Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Bay Post Acute during CMS and state inspections, most recent first.
A resident with a history of stroke and left-sided hemiplegia, who was cognitively intact, was physically assaulted by a cognitively intact roommate with Wernicke’s encephalopathy and a known history of aggressive, resident-to-resident altercations. As the first resident passed the roommate’s bed in a shared room, the aggressive resident attempted to punch him, then got out of bed, pushed the wheelchair-bound resident across the room, struck the back of his head, and followed him into the hallway while forcefully shaking his wheelchair. A CNA, familiar with the aggressive resident’s prior behavior, witnessed the shaking and noted the victim appeared scared and the aggressor appeared angry. Despite an existing care plan addressing the aggressor’s prior physical incidents and a facility abuse policy requiring assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, the assault still occurred.
Licensed nurses did not revise the care plan for a resident with Wernicke's Encephalopathy and intact cognition despite multiple documented resident-to-resident physical altercations, including incidents reported by roommates and other residents. SBAR notes described several episodes where the resident struck or made physical contact with others, yet the care plan was not updated to reflect involvement in at least one of these altercations or to add new interventions. The DON acknowledged the resident’s history of physical and verbal abuse and confirmed the omission, which was inconsistent with the facility’s Abuse, Neglect and Exploitation policy requiring care plan revision when needs change after an incident of abuse.
Rust-Corroded Walk-In Refrigerator Shelves: Multiple shelves inside the walk-in refrigerator were observed with dark brown and rust-colored markings during a kitchen tour. The DM later confirmed the shelves were very rusty, needed replacement, and could not be sanitized. The facility P&P for sanitation stated that all shelves shall be free from corrosions.
Resident Meal Tickets Discarded in Regular Trash: A Dietary Aide was observed in the kitchen dishwashing area sorting tray contents and throwing residents' meal tickets into the regular trash with food scraps. The meal tickets visibly displayed resident names, room numbers, diet orders, allergies, and food likes and dislikes, and the DM and DON confirmed this information was resident health information that should not have been discarded in the regular trash.
Inaccurate PASARR Assessments for Residents With Serious Mental Illness: The facility failed to ensure PASARR Level 1 assessments accurately reflected the diagnoses of four residents. Records showed that residents with major depression, anxiety disorder, PTSD, depression, and schizophrenia had PASARRs that did not list those serious mental illness diagnoses, and one resident with schizophrenia was not referred for a PASARR Level II. The MDSC and DON acknowledged the assessments were incorrect.
Baseline care plans were not completed within 48 hours of admission for four residents. A resident admitted with depression, anxiety, and PTSD had no evidence of timely BCP completion, another resident with the same diagnoses also lacked timely completion, a resident with depression and schizophrenia had no timely BCP, and a resident with HTN and AKI had a BCP completed late. The MDSC and DON both verified the facility policy required completion within 48 hours.
Failure to notify the physician of a significant change in condition: A resident with Alzheimer's disease developed increased confusion, urinary frequency, and painful urination consistent with a UTI. Nursing staff monitored the resident, but there was no documentation that the MD was notified within 24 hours. The RP later took the resident to the hospital, where she was admitted with a UTI, and the DON acknowledged the lack of documented physician notification.
The facility failed to provide a clean, comfortable, and homelike environment for three residents. One resident’s ceiling had an unfinished leak repair with a large patch and fresh plaster, while two other residents’ rooms had dirty, deteriorated walls with curling paint, large flakes of peeling paint, and deep cracks exposing plaster. An MS said the ceiling issue had been present for about a year, an LPN said the wall conditions did not present a homelike environment, and the DON agreed the peeling paint, dirt, gashes, and unfinished repairs were not homelike.
Failure to Report Alleged Misappropriation of Resident Property: A resident reported that his wallet and bank cards were missing and that his card had been used for about $6,000 in unauthorized purchases. The SSD documented the complaint, and the admin, DON, MDSC, and an LN all acknowledged the allegation was financial abuse/misappropriation that should have been reported to the state licensing agency and Ombudsman within 2 hours, but it was not.
Bordered dressing was applied to a resident’s DTIs without a physician order. An LN stated she had used the bordered dressings on the resident’s wounds in the past and on the observed date, and the resident said staff had been placing the dressings on her legs and buttocks for a while. The MDSC verified there were no prior orders for the bordered dressing, and the DON confirmed a physician order was required before using it.
Two residents who needed staff assistance with personal hygiene were observed with long fingernails and brownish material underneath while eating lunch. One resident with hemiplegia and muscle weakness and another resident with TBI were both dependent on staff for nail care, and the DSD and DON verified the fingernails were not kept short and clean as expected.
A resident with dementia had a bed cane ordered as an enabler for bed mobility, but the facility did not complete entrapment evaluations during repeated bed rail reviews and did not have the initial informed consent in the EHR. Staff stated consent was not obtained because the device was viewed as different from a bed rail, even though the device had visible risk-for-entrapment warnings. The bed cane was also observed to be installed incorrectly, and the MS and DON both agreed it was not set up per instructions.
Controlled Medication Not Documented on MAR: A resident’s Oxycodone 5 mg PRN dose was signed out in the narcotic log by an LPN, but the MAR did not show the medication was administered. LN verified the omission, and the DON stated controlled meds should be documented in both the narcotic log and the MAR after administration. Facility policy required immediate MAR documentation, including date, time, medication, and dose.
Failure to Provide Timely Dental Follow-Up: A resident with dementia had broken teeth, mouth pain, and weight loss while on a mechanical soft diet. The SSD and DON confirmed a dental referral had been made but there was no documented appointment or informative treatment plan, and the resident reported difficulty eating because of the pain.
Improperly Labeled and Expired Food in Resident Refrigerator: The facility failed to maintain the resident food refrigerator when an open pack of string cheese was found with incomplete labeling and an expired use-by date, and a container of ice cream was labeled only with a month and year. The DON stated items in the refrigerator should be properly labeled with dates and ownership, and expired foods should be removed. The facility policy required food brought by family or visitors to be labeled, stored in a distinguishable manner, and discarded on or before the use-by date.
A resident with Schizophrenia and Depression had smoking safety failures when the admission smoking evaluation was not completed on admission, quarterly smoking assessments were not done, and a pack of cigarettes was found tucked under the bed. The care plan and smoking-safety screen indicated the activity department was to store the resident's cigarettes and lighter, and the DON and DSD verified the cigarettes were not supposed to be kept in the room.
Licensed nurses did not remove an old scopolamine transdermal patch before applying a new one, resulting in a resident having two patches in place at the same time. This was contrary to physician orders and manufacturer instructions, as confirmed by staff interviews and facility policy.
A resident with a history of physical aggression and on multiple psychotropic medications engaged in a verbal argument with another resident, which escalated to physical abuse when one resident punched the other in the eye, causing a bruise. The injured resident, who had mild cognitive impairment and chronic health conditions, experienced pain and emotional distress as a result of the altercation. Staff documented the incident and involved law enforcement.
A resident with a Foley catheter had their drainage bag observed touching the floor, and staff handled the catheter without wearing a gown as required by Enhanced Barrier Precautions (EBP). Both staff and nursing leadership confirmed these actions were not in line with facility policy or CDC guidelines, which require catheter bags to be kept off the floor and the use of gloves and gowns during high-contact care activities.
A resident's call light was found tangled and out of reach, preventing the resident from requesting assistance when needed. Staff and nursing leadership confirmed that the call light should have been clipped to the resident's clothing or pillowcase, in accordance with facility policy, but this was not done.
A facility failed to suspend a CNA after allegations of physical and sexual abuse were made, allowing the CNA to return to work before the abuse investigation was completed. A resident, who was cognitively intact, reported feeling unsafe and observed the CNA in the facility during the ongoing investigation, despite facility policy requiring suspension of staff involved in abuse allegations.
A resident with significant mobility and incontinence issues developed open areas on the coccyx and left buttocks, which were documented by a CNA and reported to nursing staff. Despite facility policy requiring licensed nurse assessment and documentation for new skin issues, no nursing assessment was entered into the medical record, and only treatment orders for barrier cream and a low-air loss mattress were documented.
A resident with COPD and lung cancer experienced severe respiratory distress and hypoxia, during which nursing staff failed to perform required assessments, did not administer oxygen or Albuterol as ordered, delayed contacting the physician and emergency services, and did not document interventions or oxygen saturation levels. These failures resulted in the resident being transferred to the hospital in critical condition and requiring intensive care.
