Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Redwood Cove Healthcare Center during CMS and state inspections, most recent first.
The facility failed to follow EBP for two residents, including a resident with wounds and a resident with a colostomy. Staff did not wear gowns during high-contact care such as wound care, linen changes, and toileting hygiene, and there was no EBP signage posted outside either room. The DON and interim IP confirmed the lapse, and the IPC policy was also not reviewed annually as required.
Failure to designate a qualified IP for the infection prevention and control program. The DON confirmed the facility had gone about a month without a designated certified IP, and he and the interim IP were covering the role even though neither was certified. The interim IP stated she was still training, while the MDSC, although certified as an IP, said her job was focused on MDSC duties and that she was not directing the infection control program.
Cracked and Broken Kitchen Floor Tiles: Surveyors observed several cracked and broken floor tiles in the kitchen during an initial tour, and the DM confirmed the condition during interview. The damaged flooring was documented with photos and cited under 42 CFR 483.90(i) for failing to provide a safe, functional, sanitary, and comfortable environment.
Ineffective Pest Control Program: Cockroaches were observed crawling under the dishwashing sink in the kitchen, and staff confirmed the infestation was ongoing and seen daily. The DM, kitchen staff, RN, RD, and county environmental health PM all acknowledged the problem, and the pest control company reported a severe German cockroach infestation with treatments done only as needed rather than at the recommended frequency. The facility policy stated it would maintain an effective pest control program to keep the facility free of insects and rodents.
Failure to Obtain Informed Consent for Antidepressant Medication: A resident with major depressive disorder was prescribed Trazodone for depression-related insomnia, but the chart lacked informed consent documentation showing that the resident or RP had been informed of the risks and benefits before the medication was given. During record review, the RN confirmed the absence of consent documentation.
A resident with major depressive disorder and no memory impairment was moved to another room because the facility needed her room for a new admission. She stated the change upset her and made her feel like she did not have a choice. The DON confirmed the room move, but no documentation was provided showing the reason was discussed with or agreed to by the resident, despite facility policies stating resident preferences and self-determination are to be respected.
Failure to provide baseline care plan summaries to residents or their RPs was identified for three residents. One resident had muscle weakness and dysphagia, another had muscle weakness and difficulty walking, and a third had hypothyroidism and hyperlipidemia. The DON verified the summaries were not provided, and one resident’s BCP was completed late, beyond the 48-hour timeframe required by policy.
Medication error rate exceeded 5 percent. Surveyors found two medication errors in 33 medication administration opportunities, including an LPN giving a resident Metoprolol Tartrate 25 mg and Amiodarone 100 mg despite order parameters that required holding the medications based on BP limits. The DON confirmed the orders and acknowledged the medications were administered outside the prescribed parameters.
Unsafe Bedside Medication Storage and Unauthorized Self-Administration: A resident with COPD and HTN had ASA 81 mg ordered, but ASA 325 mg and antacid tablets were found at the bedside without a physician order or completed self-administration assessment. The resident said she had been using and storing the medications in her room for over a month, and the DON confirmed this was not permitted and that the POS did not include orders for the antacid or self-administration.
A resident with chronic medical and mental health conditions experienced repeated instances where staff entered the room and opened privacy curtains without knocking, announcing, or waiting for an invitation, despite the resident's explicit request for privacy. This led to the resident feeling anxious and unsafe, and staff education and care plan interventions addressing these needs were not consistently followed.
A CNA was found to have worked multiple shifts with an expired certification, as confirmed by certificate verification and daily nursing schedules. The DSD acknowledged the lapse, and the Administrator was unaware until notified. Facility policy required all nursing staff to maintain current licensure and certification.
Nursing staff did not document required monitoring of a resident's PICC line site for signs of infection, as ordered by the physician, due to the order being placed on the IV Administration Record instead of the MAR. This failure was identified through record review and staff interviews, and was not in accordance with facility policy or physician orders.
A resident with a history of osteomyelitis and MRSA infection did not have a dose of ordered IV daptomycin documented as administered. The MAR lacked evidence of administration, and the DON confirmed the absence of documentation, making it impossible to verify if the medication was given as required by facility policy.
The facility did not comply with federal guidelines by failing to designate a qualified Director of Food and Nutrition Services. The Dietary Manager was not certified, and the Registered Dietician was only part-time, visiting once a week. The DM lacked necessary qualifications and training, and the HR department did not provide the DM's file when requested.
The facility failed to ensure timely completion of Basic Care Plans (BCPs) within 48 hours of admission for several residents, as required by policy. Staff interviews revealed a lack of awareness about BCPs and their completion timeframe, leading to incomplete or delayed BCPs for residents with various medical conditions. This deficiency posed potential risks to residents' safety and care.
A resident receiving tube feeding was not properly monitored for the amount of formula administered, leading to discrepancies in expected versus actual intake. Staff were unable to calculate the correct formula amounts, and input and output (I&O) monitoring was not conducted, despite its importance for residents on tube feedings. This oversight put the resident at risk for dehydration and malnutrition.
