Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Piners Nursing Home during CMS and state inspections, most recent first.
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 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
We read the 596 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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 | ★★★★★ | 1 | 0 |
| Napa Post Acute | 0.9 mi | ★★★★★ | 29 | 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 July 2026) and official state health department websites.