The facility failed to maintain a sanitary and safe environment, with all 21 residents' bathrooms in disrepair, including uneven surfaces and mold-like substances. A resident's privacy curtain was found unsanitary, and water temperatures in five rooms were below required levels. Residents expressed dissatisfaction, and maintenance issues were not addressed, violating residents' rights to a safe, clean, and comfortable environment.
A facility's abuse prevention program failed to protect residents, as seen in the case of a resident involved in an altercation who felt unsafe and wanted to transfer. The Social Services Director did not follow up on the transfer request, and the QAPI program did not analyze abuse reports. The facility also lacked a policy to prevent retaliation against those reporting abuse, with the Administrator dismissing the possibility of resident retaliation.
The facility failed to ensure competency in medication administration for five nurses, resulting in a 24% medication error rate. Observations revealed errors during administration to six residents. The DON stated that competency evaluations were conducted upon hire, but the Pharmacist, who was supposed to conduct audits, stated it was not his responsibility. The facility's policies required competency evaluations and performance reviews, but these were not effectively implemented.
A LTC facility experienced a 24% medication error rate due to multiple incidents involving incorrect medication administration. Errors included insufficient water with potassium, failure to instruct a resident to remain upright after potassium-phosphate, double dosing of cholecalciferol, incorrect preparation of polyethylene glycol, and insulin administration errors. These incidents reflect a failure to adhere to physician orders and manufacturer guidelines.
The facility's QAPI committee failed to maintain documentation and evidence of sustaining the QAPI program during leadership transitions, resulting in a 24% medication error rate. Medication administration audits by the Pharmacist were not completed as planned, and there was confusion about responsibility for these audits. The Administrator, who started in June 2024, was unaware of the audits, and the facility could not provide documentation of audits from February to December 2024.
The facility's QAPI program failed to identify and address systemic deficiencies in areas such as nursing medication administration, infection control, and abuse program. Despite having a policy for comprehensive quality improvement, the facility did not conduct or evaluate necessary Performance Improvement Projects (PIPs), as confirmed by the Administrator. This lack of oversight potentially affected the safety and quality of care for 94 residents.
A long-term care facility failed to implement adequate infection prevention and control measures, including not conducting monthly Legionella water testing, outdated policies, improper storage of toilet plungers and urinals, and staff not adhering to Enhanced Barrier Precautions and other transmission-based precautions. These deficiencies increased the risk of cross-contamination and infection spread among residents and staff.
The facility failed to provide adequate procedures for reporting abuse and training for several staff members, including a Social Services Director, RN, LVN, and CNAs. A resident reported verbal abuse, but no action was taken. Staff interviews revealed a lack of understanding of immediate reporting requirements, and record reviews showed incorrect answers on abuse training post-tests. Some files lacked post-tests, and there was no tracking system for staff struggling with training information.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS incorrectly indicated discharge to a hospital instead of home, while another resident's significant weight loss was not accurately reflected. These inaccuracies were confirmed through interviews and record reviews, highlighting the importance of precise MDS coding for effective care planning.
The facility failed to properly store and label medications, including leaving treatment and medication carts unlocked and unattended, and not dating insulin pens for two residents. A yellow tablet was found on the floor, and insulin pens lacked opened dates, risking expired medication use. Staff acknowledged these lapses, which violate facility policies.
A facility failed to monitor the effective use of Amoxicillin-Pot Clavulanate for a resident with a UTI. The resident was prescribed the antibiotic for 14 days, but there was no documentation of monitoring by the antibiotic stewardship program for two months. The Infection Preventionist confirmed the lack of monitoring, which should have been done monthly according to the facility's policy.
The facility failed to provide adequate living space for residents in 24 rooms, each housing three residents. Resident 54, who used a walker, was in a room where Bed C's space was only 74.75 square feet, below the required 80 square feet. This issue affected 23 residents, and the facility lacked a policy to ensure adequate space.
The facility failed to provide essential information in the preferred languages of two residents, resulting in them being uninformed about menu options, activities, and translation services. A resident who spoke only Spanish and another who spoke only Mandarin had important documents posted in English, contrary to the facility's language access policy. Staff interviews confirmed the absence of translated materials, highlighting a deficiency in ensuring residents were fully informed about their care.
A resident with hemiplegia and aphasia was unable to reach the call light, preventing them from contacting staff for assistance. The resident was observed in a geriatric chair without access to the call light, which was on the floor. Interviews confirmed the resident's non-verbal status and need for maximum assistance, and the DON acknowledged the call light should have been within reach.
A facility failed to inform a resident or their legal representative about Advance Directives, as required by policy. The resident, with moderate cognitive impairment, was admitted with multiple diagnoses, including hypertension. The facility's policy mandates that residents be informed about Advance Directives upon admission, but there was no evidence that this was done for the resident, and the required acknowledgment form was not signed.
The facility failed to screen and follow up on an RN with a disciplinary action for neglect, as required by their policy. The RN had a conviction for child endangerment, but the facility did not investigate or address the issue, potentially compromising safety.
The facility failed to notify the Office of the State Long-Term Care Ombudsman about the transfers of two residents to a General Acute Care Hospital. One resident was transferred due to a high temperature and irregular heart rate, while another was transferred for osteomyelitis. The facility's policy requires that a copy of the transfer notice be sent to the Ombudsman, but this was not done.
A facility failed to identify a mental illness in a resident and did not refer her for a Level II PASRR screening, resulting in her not receiving necessary mental health services. The resident had active diagnoses of anxiety disorder and PTSD, which were not reflected in the PASRR conditions. Despite severe depression and thoughts of self-harm, the Social Services Director did not arrange the required PASRR evaluation, contrary to the facility's policy.
A resident with a brain tumor was at risk of falls due to agitation and movement in bed. Despite a care plan requiring a fall mat at the bedside, observations revealed its absence. Staff interviews confirmed the mat was not consistently used, potentially due to cleaning. The facility's policy required interventions based on specific risks, which were not followed.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall resulting in a skin tear. The facility failed to update the resident's care plan with new interventions post-fall, as required by policy, placing the resident's health and safety at risk. Interviews with an LVN and the DON confirmed the oversight.
An LVN failed to follow professional standards by preparing medications for two residents simultaneously and not observing them ingest the medications. The LVN placed the medicine cups on the residents' bedside tables without ensuring they took the medications, contrary to the facility's policy requiring observation during administration.
A resident with diabetic retinopathy was without eyeglasses for over two weeks, affecting his ability to enjoy crossword puzzles. The Social Services Director failed to document or follow up on the resident's request for new eyeglasses, and the facility lacked a policy to ensure residents received necessary assistive devices.
A facility failed to ensure timely physician visits for a resident with multiple health conditions, including a brain tumor and diabetes. The Medical Director was unaware of the specific visit requirements and did not document all visits. A review revealed no documented visits for 58 days, contrary to the facility's policy requiring visits every thirty days.
A resident with depression, anxiety, and PTSD was not provided with necessary mental health services despite expressing a need for counseling and having a recommendation for psychological evaluation. The resident remained isolated and in bed most of the day, and staff interviews confirmed the lack of mental health support, contrary to the facility's policy.
A facility failed to follow up on a transfer request for a resident who felt unsafe after an altercation, did not properly screen another resident for PASARR despite mental health diagnoses, and did not provide necessary mental health services. The Social Services Director did not follow up on the transfer or refer the resident for PASARR clarification, and the resident did not receive counseling despite expressing a need for it.
A facility failed to conduct Monthly Medication Reviews (MMR) for a resident with Lewy body dementia and major depressive disorder, potentially leading to unnecessary medication use. The pharmacist acknowledged the responsibility to perform MMRs and communicate findings to the DON, but records showed missing reviews for two months. The facility's policy mandates monthly reviews and documentation within 72 hours.
