resident, who was only a few feet away in the lobby, and upon hearing the DON’s comments, the resident began sobbing. The CW described the DON’s behavior as physically and verbally aggressive and perceived it as bullying the resident. A subsequent progress note dated 1/9/26 at 5:20 p.m. documented that the resident had facial redness, shaking, shortness of breath, emotional distress, and crying, and was sent to the ED for further evaluation. The facility’s Resident Rights policy, last reviewed 3/31/26, states that employees shall treat all residents with kindness, respect, and dignity.
Failure to Inform Resident Representative of Pain and Psychotropic Medication Changes
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident’s family member of significant changes to the resident’s treatment plan for pain and behaviors, despite the resident lacking capacity to make healthcare decisions. The family member reported receiving a call that the resident was in respiratory distress after an increase in her fentanyl patch dose to 50 mcg/hr, and stated that he would not have agreed to this increase because the resident was already on multiple central nervous system depressants. He also reported that the resident’s Seroquel dose had been doubled in the hospital and continued upon her return to the facility without any discussion with him, even though the resident had delirium and was not at her baseline during the hospitalization. The family member described finding the resident slumped over in a chair and slurring her words, and later learned via text communication with the physician that there was also a PRN Seroquel order that he had not been informed about. Record review showed that the resident had multiple diagnoses including dementia with behavioral disturbance, epilepsy, chronic pain, traumatic brain injury, bipolar disorder, anxiety disorder, and cerebral infarction. The face sheet listed the resident as her own responsible party, but the medical director had previously informed surveyors that the resident did not have capacity to make healthcare decisions and confirmed that this had not changed and no county conservator had been arranged. Physician orders and MARs showed a fentanyl patch 25 mcg/hr ordered in November and discontinued in late January, with a new order for a fentanyl patch 50 mcg/hr dated 1/30 and administered on 1/30, as well as Seroquel 25 mg three times daily for agitation and later Seroquel 50 mg three times daily with an added PRN Seroquel 25 mg every six hours for agitation. Nursing progress notes documented discontinuation of the 25 mcg patch and initiation of the 50 mcg patch but contained no documentation that the family member was notified of this change. Interviews with facility staff confirmed the lack of family notification and informed consent. One licensed nurse stated that the family member was not informed of the decision to increase the fentanyl patch at the end of January. Another licensed nurse verified there was no informed consent signed for the increased Seroquel dose or the PRN Seroquel order and acknowledged that a new consent should have been obtained when the dose was increased and a PRN dose added in the hospital. The medical director confirmed that the resident still lacked decision-making capacity and stated that residents’ families have the right to participate in the plan of care and that he expected nursing staff to have informed the family member of the fentanyl dose increase. Facility policies on resident rights, psychotropic medication use, and comprehensive person-centered care planning required resident or representative participation in treatment decisions and care planning, informed consent for psychotropic medication changes, and documentation when resident or representative participation in care planning was not practicable, which did not occur in this case.
Failure to Re-Evaluate PRN Antipsychotic Order Within Required 14-Day Limit
Penalty
Summary
The deficiency involves the facility’s failure to comply with requirements for PRN antipsychotic medications, resulting in a chemical restraint concern for one resident. The resident, an older adult with dementia, epilepsy, chronic pain, bipolar disorder, anxiety disorder, and a history of cerebral infarction, had a physician order for Seroquel 25 mg to be given by mouth three times a day as needed for agitation related to anxiety disorder, starting on 2/3/26. The February MAR showed that the PRN Seroquel was administered on three occasions (2/11/26, 2/14/26, and 2/22/26). Observations on 3/12/26 documented the resident in a wheelchair in the lobby with eyes closed, chin resting on the chest, and later with the tongue hanging out of the mouth, while a musician performed nearby. Record review and staff interviews revealed that the PRN Seroquel order remained active from 2/3/26 through at least 3/26/26 without documented re-evaluation by the physician or a mental health provider, despite facility policy limiting PRN psychotropic orders to 14 days and requiring an evaluation and documentation to renew PRN antipsychotic orders. A nurse stated that the physician re-evaluated PRN antipsychotics during quarterly gradual dose reductions and monthly order recapitulations, but could not identify any documentation of a specific re-evaluation or rationale for continuing this PRN Seroquel order. The medical director could not recall if he documented a re-evaluation and appeared unaware that documentation every 14 days was required to continue a PRN antipsychotic. The facility’s pharmacist reported that, during a recent medication regimen review, she noted the PRN Seroquel order and recommended its discontinuation. This failure resulted in the resident having the potential to receive an antipsychotic dose beyond the 14-day limit without the required re-evaluation.