A facility failed to attempt a Gradual Dose Reduction (GDR) for a resident on psychotropic medications, despite the absence of documented behaviors necessitating such medications. The resident, with Lewy body dementia and major depressive disorder, showed no aggressive behaviors over 9 1/2 months. Recommendations to reduce or discontinue medications were not followed by the Medical Director, contrary to facility policy requiring GDR attempts within the first year of admission.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident struck another on the back of the head and forcefully shook the resident’s wheelchair. Resident 1, who had a history of cerebral infarction with left-sided hemiplegia and an intact BIMS score of 14/15, reported that while passing Resident 2’s bed in their shared three-bed room, Resident 2 attempted to punch him but missed. Resident 1 continued toward his own bed, at which point Resident 2 got out of bed, pushed Resident 1 in his wheelchair across the room toward the window by Resident 2’s bed, and hit him on the back of the head. Resident 1 then wheeled himself into the hallway, followed by Resident 2, who began forcefully shaking the back of Resident 1’s wheelchair. Certified Nursing Assistant 1, who was in the hallway, heard his name called urgently and observed Resident 2 forcefully shaking the back of Resident 1’s wheelchair. CNA 1 stated that Resident 1 appeared scared and Resident 2 appeared angry, and that he was familiar with Resident 2’s occasional aggression. Record review showed Resident 2 had a diagnosis of Wernicke’s Encephalopathy and an intact BIMS score of 13/15, and had prior documented resident-to-resident physical altercations on multiple dates, including incidents involving physical contact after becoming upset. Resident 2’s care plan identified involvement in a prior resident physical incident and included goals and interventions related to preventing further verbal or physical altercations. The facility’s Abuse, Neglect and Exploitation policy stated it would implement policies and procedures to prevent and prohibit all types of abuse, including identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with behaviors that might lead to conflict, yet Resident 2 was still able to physically assault Resident 1.
Failure to Revise Care Plan After Repeated Resident-to-Resident Altercations
Penalty
Summary
Licensed nurses failed to revise the comprehensive care plan for one resident after multiple resident-to-resident physical altercations. Resident 2 was admitted with Wernicke's Encephalopathy, a condition associated with severe thiamine deficiency and alcohol abuse. SBAR documentation showed a pattern of physical incidents involving Resident 2: on 6/10/25, Resident 2's hand made contact with another resident's face after becoming upset over cursing; on 10/2/25, staff heard yelling from Resident 2's room and the roommate reported a physical altercation; and on 3/21/26, another resident reported being hit on the right side of the head by Resident 2. A Minimum Data Set dated 2/19/26 documented a BIMS score of 13/15, indicating intact cognition for Resident 2. Despite this history of physical and verbal abuse, the care plan for Resident 2 was not revised to reflect involvement in the physical altercation that occurred on 10/2/25 or to add new interventions following additional incidents. In an interview, the DON acknowledged that Resident 2 had a history of physical and verbal abuse and confirmed that the care plan did not include the 10/2/25 altercation, stating that the care plan is supposed to reflect new interventions with every additional incident. The facility’s Abuse, Neglect and Exploitation policy, dated December 2022, stated that the facility would protect residents from physical and psychological harm during and after investigations, including revising the resident’s care plan if nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. This policy requirement was not followed for Resident 2.
Rust-Corroded Walk-In Refrigerator Shelves
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions and in accordance with professional standards when multiple shelves inside the walk-in refrigerator were observed with dark brown and rust-colored markings. During the initial kitchen tour, these shelf surfaces were noted to be discolored and deteriorated. On a later observation with the Dietary Manager, the same shelves were again observed, and the Dietary Manager described them as very rusty and needing replacement, while also acknowledging that the rusted surfaces could not be sanitized. The facility policy titled Sanitation stated that all shelves shall be free from corrosions.
Resident Meal Tickets Discarded in Regular Trash
Penalty
Summary
The facility failed to protect resident health information when meal tickets containing resident identifiers were discarded in the regular trash for a census of 92. During a concurrent observation and interview in the kitchen dishwashing area, a Dietary Aide was observed removing trays from soiled tray carts, sorting the tray contents, and throwing residents' meal tickets into the garbage can with food scraps. An observation of the garbage can showed 4 meal tickets in the trash, and the Dietary Aide stated the meal tickets were thrown into the regular trash with food scraps. During interview, the Dietary Manager stated the meal tickets were thrown into the regular trash and agreed the tickets clearly displayed the resident's name, room number, diet order, allergies, and likes and dislikes. The DON stated any information with resident identifiers was not to be disposed of in the regular trash and confirmed the meal tickets contained resident health information, including the resident's name, room number, diet order and texture, food likes and dislikes, and food allergies. Review of the facility policy titled Confidentiality of Information and Personal Privacy indicated the facility would protect and safeguard resident confidentiality and personal privacy and safeguard the personal privacy and confidentiality of all resident personal and medical records.
Inaccurate PASARR Assessments for Residents With Serious Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of PASARR Level 1 assessments for four sampled residents. Resident 58’s face sheet listed major depression, anxiety disorder, and PTSD, but the PASARR dated 10/23/2024 did not include those diagnoses. Resident 5’s face sheet listed major depression, anxiety disorder, and PTSD, but the PASARR dated 12/19/25 did not include those diagnoses. Resident 72’s face sheet listed depression and schizophrenia, but the PASARR dated 9/20/24 did not include those diagnoses. Resident 55’s admission record listed schizophrenia, but the PASARR dated 9/17/25 indicated he did not have a serious mental illness and was not referred for a PASARR Level II. During interviews and record review, the MDS Coordinator verified that Residents 58, 5, and 72’s PASARRs were inaccurate because they did not accurately capture the residents’ diagnoses of serious mental illness. The MDS Coordinator also agreed that Resident 55’s PASARR was incorrect and stated he should have been flagged for a PASARR Level II. The DON stated PASARR screenings should be reviewed for accuracy, corrected if an error is found, and a referral for a PASARR Level II screening if necessary. The facility policy stated it coordinates assessments with the PASARR program under Medicaid to ensure the most suitable setting for individuals with qualifying conditions.
Baseline care plans were not completed within 48 hours of admission
Penalty
Summary
The facility failed to ensure baseline care plans were completed within 48 hours of admission for four sampled residents. Resident 58 was admitted on 1/31/25 with diagnoses of major depression, anxiety disorder, and PTSD, and the baseline care plan did not indicate it was completed within 48 hours of admission. Resident 5 was admitted in 3/2025 with diagnoses of major depression, anxiety disorder, and PTSD, and the baseline care plan also did not indicate timely completion. Resident 72 was admitted in 9/2024 with diagnoses of depression and schizophrenia, and the baseline care plan did not indicate it was completed within 48 hours of admission. Resident 106 was admitted on 12/19/25 with diagnoses of HTN and AKI, and the baseline care plan was completed on 12/22/25. During a concurrent interview and record review on 01/09/2026, the MDS coordinator verified that Resident 106's baseline care plan was late and that the plans for Residents 5, 58, and 72 did not indicate completion within 48 hours of admission. The MDS coordinator stated the facility policy was to complete the baseline care plan within 48 hours of admission. The DON also stated baseline care plans were expected to be completed within 48 hours per facility policy and acknowledged the deficient practice.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician within 24 hours of a significant change in condition for one resident who had ongoing confusion, urinary frequency, and painful urination consistent with a UTI. Resident 33 had a history of Alzheimer's disease and was documented as having increased confusion for 2 days, more frequent urination, and increased need for assistance with ADLs. Nursing staff monitored the resident's confusion and urinary symptoms, but there was no documentation that the physician was notified at the time the change was identified. The resident's progress note documented monitoring for increased confusion, frequent urination, and painful urination, but did not show physician notification. The resident's care plan directed staff to monitor, document, and report changes in cognitive function. During interviews, the licensed nurse stated she notified the primary physician by text message, but could not produce documentation showing the physician was notified before the documented change. The resident's responsible party later reported finding the resident improperly dressed and with a wet bed, then taking her to the hospital where she was admitted with a UTI. The DON stated he expected staff to notify the physician when a change in condition occurred and acknowledged there was no documentation that the physician was notified or responded.
Homelike Environment Deficiencies
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three sampled residents. In one resident’s room, the ceiling had an unfinished repair with a large rectangular beige patch and several areas of fresh, unsanded white plaster. The resident stated the repair was due to a leak in the ceiling, and the Maintenance Supervisor said he did not know when the repair had been completed and that the issue had been present since he started working at the facility about one year earlier. In two other residents’ rooms, the walls next to the beds were observed to be dirty and deteriorated, with food debris, curling and falling paint in large flakes, and deep vertical cracks exposing peeling paint and plaster. A nurse stated the walls were in need of repair due to chipping paint and that the condition did not present a homelike environment. The DON agreed that peeling paint, dirt, gashes on the walls, and unfinished repairs do not present a homelike environment, and stated repairs should not take as long as a year to be completed. The facility policy stated residents are provided with a clean and homelike environment.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that an allegation of misappropriation of property for Resident 106 was reported to the state licensing agency and the Ombudsman within 2 hours. Resident 106’s face sheet showed an admission date in 12/2025, and the inventory of personal effects dated 12/19/25 listed a black wallet. A promissory note dated 12/23/25, signed by Resident 106 and the SSD, indicated the resident had 3 bank cards. On 1/7/26 at 12:51 p.m., a Social Services note documented that Resident 106 reported someone had taken his money and that his wallet was missing. During an interview on 1/7/26 at 3:36 p.m., Resident 106 stated he had his wallet in his room and that his wallet and bank cards were missing after his bank alerted him to about $6,000 in unauthorized purchases since 1/4/26. He stated he reported the incident to the SSD before lunch on 1/7/26. On 1/8/26, the administrator, DON, MDSC, SSD, and an LN all acknowledged the allegation involved missing property and unauthorized card use and that it should have been reported to the state licensing agency and the Ombudsman within 2 hours, but it was not. The facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 9/2022, stated suspected misappropriation must be reported immediately to the admin and to the state licensing/certification agency and state ombudsman, with immediately defined as within 2 hours of any allegation involving abuse or serious bodily injury.
Bordered Dressing Applied to DTIs Without Physician Order
Penalty
Summary
The facility failed to deliver professional standards of quality for one sampled resident with two deep tissue injuries on the posterior legs. A review of the resident’s MDS dated 11/26/25 showed the resident had two DTIs. The resident’s POS active orders as of 1/9/26 included an order that the resident may self-apply bordered dressing as needed per the patient’s request for preventative treatment for wound care management, with a start date of 1/7/26. The resident’s ETAR for 1/2026 did not show an order to apply bordered dressing for treatment. During a concurrent observation and interview on 01/07/2026, an LN was observed with two bordered dressings and stated she had used the bordered dressings to treat the resident’s DTIs both in the past and on that date. The LN confirmed a physician order was required to use the bordered dressing on the resident’s DTIs and acknowledged there was no such order. The resident stated staff had been placing bordered dressings on the DTIs on her legs and buttocks for a while and that 1/7/26 was not the first time. The MDSC reviewed the POS and verified the bordered dressing order was provided on 1/7/26 and there were no previous orders to apply bordered dressing in the past. The MDSC and DON both stated a physician’s order was needed prior to using bordered dressing, and the facility policy stated medications are administered in accordance with written orders of the attending physician.
Residents Had Long Fingernails With Brownish Material Underneath
Penalty
Summary
The facility failed to ensure that two sampled residents received assistance with grooming and nail care when their fingernails were long and had brownish material underneath. Resident 37 was admitted in 4/2025 with diagnoses of hemiplegia and muscle weakness, and the MDS dated 10/29/25 indicated the resident needed moderate assistance from staff for personal hygiene tasks. Resident 80 was admitted in 1/2019 with a diagnosis of traumatic brain injury, and the MDS dated 11/30/25 indicated the resident needed maximum assistance from staff for personal hygiene tasks. During a concurrent observation and interview on 01/06/26, Resident 80 was observed eating lunch with long fingernails and brownish material underneath them, and the resident stated there was dirt under the fingernails and that they were long because no one would cut them. At the same time, Resident 37 was observed eating lunch with long fingernails and brownish material underneath. The DSD later verified that both residents' fingernails were long and had brownish material underneath and stated this was not acceptable because the residents were dependent on staff to keep their nails short and clean. The DON also stated it was not acceptable for the residents to have long fingernails with brownish material underneath and stated the expectation was that fingernails would be kept short and clean.
Bed Cane Installed Without Entrapment Review, Consent, or Proper Setup
Penalty
Summary
The facility failed to ensure proper use of a bed cane for a resident admitted with unspecified dementia. The physician order dated 9/21/24 indicated a bed cane x 1 as an enabler to assist with bed mobility. Reviews of the resident’s bed rail evaluations dated 10/7/24, 4/7/25, 7/8/25, and 10/16/25 showed that entrapment evaluations had not been completed during any of those reviews, even though a bed cane was in use. The Minimum Data Set Coordinator stated entrapment assessments were completed by maintenance prior to installation of bed canes and bed rails, and the Director of Nursing stated maintenance kept records of those evaluations, but a copy of the resident’s entrapment evaluation was not provided. The facility also did not obtain informed consent before the bed cane was installed. The Minimum Data Set Coordinator stated informed consent should be obtained prior to installation and that the initial consent for the resident’s bed cane was not in the EHR. The Director of Nursing stated consent had been obtained prior to installation of a bed rail because of entrapment risk, but not prior to installation of the bed cane because it was considered different from a bed rail and there was not risk for entrapment. During observation, the bed cane was seen installed on the left side of the bed with three visible risk-for-entrapment warnings, and the safety strap was looped over and around the central frame bar repeatedly. The Maintenance Supervisor stated the straps should go across the bed frame and later agreed the bed cane was not installed properly. The facility policy stated bed rails include grab assist bars, must be installed according to manufacturer instructions, and require resident assessment and informed consent.
Controlled Medication Not Documented on MAR
Penalty
Summary
The facility failed to maintain accurate records of a controlled medication for one resident, Resident 24. Resident 24 had an order for Oxycodone 5 mg, one tablet by mouth every six hours as needed for severe pain. During a concurrent interview and record review, Resident 24’s Antibiotic or Controlled Drug Record showed that Oxycodone 5 mg was signed out by a nurse at 9:30 p.m., but the corresponding MAR for that date did not show that the medication was administered. Licensed Nurse 1 verified that the Oxycodone had been signed out in the narcotic log but was not entered on the MAR to show it had been given. LN 1 stated that controlled medications were expected to be documented on the resident’s MAR after administration, including the date and time. The DON stated that a narcotic given to a resident should be documented in both the narcotic log and the MAR, and that if a narcotic logged out was not documented in the MAR, there could be a potential issue with narcotic diversion. The facility policy required the person administering medication to record it on the MAR directly after it was given and to document PRN medications with the date, time, medication, and dose.
Failure to Provide Timely Dental Follow-Up
Penalty
Summary
The facility failed to ensure that one resident received timely and appropriate dental evaluation and treatment. Resident 6 was admitted with a diagnosis of dementia, and her MDS dated 9/26/25 indicated no memory impairment. Progress notes from 12/8/25 to 12/9/25 showed she was being monitored for unplanned weight loss, and her weight decreased from 109 lbs. on 8/4/25 to 101 lbs. on 12/8/25. A physician order dated 12/5/25 directed health shakes three times daily and monitoring of meal intake. During interview, Resident 6 stated she had mouth pain that affected her ability to eat, did not like her mechanical soft diet, and wanted food with a more normal texture. She rated her mouth pain as 5/10 and, during observation, pointed to her right lower jaw; she had only five remaining teeth in the front lower jaw. The SSD acknowledged the resident needed to see a dentist and stated that dental treatment would likely help her eat more, gain weight, and have more energy. Review of the resident’s dental notes showed the SSD had reviewed them and found they were not informative regarding any plan to improve oral health. The SSD confirmed that a referral to a local dentist had been made on 2/13/25, but there was no documentation that an appointment had been made. The DON stated he expected timely follow-up for outside services and confirmed there had not been timely follow-up and that treatment appointments had not been made as expected. The facility’s Dental Services Policy stated Social Services would assist residents in making dental appointments.
Improperly Labeled and Expired Food in Resident Refrigerator
Penalty
Summary
The facility failed to properly maintain the residents' food refrigerator for a census of 92 when an open pack of string cheese was found with five pieces remaining, labeled with the resident's room and bed number and a date in 9/30/25, while the cheese itself had an expiration date of 12/26/25. The resident refrigerator's freezer also contained one quart of cookie butter ice cream labeled only with a date in 11/25. During interview, the DON stated he expected items placed in the resident refrigerator to be labeled properly with dates and who the items belonged to, and that foods should be removed when expired. The facility policy titled, Food Brought by Family/Visitors, stated items left for the resident to consume later will be labeled and stored in a distinguishable manner and nursing staff will discard foods on or before the use by date.