Annual Competency and TIC Training Not Completed
Penalty
Summary
Licensed nurses and Certified Nursing Aides were not provided annual skills competency assessments. During an interview, the Director of Staff Development stated he was responsible for completing the annual skills competency assessments for both LNs and CNAs, but said no annual competency assessments had been done for years. He stated the last annual skills competency for LNs and CNAs was completed in 2022 and that he had been the DSD for 2 years without completing any annual skills competency assessments for either group. The DON stated she was not aware the annual skills competency assessments had not been completed for LNs and CNAs since 2022. She stated these assessments should be done annually to ensure staff have the skill set to care for residents safely, and said not having them completed annually put residents at risk for injury, trauma, and accidents. The ADON stated her last LN annual skills competency assessment was about 2022, and Unlicensed Staff C stated she had not received CNA annual skill competency assessments for years and believed the last one was in 2022. Staff were also not aware of Trauma Informed Care. The DSD stated the facility admits residents with behavioral issues, was not aware of what TIC was, and had not provided any in-service on TIC. The DON stated the facility assessment identified residents with PTSD and that one competency overseen by the facility was caring for residents with mental and psychosocial disorders and PTSD. She stated she was not aware of what TIC was and had not received an in-service on it. Unlicensed Staff C and the ADON also stated they had not received in-service on TIC and did not really know what it was.
RN Coverage and Staffing Policy Did Not Meet Current Requirement
Penalty
Summary
The facility failed to ensure that an RN provided services at least eight consecutive hours a day, seven days a week. A review of the PBJ staffing data showed there was no RN coverage for 8 consecutive hours on multiple dates in the first quarter, including 1/4/25, 1/18/25, 1/25/25, 2/15/25, 2/22/25, 2/23/25, 3/8/25, and 3/22/25. During a concurrent interview and record review on 08/28/2025 at 11:23 a.m., the DON verified there were no RNs present at the facility on those dates. The facility also failed to ensure its staffing policy and procedure reflected the current requirement. The policy titled "[Facility name] Nursing Home (PNH) Staffing, Sufficient and Competent Nursing" stated that a licensed nurse may be an RN or an LVN and that a licensed nurse provides services at least eight consecutive hours every 24 hours, seven days a week. The DON stated the policy did not reflect the current regulation requiring an RN to be on duty eight consecutive hours a day, seven days a week. The DON also stated that LVNs could not assess residents or administer IV medications, and that RNs have more autonomy and could manage more unstable or high-risk patients.
Improper Disposal of Unused Medications and Controlled Substances
Penalty
Summary
The facility failed to ensure that unused and unwanted medications, including controlled substances, were destroyed in a manner that rendered them unusable and prevented diversion or accidental exposure. During observation in the medication storage room, a large cardboard box was found containing residents’ medications in blister packs that the ADON identified as medications awaiting disposal. The ADON stated the facility’s disposal method involved removing pills from blister packs into a plastic container with a solution, while the DON later described a different process in which pills were removed from blister packs into a dry plastic bin for pickup by a medical waste company. During further observation, the DSD confirmed the medication destruction container was stored in a locked area but did not have a securely attached lid, contained whole pills at the bottom, and did not contain a substance to render the medications unusable. The DSD acknowledged that anyone could reach into the bin and access the medications. The ADON and DON also described the handling of controlled substances as involving reconciliation of blister packs or pharmaceutical containers, signatures of two licensed nurses, transfer to the DON in a locked box, and later crushing of the pills before placing them in a dry red biohazard bag. The ADON and DON both acknowledged that crushing controlled substances and placing them in a dry bag did not render them unusable or irretrievable. The facility’s pharmacist and pharmacy consultant both stated that the destruction process should include a solution or substance to render medications and controlled substances irretrievable, and both confirmed the facility’s current method was not appropriate. The facility policy required non-controlled and Schedule V controlled drugs to be destroyed in the presence of two licensed nurses and required the medication disposition record to include the method of destruction.