Smoking safety assessment and storage failures
Penalty
Summary
The facility failed to ensure smoking safety was practiced for one of four sampled residents who smoked. Resident 72 was admitted with diagnoses of Schizophrenia and Depression. The resident's chart included a care plan titled "Resident 72 is a smoker," dated 2/14/25, which indicated the resident's smoking supplies were to be stored at the activity department. A Smoking-Safety Screen assessment dated 1/6/25 indicated the facility was to store Resident 72's lighter and cigarettes, and the facility policy stated residents were to be evaluated on admission to determine smoking status and that smoking ability was to be evaluated quarterly. The Minimum Data Set coordinator verified the Smoking-Safety Screen assessment should have been completed upon admission, but it was not completed until 1/6/25, and no other smoking assessments were completed after that one. During an observation on 01/07/2026 at 10:13 a.m., Resident 72 had a pack of cigarettes tucked underneath the right side of the bed. The Director of Staff Development verified the cigarettes were in the room and stated the resident was not supposed to keep cigarettes there for safety purposes. The DON also verified the resident was not supposed to keep cigarettes in the room and that the activity department was to keep them, consistent with the care plan.
Failure to Remove Old Transdermal Patch Before Applying New Patch
Penalty
Summary
Licensed nurses failed to follow physician orders for a resident who was prescribed a scopolamine transdermal patch to be applied every three days for secretion control. During observation, the resident was found to have two identical scopolamine patches in place—one near each ear—despite the physician's order and manufacturer instructions specifying that only one patch should be worn at any time. The patch near the right ear was dated two days prior, while the writing on the patch near the left ear was smudged and unreadable. Interviews with nursing staff confirmed that the resident was not supposed to have two patches applied simultaneously, and the Director of Nursing acknowledged that the physician's orders were not followed. Facility policy also required medications to be administered according to written physician orders. The failure to remove the old patch before applying a new one resulted in the resident wearing two patches at once, contrary to both medical orders and manufacturer guidelines.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident punched him in the eye, resulting in a bruise. Resident 2, who had a history of angry outbursts and physical aggression and was prescribed multiple psychotropic medications, engaged in a verbal argument with Resident 1 after being asked to turn off the light. The argument escalated, and Resident 2 physically struck Resident 1. Documentation and interviews confirmed that Resident 1 sustained a bruise under the left eye as a result of the altercation. Resident 1, who had a history of alcoholic cirrhosis and type 2 diabetes with mild cognitive impairment, reported tolerable pain and emotional distress following the incident. Staff observed the injury and offered medical assistance, which was declined by the resident. The incident was witnessed by staff, and the police were involved, resulting in Resident 2 being removed from the facility. The facility's policy states that each resident has the right to be free from abuse, but this right was not upheld in this instance.
Failure to Maintain Infection Control with Foley Catheter Care
Penalty
Summary
The facility failed to maintain a sanitary environment and adhere to infection prevention protocols for one resident with a Foley catheter. During an observation, a staff member was seen allowing the resident's Foley catheter drainage bag to touch the floor. The staff member acknowledged that the drainage bag should not be on the floor due to infection control concerns, a sentiment echoed by both a licensed nurse and the Director of Nursing, who confirmed that such practice increases the risk of infection. Review of the facility's policy also indicated that catheter tubing and drainage bags must be kept off the floor. Additionally, staff did not follow Enhanced Barrier Precautions (EBP) when handling the resident's Foley catheter. Despite signage indicating the resident was on EBP, a staff member handled the catheter drainage bag without wearing a gown, contrary to CDC guidelines and facility policy. Both the staff member and licensed nurse confirmed that gloves and gowns are required for such care activities to prevent cross-contamination. The Director of Nursing verified that the facility follows CDC EBP guidelines, which mandate the use of gloves and gowns during high-contact care activities involving urinary catheters.
Call Light Not Accessible to Resident
Penalty
Summary
A deficiency was identified when a resident's call light was found tangled with a red string by the wall, near the foot of the bed, and not within the resident's reach. During observation and interview, the resident confirmed that the call light was too far away to be used when assistance was needed. Unlicensed staff verified the call light's position and acknowledged that it should have been clipped to the resident's clothing or pillowcase to ensure accessibility, as per facility policy. Further interviews with a licensed nurse and the Director of Nursing confirmed that the facility's policy requires call lights to be within reach of residents at all times. Review of the facility's policy and procedure also indicated that call lights must be placed within reach. The deficiency was based on direct observation, staff interviews, and review of facility policy, all confirming that the call light was not accessible to the resident as required.
Failure to Suspend CNA During Abuse Investigation
Penalty
Summary
The facility failed to follow its abuse policy by allowing a Certified Nursing Assistant (CNA) to return to work after allegations of physical and sexual abuse were made against him, before the completion of the facility's abuse investigation. The administrator initially stated that the CNA was suspended immediately after the allegations were reported, but time records showed that the CNA worked over the weekend while the investigation was still ongoing. The facility's policy requires suspension of staff involved in abuse allegations pending the outcome of the investigation to protect residents from harm or retaliation. A resident, who was cognitively intact according to her BIMS score, reported that the CNA had pushed her and had been on top of her roommate in bed, and expressed feeling unsafe if the CNA returned to work. The social worker confirmed that the resident had made multiple allegations, including physical and sexual abuse, and that the CNA was supposed to be suspended. Despite this, the CNA was observed by the resident in the facility during the investigation period, and time records confirmed the CNA worked shifts before the investigation was completed.
Failure to Document Nursing Assessment After Skin Changes
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including syncope, muscle weakness, gait abnormalities, bilateral knee replacements, and schizophrenia, did not receive nursing assessments related to changes in skin integrity documented in the medical record. The resident was at risk for pressure ulcers, required substantial assistance for mobility and transfers, was always incontinent, and used a wheelchair independently. Orders were received for a low-air loss mattress and barrier cream due to observed redness and open areas on the resident's coccyx and left buttocks, as noted on a shower sheet completed by a CNA and a nurse. Despite the CNA documenting the presence of two open areas on the resident's body map and reporting these findings, there was no corresponding nursing assessment or documentation in the resident's medical record regarding these skin changes. Interviews with staff confirmed that while the CNA reported the findings to the treatment nurse, and the DON expected a change in condition form and further assessment, no such documentation or assessment was completed. The only documentation present was related to the application of barrier cream and dressing, not a full nursing assessment of the wounds. Facility policies required licensed nurses to conduct and document pressure injury risk assessments and full skin assessments whenever a resident's condition changed or a new skin issue was identified. The lack of documentation and assessment by licensed nursing staff following the identification of new open areas on the resident's skin constituted a failure to meet professional standards of quality care, as required by facility policy and procedure.
Failure to Provide Care Consistent with Professional Standards During Respiratory Emergency
Penalty
Summary
A resident with a history of COPD and metastatic lung cancer experienced a medical emergency involving severe respiratory distress and critical hypoxia. During this event, licensed nursing staff failed to perform a physical assessment by not listening to the resident's lung sounds or assessing for the use of accessory muscles. The staff did not administer oxygen appropriately, attempting to decrease the oxygen flow despite the resident's low oxygen saturation levels, and failed to provide Albuterol as ordered by the physician. Additionally, the staff did not document the resident's oxygen saturation levels throughout the emergency, nor did they ensure prompt transfer to the hospital, with a delay of approximately 50 minutes from the discovery of the resident's critical condition to contacting emergency services. The nursing staff also did not immediately notify the resident's physician upon discovering the critical condition, with documentation showing a delay of about 50 minutes before the physician was contacted. There was a lack of documentation regarding the nursing interventions implemented during the emergency. The facility's policies and job descriptions required timely assessment, intervention, and documentation, including monitoring and reporting changes in condition, administering medications as ordered, and documenting all care and resident responses. These requirements were not met during the incident. Interviews with facility staff, the DON, and the resident's physician confirmed that the actions taken were inconsistent with professional standards of nursing care and the resident's individualized care plan. The resident was ultimately transferred to the hospital in critical condition, where she required intensive interventions, including intubation and ICU admission. The failure to follow established protocols and provide care consistent with professional standards directly contributed to the severity of the resident's condition during the emergency.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a sanitary, safe, and comfortable environment for its residents, as evidenced by the disrepair of all 21 residents' bathrooms. Observations revealed multiple issues, including uneven surfaces, large cracks, and grimy substances on the bathroom floors, which residents described as mold-like. Residents expressed dissatisfaction with the cleanliness and safety of the bathrooms, with some resorting to using personal disinfectants and towels to avoid direct contact with the floors. The Housekeeping Manager acknowledged the presence of mold-like substances that could not be removed despite deep cleaning efforts, and it was noted that previous maintenance reports were not addressed by the former Director of Maintenance. In addition to the bathroom conditions, Resident 54's privacy curtain was found to be unsanitary, with a dark brown substance smeared on it, resembling feces. The Licensed Vocational Nurse confirmed the curtain's dirty condition and mentioned that maintenance only replaced curtains upon request, which had not been made in this instance. This lack of proactive maintenance contributed to the unsanitary environment. Furthermore, the facility failed to maintain comfortable water temperatures in the bathrooms of five residents' rooms. Observations and interviews revealed that the water temperatures were significantly below the required levels, with showers being described as cold. The Maintenance staff confirmed the inadequacy of the water temperatures and admitted the absence of temperature logs, indicating a lack of regular monitoring and maintenance of water temperature controls. These deficiencies collectively violated the residents' rights to a safe, clean, and comfortable living environment.
Failure in Abuse Prevention and Resident Safety
Penalty
Summary
The facility's abuse prevention program failed to protect residents in several instances. Resident 54 was involved in a resident-to-resident altercation and expressed a desire to transfer to another facility due to feeling unsafe. Despite this, the Social Services Director did not follow up on the transfer request after initial contact with other facilities, leaving Resident 54 feeling unsafe and depressed. The Director of Nursing acknowledged the importance of addressing residents' psychosocial needs, but no further action was taken to ensure Resident 54's safety and well-being. Additionally, the facility's Quality Assurance and Performance Improvement (QAPI) program did not review or analyze reports of abuse, contrary to the facility's policy. The Administrator, who also served as the abuse coordinator, failed to track trends in abuse allegations, stating it was not QAPI's responsibility. Furthermore, the facility lacked a policy to prevent retaliation against residents, families, or visitors who reported abuse, with the Administrator dismissing the possibility of such retaliation occurring against residents. These deficiencies compromised the safety and protection of residents, staff, and visitors.
Medication Administration Competency Deficiency
Penalty
Summary
The facility failed to ensure that five licensed nurses, including four Registered Nurses and one Licensed Vocational Nurse, were competent in medication administration. This deficiency was identified through observations, interviews, and record reviews, revealing a medication error rate of 24%. The errors were observed during medication administration to six residents, indicating a significant lapse in the nurses' ability to administer medications correctly. The Director of Nursing stated that competency evaluations were conducted upon hire and during medication administration audits, which were supposed to be completed by the Pharmacist. However, the Pharmacist clarified that conducting medication administration audits was not part of his responsibilities. The facility's job descriptions for the involved nurses outlined their duties, including the preparation and administration of medications as ordered by physicians. The facility's assessment and policy indicated that competency evaluations were to be conducted upon hire and reviewed annually, with performance evaluations ensuring adherence to facility standards. Despite these protocols, the failure to conduct proper audits and ensure competency led to a high medication error rate, posing potential risks to the residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 24% error rate during the survey. This was observed when five licensed nurses made medication errors involving six different incidents. These errors included incorrect administration of medications, failure to follow physician orders, and not adhering to manufacturer guidelines. One of the errors involved a resident with chronic kidney disease who was administered potassium with insufficient water, contrary to the physician's order. Another resident with hypokalemia was not instructed to remain upright after receiving potassium-phosphate, as per the manufacturer's guidelines, and was later found lying down. Additionally, the same resident was given twice the prescribed dose of cholecalciferol. Further errors included the incorrect preparation of polyethylene glycol for a resident with metabolic encephalopathy, administering insulin after meals instead of before as ordered for a resident with diabetes, and an attempted administration of an incorrect insulin dose due to a documentation error. These incidents highlight the facility's failure to ensure medications were administered according to physician orders and manufacturer instructions.
Failure to Conduct Medication Administration Audits
Penalty
Summary
The facility's QAPI committee failed to maintain documentation and demonstrate evidence that the QAPI program was sustained during transitions in leadership. Specifically, there were no follow-ups for medication administration audits that were supposed to be conducted by the Pharmacy. This failure resulted in a medication error rate of 24%, including one significant error, which had the potential to result in severe adverse effects for all residents. The facility census was 94. During a review of the facility's QAPI Minutes from January to December 2024, it was noted that medication administration audits by the Pharmacist were planned to be completed monthly and reported to QAPI. However, the audits were not completed for February. Interviews with the Director of Nursing and the Pharmacist revealed a lack of clarity regarding responsibility for these audits. The Administrator, who started employment in June 2024, was unaware of the audits and declined to discuss issues identified by QAPI prior to his employment. The facility was unable to provide documentation that the audits were conducted from February to December 2024.
QAPI Program Fails to Address Systemic Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to identify, address, and evaluate several systemic quality deficiencies, including nursing medication administration competency, infection control, abuse program, incomplete resident records, and social services. These deficiencies were not recognized or addressed in the QAPI minutes from January to December 2024, indicating a lack of oversight and potential negative impact on resident safety and care quality. The facility census was 94, and the issues were confirmed by the Administrator during interviews, who acknowledged that no Performance Improvement Projects (PIPs) were conducted for the identified issues. Further review of the facility's QAPI agendas and minutes from June to October 2024 revealed that while some PIPs were initiated, such as for baseline care plans, handwashing, COVID vaccines, call lights, care conferences, and falls, there was no discussion or evaluation of these projects. The facility's QAPI policy and procedure outlined a comprehensive approach to identifying and addressing quality deficiencies, but the lack of implementation and evaluation of PIPs suggests a disconnect between policy and practice. The Administrator was also unaware of the existence of the Quality Assessment and Assurance Log, further highlighting the deficiencies in the facility's QAPI program.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement adequate infection prevention and control measures, as evidenced by several deficiencies observed during the survey. Firstly, the maintenance staff did not conduct monthly water testing for Legionella bacteria from January 2024 through January 2025, which is a critical component of the facility's Legionella Water Management Program. The facility's policies and procedures, which were last updated in 2001, were not revised annually as required, contributing to outdated practices. Additionally, toilet plungers were improperly stored on the floor next to toilets in multiple rooms, and urinals were found unlabeled and improperly placed, increasing the risk of cross-contamination. In another instance, a used urinal without a lid was observed on a resident's bedside table for approximately one hour, posing a potential infection control issue. The Certified Nursing Assistant (CNA) acknowledged the oversight and stated that the urinal should have been emptied, cleaned, and stored properly. The facility's policy on urinal management, last updated in 2018, was not adhered to, as the urinal was not placed in a bag within the resident's reach, nor was it removed from the bedside table. Furthermore, staff failed to follow Enhanced Barrier Precautions (EBP) and other transmission-based precautions for residents requiring such measures. A CNA did not wear a gown while providing perianal hygiene care to a resident on EBP, and an Occupational Therapist did not use PPE while providing care to a resident with a foley catheter. Additionally, a nurse did not wear a gown when entering a room with a resident on contact precautions, and a droplet precaution sign was missing for a resident with influenza. These lapses in following established protocols increased the risk of spreading infections within the facility.
Inadequate Abuse Reporting Procedures and Training
Penalty
Summary
The facility failed to provide adequate procedures for reporting incidents of abuse and training for seven staff members, including the Social Services Director, a Registered Nurse, a Licensed Vocational Nurse, and several Certified Nurse Assistants. This deficiency was identified through interviews and record reviews, revealing that staff members were unable to effectively identify the facility's procedure for reporting abuse incidents. A resident reported hearing verbal abuse directed at his roommate, but no action was taken after he reported the incident. Interviews with staff members indicated a lack of understanding of the immediate reporting requirements, with some staff stating they would report incidents to the Director of Nursing during the next shift rather than immediately. Record reviews showed that several staff members selected incorrect answers on abuse training post-tests, indicating a misunderstanding of the mandated reporting requirements according to California law. Some employee files were missing the abuse training post-test altogether, and the Director of Staff Development confirmed that there was no tracking system for staff struggling with the training information. The facility's policy and procedure on abuse prevention required staff orientation and training on reporting abuse, but the lack of effective training and understanding among staff members compromised the safety of residents, staff, and visitors.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Sets (MDS) for two residents, which could potentially affect their care. For Resident 391, the MDS inaccurately indicated that the resident was discharged to a Short-Term General Hospital, while records and interviews confirmed that the resident was actually discharged home. This discrepancy was identified during a review of the resident's discharge summary and nursing progress notes, which clearly stated the resident's discharge to home. The MDS Coordinator acknowledged the inaccuracy during an interview and record review. For Resident 25, the MDS inaccurately reflected the resident's significant weight loss. The resident experienced a 22.22% weight loss since admission, as confirmed by the Director of Nursing and the Registered Dietitian. However, the MDS was coded incorrectly, indicating no significant weight loss. This error was confirmed by the MDS Coordinator, who acknowledged the importance of accurate MDS coding as it triggers the resident's plan of care. The facility's policy and procedure on resident assessments emphasize the need for comprehensive and accurate assessments, which was not adhered to in these cases.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage and labeling protocols, leading to several deficiencies. In one instance, a yellow-colored tablet was found on the floor under a resident's bed, and the Licensed Vocational Nurse (LVN) present could not identify the medication. This indicates a lapse in ensuring medications are securely stored and accounted for, as per the facility's policy that mandates all medications be stored in locked compartments. Additionally, the facility was observed to have left treatment and medication carts unlocked and unattended on multiple occasions. One treatment cart was left unlocked near the nurses' station, and a medication cart was found unattended with an unidentified pill in the top drawer. Both LVN and Registered Nurse (RN) staff acknowledged these oversights, which contravene the facility's policy requiring carts to be locked when not in use to prevent unauthorized access. Furthermore, the facility failed to properly label insulin pens for two residents, as the pens were missing the date they were opened. This is critical because insulin pens are only viable for 28 days after opening, and without proper labeling, there is a risk of administering expired medication. The facility's policy clearly states that multi-dose vials should be dated when opened, highlighting a significant oversight in medication management for residents with diabetes.