Unlocked Medication Carts and Expired Tuberculin Vial
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and that multi-dose biologicals were properly labeled and removed from use when expired. During observations at the nursing station and in the hallway, three mobile carts were found unattended and unlocked: a Lab cart containing sharp objects such as needles, a TX cart containing scissors, general use creams and lotions, and prescribed topical treatments, and another TX cart on the east side. Staff acknowledged each cart was unlocked and unattended, and confirmed the carts should have been locked when not in use for safety and to prevent unauthorized access. In the medication storage room, one multi-dose vial of tuberculin was observed open without an open date. The box had a handwritten date of 7/10/25 and the vial had a printed label with a date of 7/7/25. Nursing staff and the DON acknowledged the vial was open, lacked an open date, and was expired because tuberculin expires 30 days after opening. The DON and the pharmacy consultant confirmed that multi-dose vials require an open date and that expired medications and biologicals should be removed from use and discarded. The facility policy stated medications and biologicals are to be stored in locked compartments, carts are not to be left unattended if open, and opened multi-dose vials are to be dated and discarded within 28 days unless the manufacturer specifies otherwise.
Failure to Address Annual Staff Competency Assessments in QAPI
Penalty
Summary
The facility's governing body failed to implement its policy for annual skills competency assessment for LNs and CNAs when leadership staff did not address the lack of annual assessments during QAPI meetings. Review of the QAPI agendas for 3/2025 and 6/2025 did not show that the missing annual skill competency assessments for LNs and CNAs were discussed. During an interview on 08/28/2025 at 11:23 AM, the AA stated she was not aware the annual skill competency assessments for LNs and CNAs were not being done and said the issue was not included as a topic in QAPI. The AA stated the lack of annual skill competencies was a concern because it put all residents at risk and explained that QAPI was important because it identified issues to prevent problems from recurring and support better resident outcomes and resident safety. The facility did not provide the QAPI policy and procedure when requested.
Unsafe and Unclean Environment Due to Wheelchair Maintenance and Kitchen Floor Deficiencies
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment when preventive maintenance and cleaning were not performed for Resident 8's, Resident 23's, and Resident 30's wheelchairs. Resident 8 stated her wheelchair had not been cleaned as far as she could remember and said she would like it cleaned. Resident 23 stated he uses a wheelchair that stays in his room but was not aware of it being maintained or cleaned by facility staff. Unlicensed Staff C stated the Maintenance Supervisor used to wash residents' wheelchairs, especially Resident 30's wheelchair because she spits food and it gets dirty, but no one is cleaning the wheelchairs anymore. Maintenance Staff I stated he was not sure whether there was a schedule for wheelchair maintenance and cleaning and said he had not cleaned residents' wheelchairs since being hired in February 2025. The Maintenance Supervisor stated wheelchair maintenance and cleaning was done on an as-needed basis and that there were no logs or documentation showing it had been performed. The facility policy stated wheelchairs should be regularly cleaned, inspected, and lubricated, with daily wiping and monthly cleaning, lubrication, and inspection recommended. The facility also failed to repair broken, cracked, and missing tiles in the kitchen floor. During observation, several broken, cracked, and missing tiles were seen in the kitchen floor, and photographs were taken. The Certified Dietary Manager acknowledged the cracks, broken, and missing tiles and stated she had discussed the tile concerns with the facility owner previously and that the floors needed to be repaired. The Maintenance Supervisor was asked to provide the policy and procedure on maintenance cleaning of residents' equipment and the kitchen floor, and a follow-up request was made to the Assistant Administrator for the kitchen floor maintenance policy, but the policy was never provided.