Failure to Monitor Antibiotic Use for UTI Treatment
Penalty
Summary
The facility failed to ensure the effective monitoring of antibiotic use for a resident diagnosed with a urinary tract infection (UTI). The resident was prescribed Amoxicillin-Pot Clavulanate to be taken twice daily for 14 days. However, during a review of the facility's records, it was found that there was no documentation of antibiotic stewardship monitoring for the months of October and November 2024. The Infection Preventionist confirmed the absence of documentation and acknowledged that the monitoring should have been conducted monthly. The facility's policy on antibiotic stewardship, dated 2001, states that the purpose of the program is to monitor antibiotic use among residents.
Inadequate Living Space for Residents
Penalty
Summary
The facility failed to provide adequate living space for residents in 24 rooms, each housing three residents. This deficiency was identified through observations, interviews, and record reviews. Specifically, Resident 54, who used a walker, was residing in a room where Bed C's living space was significantly smaller than the spaces for Beds A and B. The living space for Bed C was measured at 74.75 square feet, which is below the required 80 square feet per resident in multiple occupancy rooms. This inadequate space was confirmed by both the Maintenance Director and the Administrator during their assessments. Further investigation revealed that all 24 rooms with a Bed C had individual living spaces below the required 80 square feet. The facility was unable to provide a policy or procedure that ensured adequate resident living space, indicating a systemic issue affecting 23 residents. The lack of sufficient space had the potential to compromise the safety of residents, particularly those requiring assistive devices like walkers, due to the limited maneuverability within their living quarters.
Failure to Provide Information in Residents' Preferred Languages
Penalty
Summary
The facility failed to provide essential information in the preferred languages of two residents, leading to a deficiency in ensuring that residents were fully informed about their health status, care, and treatments. Resident 342, who only spoke and read Spanish, had important documents such as the weekly menu, activity calendar, and instructions for accessing interpreter services posted in English. This oversight was confirmed through interviews with facility staff, including a registered nurse and a registered dietician, who acknowledged the absence of translated materials and the importance of providing information in residents' primary languages. The facility's policy on language access, which mandates meaningful access to information for individuals with limited English proficiency, was not adhered to in this case. Similarly, Resident 8, whose primary language was Mandarin, also had essential information posted in English only. Interviews with a licensed vocational nurse and a certified nurse assistant confirmed that Resident 8 spoke only Mandarin and had not received translated materials. The facility's assessment indicated the capability to accommodate language preferences, yet this was not reflected in practice. The failure to provide translated materials for these residents resulted in them being uninformed about menu options, activities, and how to obtain translation services, contrary to the facility's stated policies and procedures.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, resulting in the resident being unable to contact staff for assistance. The resident, who was admitted with diagnoses of hemiplegia following a cerebral infarction affecting the right dominant side, aphasia, and weakness, was observed in a geriatric chair in the middle of the room without access to a call light. The resident attempted to gain attention by throwing a pillowcase and waving, while grunting and pointing at the call light on the floor. Interviews and record reviews revealed that the resident was non-verbal and required maximum assistance for all activities of daily living. The Certified Nursing Assistant confirmed that the call light was not within the resident's reach. The Director of Nursing acknowledged that the call light should have been accessible to the resident at all times. The resident's care plans and the facility's policy emphasized the importance of having the call light within reach to ensure a safe environment, which was not adhered to in this instance.
Failure to Provide Advance Directive Information to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 83, or their legal representative was informed and provided with written information about Advance Directives (AD). This deficiency was identified during a review of Resident 83's records, which showed that the resident was admitted with multiple diagnoses, including hypertension and muscle weakness. The Minimum Data Set (MDS) assessment indicated that Resident 83 had moderate cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 12. Despite this, there was no documented evidence that the resident's Responsible Party 1 (RP 1) was provided with information regarding AD or that they signed the Advance Directive Acknowledgment form. During interviews and record reviews, it was revealed that the facility's policy required the determination of whether a resident had executed an advance directive upon admission and to provide information if they had not. The Director of Nursing (DON) stated that it was the responsibility of the physician and nurses to ensure that information regarding the advanced directive was discussed and documented. However, the review of Resident 83's Physician Orders for Life-Sustaining Treatment (POLST) showed that the section for information and signatures was incomplete, indicating a failure to comply with the facility's policy and procedure regarding residents' rights and advance directives.
Failure to Screen RN with Disciplinary Action
Penalty
Summary
The facility failed to ensure proper screening and follow-up for a Registered Nurse (RN) who had been found guilty of neglect by a court of law. The RN had an administrative disciplinary action against their license, which was not investigated or addressed by the facility. The RN's employee file indicated a disciplinary action posted on their license, and a public court document confirmed a conviction for child endangerment. Despite this, the facility did not provide documentation of any investigation into the disciplinary action. The facility's policy and procedure on abuse, neglect, exploitation, and misappropriation prevention required conducting employee background checks and not employing individuals with findings of abuse, neglect, or disciplinary actions against their professional license. However, the facility did not adhere to this policy, as evidenced by the RN's continued employment despite the disciplinary action. This oversight had the potential to compromise the safety of residents, staff, and visitors, given the RN's history of neglect.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to send a copy of the transfer notification to the Office of the State Long-Term Care Ombudsman for two residents, resulting in the Ombudsman not being informed of their transfers to a General Acute Care Hospital (GACH). Resident 77, who was admitted with chronic obstructive pulmonary disease, was transferred to the hospital on 11/10/24 due to a high temperature and irregular heart rate. The Medical Records Director confirmed that the Notice of Transfer or Discharge was not sent to the Ombudsman, as required by the facility's policy. Similarly, Resident 84 was transferred to the hospital on 11/15/24 for osteomyelitis of the great left toe. The Medical Records Director also confirmed that the Notice of Transfer or Discharge was not present in Resident 84's medical record. The facility's policy, which mandates that a copy of the notice be sent to the Ombudsman at the same time it is provided to the resident and their representative, was not followed in these instances.