Late Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure the Notice of Medicare Non Coverage (NOMNC) and the Advance Beneficiary Notice (ABN) were issued within 48 hours of anticipated Medicare non-coverage for one sampled resident. Review of the resident’s NOMNC and ABN showed a Medicare last covered day of 8/20/25, and the resident signed both notices on 8/19/25. During interviews and record review with the Social Services Director and the Administrator Assistant, both verified the notices were issued and signed on 8/19/25 and stated the NOMNC and ABN should be issued within 48 hours of the last covered day. The Social Services Director confirmed the resident’s Medicare last covered day was 8/20/25 and acknowledged the importance of timely notice so residents have time to appeal and understand any financial responsibility. The Administrator Assistant also verified that the NOMNC and ABN were issued late and did not meet the 48-hour requirement. The facility policy for NOMNC and ABN was requested but not provided. The report also cited CMS instructions stating the NOMNC must be given no later than two days before termination of services and the ABN must be delivered far enough in advance for the beneficiary or representative to make an informed choice.
Missing transfer, discharge, and bed-hold notices
Penalty
Summary
The facility failed to provide required transfer and discharge documentation for two residents. For one resident, the Ombudsman was not provided a copy of the Notice of Transfer and Discharge when the resident was discharged home. The resident’s face sheet showed an admission in June 2025, and the Notice of Transfer and Discharge form showed discharge to home on 6/22/25. During interviews, the Social Services Assistant and the Administrator Assistant stated the facility’s policy was to notify the Ombudsman whenever a resident was discharged, and the Social Services Assistant later confirmed she could not find fax confirmation or other documentation showing the Ombudsman had been notified. For another resident, who was admitted in July 2025 with diagnoses including intracerebral hemorrhage with left-sided weakness, the facility transferred the resident to the emergency room after a change in condition that included increased confusion and difficulty swallowing. The licensed nurse notified the Medical Director, who ordered transfer to the hospital ED, and the resident’s Responsible Party was aware. However, the record contained no documented evidence that the resident or Responsible Party received a Notice of Transfer and Discharge or the Notification of Resident’s Right to Hold Bed, and there was no evidence the Ombudsman was notified. The Social Services Assistant confirmed these notices had not been provided and acknowledged they were required for residents who were transferred or discharged.
Baseline Care Plan Not Completed or Shared Timely
Penalty
Summary
The facility failed to ensure the baseline care plan (BCP) was completed within 48 hours of admission for one sampled resident, Resident 9. Resident 9 was admitted on [DATE], but the rehabilitation and nursing departments did not complete the BCP until 6/24/25. The BCP summary for Resident 9 did not indicate that it was provided to the resident or the responsible party (RP). The facility also failed to provide the BCP summary to Resident 34 or the RP. Resident 34 was admitted on [DATE], and the BCP summary did not show that it had been given to the resident or RP. During interview and record review, the ADON acknowledged she was not aware of the exact timeframe for completing a BCP and verified that the BCP summary was not given to either resident. The DON stated the facility policy required the BCP to be completed within 48 hours of admission and the BCP summary to be provided to the resident or RP, and that failure to do so meant the policy was not followed.
Failure to Prevent Shoe-Related Left Heel Wound
Penalty
Summary
The facility failed to identify and provide needed care and services to preserve skin integrity and prevent the development of a wound for one resident who acquired a left heel wound while residing in the facility. The resident was admitted in June 2025 with diagnoses including Adult Failure to Thrive and edema. Baseline and subsequent skin assessments from admission through mid-August documented clean, dry, intact skin with no open areas, and the resident’s MDS indicated no open lesions on the feet and no dressings or topical medications. The resident’s care plan for risk for skin integrity, initiated in late June 2025, did not include interventions specific to preventing a wound on the left heel. On 8/19/25, the resident’s skin assessment documented a new left heel open wound measuring 3 cm by 3 cm with clear drainage, and the care plan was updated to reflect the wound. A surgical and wound care note dated 8/25/25 described a full thickness traumatic wound with slough on the posterior left heel, and the physician believed the injury was caused by the resident’s shoes. During observation, the resident was wearing shoes with a low heel counter that touched the left heel dressing, and the resident stated the shoes had been worn since admission and caused friction and pain. The resident stated no one at the facility told her not to continue wearing them. A nurse confirmed the wound was acquired in the facility and stated staff had noticed the footwear was creating friction on the heels. The DON also verified the wound was acquired in the facility from the resident’s shoes and that the skin-at-risk care plan had no interventions to address reopening of the left heel wound.
Failure to Supervise Resident During Meal
Penalty
Summary
The facility failed to ensure adequate supervision for one resident during lunch in the social dining room. The resident had been admitted with diagnoses including acute respiratory failure with hypoxia and dysphagia, and the physician orders included aspiration precautions such as upright positioning at about 90 degrees, monitoring for aspiration precautions, monitoring for shortness of breath, and being up in a chair or at 90 degrees for all meals. The care plan also identified a history of dysphagia, choking, and aspiration, with interventions for meal tray set-up, encouragement to feed self, supervision during meals, and monitoring for signs of choking and aspiration. During a dining observation, about six residents were seated at a table in the social dining room without staff supervision. The resident was observed in a wheelchair at the table in a hunched posture, picking and poking at the meal with a fork. Later, the resident pushed away from the table, was drooling, coughing, and hunched over, and stated, "I can't breathe." A nurse was alerted to the resident's respiratory distress and acknowledged that residents were not adequately supervised and that staff should provide supervision during mealtimes. The activity director stated activity staff provided supervision in the social dining area, and the DON confirmed residents in social dining should be supervised by facility staff to ensure safety during meals. The facility was unable to provide a policy and procedure for supervision of residents during mealtimes.
Inadequate Pain Management and Lack of Reassessment
Penalty
Summary
Safe, appropriate pain management was not provided for one resident who had an admission diagnosis of pain disorder with related psychological factors and anxiety disorder. The resident’s MDS dated 6/30/25 indicated she was almost constantly in pain, affecting sleep, therapy, and day-to-day activities. Her BIMS score on 8/20/25 was 13 out of 15, indicating intact cognition, and her pain assessment on the same date documented frequent pain, interference with therapy, and a pain level of 8 out of 10, with pain in the lower right leg. The resident’s August 2025 EMAR showed orders for a lidocaine patch daily, acetaminophen 650 mg three times daily and every 6 hours PRN, and an opioid analgesic solution 0.5 ml every 6 hours PRN. The resident received the PRN opioid almost daily and at times twice a day, yet there was no reevaluation from nursing staff or the physician despite the ongoing use. The resident reported pain levels of 8 and 9 on multiple dates in August and stated the medications were not enough to control her pain. During observations, she was found in bed grimacing, complaining of pain in her back, knees, and legs, and stated she had not yet received her pain medication during one observation. The resident also stated the pain in her knees and legs began after a fall and that she had asked for patches for both knees and legs, but staff had not responded. She said she felt helpless at times and was in constant pain. The DON confirmed the PRN opioid was being given almost daily and stated the nurses should have contacted the physician to reevaluate the pain regimen. The facility’s pain policy stated that the physician would order appropriate nonpharmacological interventions and that if there were more than occasional analgesic requests, the physician would consider changing the analgesic regimen or adding nonpharmacologic measures.