Failure to Identify and Refer Resident for PASRR Screening
Penalty
Summary
The facility failed to identify a mental illness in one of the residents, referred to as Resident 71, and did not refer her for a Level II PASRR screening. This oversight resulted in Resident 71 not receiving the specialized mental health services she required. The PASRR screening dated 7/14/23 indicated a negative Level 1 screening, suggesting that Resident 71 was not diagnosed with a mental disorder and was not prescribed psychotropic medications. However, a subsequent review of Resident 71's Minimum Data Set (MDS) dated 7/20/23 revealed active diagnoses of anxiety disorder and post-traumatic stress disorder (PTSD), which were not reflected in the PASRR conditions. Further investigation through the Care Area Assessment (CAA) Worksheet dated 7/20/23 indicated that Resident 71 had severe depression, thoughts of self-harm, and was on medication for PTSD and psychosis. Despite these findings, the Social Services Director (SSD) acknowledged that it was her responsibility to arrange the referral for a PASRR evaluation, which was not done. The facility's policy on PASRR, dated July 2016, mandates the completion and submission of a PASRR screening, especially when there is a significant change in a resident's mental condition. This policy was not adhered to, leading to the deficiency.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to reduce the risk of falls for a resident diagnosed with a malignant neoplasm of the temporal lobe. The resident was admitted to the facility with a care plan that included the use of a fall mat at the bedside due to a history of crawling out of bed. However, during multiple observations, no fall mat was present at the resident's bedside. Interviews with staff, including a CNA, RN, and the Director of Nursing, confirmed the absence of the fall mat, which was a required intervention according to the resident's care plan. The deficiency was highlighted when the resident rolled out of bed, as reported by the resident's responsible party. Staff interviews revealed that the resident was prone to agitation and movement in bed, necessitating the use of a fall mat to prevent injuries. Despite this, the fall mat was not consistently in place, and staff suggested it might have been removed for cleaning. The facility's policy on managing falls and fall risks emphasized the importance of identifying and implementing interventions based on the resident's specific risks, which was not adhered to in this case.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise and implement a person-centered comprehensive care plan for a resident who experienced a fall. The resident, who was admitted with diagnoses including repeated falls, muscle weakness, and dementia, had a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 3. Despite an unwitnessed fall on January 12, 2025, which resulted in a skin tear on the resident's left elbow, the care plan was not updated with new interventions to address the fall risk. During interviews and record reviews, it was revealed that the care plan, dated September 7, 2024, did not include updated interventions following the fall. A Licensed Vocational Nurse (LVN) acknowledged that the care plan should have been updated post-fall to implement and measure effective interventions. The Director of Nursing (DON) confirmed that the facility's policy required care plans to be updated after falls to prevent serious injuries, but this was not done, placing the resident's health and safety at risk.
Failure to Observe Medication Administration
Penalty
Summary
The facility failed to ensure that medication administration met professional standards of practice when a Licensed Vocational Nurse (LVN) prepared medications for two unsampled residents, Resident 39 and Resident 193, without observing them ingest the medications. During an observation, LVN 2 was seen preparing medications for both residents simultaneously, labeling the medicine cups with black marker, and then walking approximately 65 feet to the residents' room. The LVN placed the medicine cups on the bedside tables of the respective residents without observing them take the medications or informing them of the contents of the cups. In an interview, LVN 2 acknowledged that she did not follow the expected procedure, which required her to push the medication cart to each resident's room and prepare medications for one resident at a time. The Director of Nursing (DON) confirmed that the facility's policy was to administer medications at the time they are prepared and to observe residents ingesting their medications to ensure the dose was completely taken. The failure to adhere to these procedures had the potential to result in medication errors for the residents involved.
Failure to Provide Vision Assistive Device
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 290, received an assistive device for his vision needs. Resident 290, who was admitted with a diagnosis of diabetic retinopathy, reported that he had been without eyeglasses for more than two weeks, which hindered his ability to engage in his favorite hobby of solving crossword puzzles. During an observation and interview, Resident 290 expressed his difficulty in performing this activity due to the absence of his eyeglasses, which he had reported missing to the Social Services Director (SSD). The SSD acknowledged having a conversation with Resident 290 about the need for a consultation to obtain new eyeglasses but admitted to not documenting the interaction or following up on the matter. The SSD also mentioned that if residents approached her outside of her office, she sometimes forgot to record their concerns. The facility was unable to provide a policy or procedure to ensure residents received necessary assistive devices like eyeglasses. This oversight negatively impacted Resident 290's quality of life, as confirmed by the SSD.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted once every thirty days for a resident, identified as Resident 25. This deficiency was identified through interviews and record reviews. Resident 25 was admitted with several diagnoses, including a malignant neoplasm of the temporal lobe, iron deficiency anemia, type 2 diabetes mellitus, and dysphasia. During an interview, the Medical Director (MD) stated that she visited the facility daily and attempted to see all residents monthly, but was unaware of the specific requirements for physician visits. She mentioned that she sometimes visited residents without documenting these visits unless an examination was performed. A review of Resident 25's medical records, conducted with the Director of Nursing (DON), revealed a lack of documentation indicating that the MD had seen Resident 25 between September 20 and November 28, a span of 58 days. The DON confirmed the absence of documentation and acknowledged that the MD likely did not visit Resident 25 during this period. The facility's policy and procedure on physician visits, dated April 2013, required attending physicians to visit patients at least once every thirty days for the first ninety days, with appropriate documentation of the resident's care program.
Failure to Provide Mental Health Services
Penalty
Summary
The facility failed to provide necessary mental health services to a resident diagnosed with depression, panic disorder, generalized anxiety disorder, and chronic post-traumatic stress disorder. The resident, who was admitted with these diagnoses, was observed to be isolated and lying in bed most of the day. Despite expressing a desire for counseling to the Social Services Director, the resident had not been evaluated or seen by any mental health professional since admission. Interviews with staff, including a registered nurse and the medical director, confirmed the resident's ongoing depression and occasional aggression. A review of the resident's Care Area Assessment Worksheet indicated severe depression and recommended a referral to a psychologist, which was not acted upon. The facility's policy on behavioral health services stated that residents would receive such services, yet the resident did not receive any mental health support. The administrator acknowledged the oversight, expressing surprise that the resident had not received the necessary help. This lack of action had the potential to negatively affect the resident's psychosocial well-being.
Deficiencies in Resident Transfer, PASARR Screening, and Mental Health Services
Penalty
Summary
The facility failed to follow up on a transfer request for a resident who did not feel safe after a resident-to-resident altercation. The resident expressed a desire to transfer to another facility, but the Social Services Director did not follow up with potential facilities after initial contact attempts. The resident continued to feel unsafe and expressed feelings of depression related to the facility environment, as noted in a psychiatric progress report. Another deficiency involved the improper screening for Preadmission Screening and Resident Review (PASARR) for a resident with mental health diagnoses. The resident's PASARR screening was negative, despite having active diagnoses of anxiety disorder and post-traumatic stress disorder, and being on medications for these conditions. The Social Services Director acknowledged that the resident should have been referred for PASARR clarification but was not. Additionally, the facility failed to arrange and provide mental/psychosocial counseling services for the same resident. Despite the resident's expressed need for counseling and a history of severe depression, no mental health services were provided. The resident remained isolated in her room, and the facility's policy on behavioral health services was not followed, as confirmed by the facility's administrator.
Failure to Conduct Monthly Medication Reviews
Penalty
Summary
The facility failed to ensure that Monthly Medication Reviews (MMR) were conducted for a resident, identified as Resident 61, which resulted in the potential for the resident to receive unnecessary medications. Resident 61 was admitted with diagnoses including Lewy body dementia and major depressive disorder. During an interview, the pharmacist stated that he is responsible for conducting MMRs every month to identify any medication concerns and communicate the results to the Director of Nursing (DON). However, a review of Resident 61's medical records revealed that MMRs were not documented for January and August 2024. The DON confirmed that these reviews were not conducted. The facility's policy, dated December 2016, requires the consultant pharmacist to perform a comprehensive medication regimen review at least monthly and document the findings within 72 hours.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a Gradual Dose Reduction (GDR) for a resident who was receiving psychotropic medications, specifically escitalopram and quetiapine, despite the absence of documented behaviors that would necessitate such medications. The resident, diagnosed with Lewy body dementia and major depressive disorder, was noted to have no aggressive behaviors, striking out, depression, or excessive pacing over a period of 9 1/2 months. Despite recommendations from the Executive Mental Health Doctor and the facility's pharmacist to reduce or discontinue these medications, the Medical Director did not attempt a GDR or discuss it with the resident's responsible party. The facility's policy requires a GDR to be attempted within the first year of admission on psychotropic medication or after initiation, in two separate quarters, unless clinically contraindicated. However, there was no documentation of a GDR attempt for the resident from the time of admission to the time of the survey. The Medical Director acknowledged awareness of the recommendations but confirmed no GDR was attempted. The facility's failure to adhere to its policy and the recommendations of healthcare professionals resulted in the potential for the resident to receive unnecessary and excessive doses of psychotropic medications.
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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.
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Nursing homes near Petaluma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Post Acute | 0.6 mi | ★★★★★ | 29 | 0 |
| Petaluma Post-acute Rehabilitation | 0.7 mi | ★★★★★ | 9 | 0 |
| Ridgeway Post Acute | 0.7 mi | ★★★★★ | 2 | 0 |
| Vineyard Post Acute | 2 mi | ★★★★★ | 28 | 0 |
| Novato Healthcare Center | 9.7 mi | ★★★★★ | 44 | 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 July 2026) and official state health department websites.