Unsanitary Storage of Nebulizer Mask and Urinary Drainage Bags
Penalty
Summary
The facility failed to ensure respiratory and urinary supplies were stored in a sanitary condition for one resident who was admitted with diagnoses including bronchitis and COPD. The resident had physician orders for ipratropium-albuterol inhalation solution as needed, use of a condom catheter at bedtime, and weekly changes of the urinary catheter drainage bag as needed. During a concurrent observation and interview, the resident’s nebulizer mask was found on the floor, and a handwritten sign in the room stated that the catheter bags were not to be thrown away because they were expensive. Staff acknowledged that the nebulizer mask and tubing needed to be thrown away or stored in a plastic bag for sanitary reasons. Staff also stated that the urinary drainage bags were being reused, sometimes rinsed, and placed in the resident’s bottom drawer. Later observations and interviews confirmed two urinary drainage bags were stored in the resident’s bottom drawer in plastic bags that were not properly secured, were undated, contained residual urine, and had no plastic caps on the tubing. The ADON stated the bags should be dated when changed, changed weekly or as needed, capped, and stored in a tied plastic bag after cleaning and air drying. The DON confirmed nebulizer masks and urinary drainage bags should be cleaned and stored in a sanitary manner if reused, or thrown away.
Failure to Document COVID-19 Vaccine Offer and Refusal
Penalty
Summary
The facility failed to ensure that one of three sampled residents, Resident 9, was offered the COVID-19 vaccine. Resident 9 was admitted in June 2025 with diagnoses of asthma and acute respiratory failure. A review of Resident 9's immunization record did not show whether the COVID vaccine had been offered or refused. During a concurrent interview and record review on 08/27/2025, the ADON verified that the immunization record did not indicate the COVID vaccine had been offered to Resident 9 and/or refused by Resident 9, and stated that if it is not documented, then it did not happen. Later that day, the DON also verified there was no documentation showing the COVID vaccine had been offered or refused. Facility policy titled Charting and Documentation required documentation of care details, including whether a resident refused a procedure or treatment, and the Vaccination of Residents policy stated residents or legal representatives were to receive information and education before vaccination and that refusals were to be documented in the medical record.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its abuse prevention policy and procedures when a resident reported an incident of alleged physical abuse by a certified nursing assistant (CNA). The resident claimed that the CNA pulled on her arms, resulting in a 2.5 cm x 2 cm discoloration on her left hand near the thumb. Despite this report, the facility did not conduct an investigation nor document any findings related to the incident. The resident's medical record contained a nurse's note documenting the alleged abuse, but there were no additional notes or interdisciplinary team (IDT) documentation addressing the incident. During interviews, facility staff confirmed the absence of documentation related to an in-house investigation or IDT notes regarding the incident. The facility's policy requires that all allegations of abuse be investigated and reported within the timeframes required by federal requirements. However, the facility did not provide a 5-day investigation summary to the State Department of Health, as required. This lack of action and documentation potentially delayed the Department's independent investigation of the incident.
Dishwasher Final Rinse Temperature Deficiency
Penalty
Summary
The facility failed to ensure the sanitization, safety, and functional environment in the kitchen when the temperature of the final rinse of the dishwasher was not maintained to adequately sanitize dinnerware and cooking utensils. During an observation and interview, it was noted that the final rinse temperature of the high-temperature dishwasher was only 150 degrees Fahrenheit, significantly below the required 180 degrees Fahrenheit. Dietary Aides E and F confirmed that the dishwasher frequently failed to reach the necessary temperature, and they had to run the dishwasher multiple times in an attempt to achieve the correct temperature. Despite these efforts, the dishwasher still did not consistently reach 180 degrees Fahrenheit, leading to the use of disposable plates and utensils as a temporary measure. A review of records revealed that the issue with the dishwasher's final rinse booster heater had been ongoing for several months. The monthly Consultant Dietitian Report Card indicated that the dishwasher was not holding temperature as early as January, with subsequent reports in February and March noting continued issues with the booster heater leaking and failing to maintain the required temperature. This prolonged failure to address the malfunctioning dishwasher compromised the facility's ability to properly sanitize dinnerware and cooking utensils, posing a risk of food contamination and potential foodborne illness among residents.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure hand hygiene was practiced by six of 15 sampled residents before meals. Observations revealed that staff did not offer or remind residents to wash or wipe their hands before eating. Interviews with staff confirmed that they did not routinely offer hand hygiene to residents, and moist wipes were not included on meal trays as previously done. The facility's policy on hand hygiene did not specify that staff should remind or offer hand hygiene to residents before meals, contributing to this oversight. The facility also failed to conduct ongoing analysis of infection surveillance. The newly appointed Infection Preventionist (IP) had not seen the infection prevention folders except for the one on Antibiotic Stewardship. Surveillance logs for the past 12 months were incomplete, and there was no documentation of data analysis or infection rate plotting. The Director of Nursing (DON) acknowledged that the infection control documents could not be located or had been misplaced, and the current IP had not started the process of overseeing infection surveillance. Additionally, the facility did not ensure that physician's orders were followed for one resident who was on oxygen therapy. The resident's nasal cannula and oxygen humidifier were not changed weekly as required, with the last documented change occurring nearly two months prior. Observations confirmed that the nasal cannula tubing and humidifier were not labeled with the date of the last change. Interviews with staff indicated that the responsibility for changing the equipment was not clearly assigned, and the DON admitted to not realizing the equipment had not been changed as scheduled.
Failure to Consistently Perform Antibiotic Stewardship
Penalty
Summary
The facility failed to consistently perform antibiotic stewardship, which had the potential to result in inappropriate or unnecessary antibiotic treatment. During an interview and records review, the Infection Preventionist (IP) stated she had only been working at the facility for three weeks and had not seen the previous IP's folders except for the one on Antibiotic Stewardship. The folder contained documentation on an antibiotic surveillance tracking form with residents' names who were treated with antibiotics from January to April 2024, but none for the past months. The Director of Nursing (DON) stated that infection control, surveillance, and monitoring documents could not be located or may have been misplaced after the previous IPs left. The DON had called the previous IP to help locate the folders. A review of the Infection Prevention and Control Line Listing Surveillance Logs indicated no antibiotic surveillance tracking was completed from August to December 2023, as there were no line listing surveillance logs for those months. The IP's job description indicated responsibility for the antibiotic stewardship program (ASP), including in-servicing, tracking, reporting, and educating families, employees, and physicians as needed. However, the IP stated she had not conducted in-services with staff on antibiotic stewardship. The facility's Antibiotic Stewardship policy, updated in January 2024, indicated that antibiotic usage and outcome data should be collected and documented using a facility-approved antibiotic surveillance tracking form. All clinical infections treated with antibiotics were supposed to undergo review by the IP or designee, but this was not consistently done, leading to the deficiency.
Failure to Diagnose and Treat Resident's Growth
Penalty
Summary
The facility failed to appropriately diagnose and treat a growth on the left side of Resident 29's nose. Resident 29, who has a history of dementia and dry eye syndrome, was observed with a large growth on her nose that had been bleeding. Unlicensed and licensed staff indicated that the growth had been consistently growing, and Resident 29 would scratch it, causing it to bleed. Despite these observations, the facility's staff only cleaned the area with saline solution and applied a band-aid, without pursuing further treatment or monitoring the growth's size and condition accurately. The Social Services Director (SSD) and various licensed staff members revealed that there had been a canceled plastic surgeon appointment and a dermatology appointment where Resident 29 became combative, preventing assessment. The Responsible Person (RP) for Resident 29 had decided against further diagnosis or treatment based on the resident's age and perceived lack of pain. However, the RP had not seen the current state of the growth, which had become larger and more prone to bleeding. The facility's weekly skin assessments failed to document the changing size and bleeding events of the growth accurately. The Director of Nursing (DON) was not aware of the growth's increase in size and its proximity to the lower eyelid. The facility's policies on charting, documentation, and skin and wound management were not followed accurately, leading to incomplete and inaccurate records. The lack of a comprehensive healthcare team approach and proper monitoring increased the risk of infection and discomfort for Resident 29.
Failure to Administer RNA Program as Ordered
Penalty
Summary
The facility failed to ensure that the Restorative Nursing Assistant (RNA) program was being administered according to physician orders for Resident 33. Resident 33, who was admitted with diagnoses including cerebral infarction, major depression disorder, and hemiplegia, had a care plan that included passive and active range of motion exercises to be performed 3 to 5 times per week. However, the records indicated that these exercises were not consistently provided, with significant gaps in the frequency of the sessions over multiple months. For example, in one six-week period, Resident 33 received the exercises only twice, whereas they should have been offered at least 12 times. Similar deficiencies were noted in subsequent periods, with the resident receiving the exercises far less frequently than ordered by the physician. This inconsistency in care delivery was corroborated by Resident 33, who expressed that promises to take him to the gym were not always kept and that he felt forgotten about. The Rehab Manager and the RNA staff confirmed that staffing shortages and the reassignment of RNA staff to CNA duties contributed to the failure to provide the ordered exercises. The facility's policies on restorative nursing services and resident mobility and range of motion were not adhered to, resulting in a failure to maintain or improve Resident 33's functional mobility and muscle strength as required by the care plan.
Failure to Ensure Appropriate Dietary Consistency in Resident Meals
Penalty
Summary
The facility failed to ensure that resident meals were served with the appropriate dietary consistency. During an observation, a licensed staff member was seen reviewing meal tray cards and dietary orders in the electronic medical record but did not check the actual food consistency before serving it to residents. The licensed staff member indicated that the meals were not uncovered to avoid touching the food. This process was common practice at the facility, and the staff member acknowledged the importance of checking meal trays to prevent residents from choking or aspirating on improperly prepared food. However, during another observation, unlicensed staff were seen delivering meal trays without the required checks, as the licensed staff member responsible was on a break and not available to perform the task. Interviews with various staff members, including the Director of Nursing (DON), revealed that there was no formal documentation or training on how to perform the task of checking meal trays for appropriate consistency. The DON was unaware that meals were not being checked by licensed staff before being served to residents and emphasized the importance of this safety measure to prevent aspiration. The facility's policy and procedure on tray line procedures indicated that assigned staff should deliver the cart to the nurses' station and announce its arrival, but it did not specify the need for checking meal consistency before serving.
Unrepaired Cracks and Missing Tiles in Kitchen
Penalty
Summary
The facility failed to ensure a safe and functional environment in the kitchen due to unrepaired cracks and missing tiles on the kitchen floor. During an initial tour of the kitchen, cracked tiles were observed in front of the entrance to the dry good storage. Further observations revealed more cracks and missing tiles by the washing sinks, the exit door to the back of the building, and the entrance to another dry good storage. The Certified Dietary Manager acknowledged the non-compliance when informed about the findings. The Food Code 2017 indicates that materials for indoor floor surfaces should be smooth, durable, and easily cleanable, which was not adhered to in this case.
Failure to Perform Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to perform annual performance reviews on two out of three sampled Certified Nursing Assistants (CNAs). During an interview, the Director of Staff Development (DSD) acknowledged that the annual performance reviews for Unlicensed Staff P and Unlicensed Staff Q were outstanding. The DSD indicated that the reviews were behind due to a three-day work schedule and that the facility was still working on completing the reviews for the current year of 2024, with 2023 reviews not yet completed for all unlicensed staff. A review of the Human Resource files for Unlicensed Staff Q and Unlicensed Staff P confirmed the absence of annual performance reviews for the year 2023 and, in the case of Unlicensed Staff P, also for 2024.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Napa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Napa Valley Care Center | 0.8 mi | ★★★★★ | 2 | 0 |
| Napa Post Acute | 0.9 mi | ★★★★★ | 31 | 1 |
| The Meadows Of Napa Valley | 2.6 mi | ★★★★★ | 0 | 0 |
| Dept Of State Hospitals - Napa D/p Snf | 3.5 mi | ★★★★★ | 25 | 0 |
| Veterans Home Of California - Yountville - Snf | 6.4 mi | ★★★★★ | 16 | 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 August 2026) and official state health department websites.