The facility failed to follow its Medication Regimen Review policy, resulting in incomplete pharmacy reviews and unaddressed recommendations for several months. Staff were unaware of a resident's G-CSF injection, preventing a thorough medication review and risking potential drug interactions. The facility lacked a policy for G-CSF usage and did not monitor the resident for side effects, compromising safety.
The facility failed to ensure food was palatable and served at appropriate temperatures, as reported by several residents. Observations showed that food temperatures did not meet guidelines, with pureed items being served cold and with an inappropriate texture. The dietary manager and registered dietician confirmed these issues, highlighting the importance of adhering to food safety policies to prevent potential health risks.
The facility failed to ensure proper food storage and labeling, with several items lacking open and discard dates, posing a risk of food-borne illness. Observations revealed unlabeled items like cooking oil, chocolate mix, and lemon juice. Staff confirmed the importance of date-marking to prevent expired food use, highlighting a safety risk for residents.
The facility failed to maintain kitchen walls and the dishwashing sink counter, leading to potential pest entry and contamination risks. Observations revealed cracks, holes, and rust, confirmed by staff, including the Dietary Manager and Maintenance Assistant. A cockroach was seen, indicating an ongoing pest issue. Staff expressed concerns about food contamination and resident illness. The Maintenance Director and Registered Dietician acknowledged the deficiencies, highlighting the need for preventive maintenance.
The facility failed to maintain an effective pest control program, as evidenced by the presence of cockroaches in the kitchen area. Staff confirmed this was an ongoing issue, posing a risk of contamination and illness to residents. The facility lacked a structured pest control program, and the measures in place were ineffective. Concerns were raised about the absence of a comprehensive pest control policy and the use of non-EPA registered pesticides.
The facility failed to honor resident rights, resulting in delayed call light responses, lack of usable prescription glasses, and unaddressed room change requests. Residents experienced neglect, with some left in soiled briefs and others unable to engage in daily activities due to missing glasses. Additionally, residents were not provided with necessary communication tools, such as a facility phone or translated documents, leading to feelings of isolation and frustration.
The facility failed to maintain a safe and sanitary environment, with inadequate hand hygiene practices, unsanitary conditions, and insufficient pest control measures. Observations revealed dirty and damaged areas, insects, and a lack of adherence to infection control policies. Staff interviews highlighted a lack of awareness and understanding of infection prevention measures.
The facility exhibited significant deficiencies in its infection control program, with observations of unsanitary conditions such as dirty carpeting, cracked surfaces, and cross-contamination risks in utility and laundry areas. Staff interviews revealed a lack of awareness and procedures for addressing these issues, and there was no monitoring of vaccination rates or hand hygiene compliance. The infection preventionist acknowledged the absence of established goals for hand hygiene, and multiple instances of staff failing to perform hand hygiene were observed.
The facility did not ensure residents had access to State Survey Agency contact information necessary for filing complaints. During a Resident Council Meeting, residents reported not knowing how to file a complaint or where to find the contact information. An LPN incorrectly identified the Ombudsman posting as the State Agency contact information. The actual contact information was found on a small paper at the end of a hallway, away from resident activities, making it difficult for residents to access.
The facility did not make the most recent State Survey results readily accessible to residents and their families. Residents were unaware of where to find the survey results, and an outdated binder was observed in a hallway. The Administrator had given the current survey binder to a family and later found it in his office, requiring residents to request it for review.
A resident experienced a significant weight loss of 19.8 pounds over five months, but the facility failed to notify the physician. Despite the resident's diagnoses of essential hypertension, dysphagia, and anxiety, and the acknowledgment by staff and the Medical Director of the need for physician notification, there was no documentation of such action. The facility's policy on weight changes was not provided, highlighting a potential procedural gap.
Two residents in an LTC facility were found without usable prescription glasses, impacting their ability to perform daily activities and enjoy leisure activities. Staff failed to ensure the residents had their glasses during meals and activities, and the need for glasses was not documented in care plans or communicated in reports. The facility's policy on sensory impairments was not followed, leading to a lack of corrective action for the residents' vision needs.
A facility failed to properly label insulin pens with resident information, leading to potential risks. An LPN administered insulin to two residents using pens labeled incorrectly on the cap or storage bag instead of the shaft. The DON confirmed the labeling error. Observations showed three more pens improperly labeled on a medication cart. The ISMP's best practices for labeling were not followed, posing risks of exposure to infectious agents and incorrect insulin administration.
The facility failed to provide a plant-based menu for residents on vegan diets, relying instead on existing food items without nutritional information. Staff, including the Dietary Manager and Registered Dietician, acknowledged the absence of a plant-based menu and its importance in ensuring adequate nutrition. The facility's policy did not address plant-based menus, leading to potential nutritional deficiencies for vegan residents.
Failure to Follow EBP and Review IPC Policy Annually
Penalty
Summary
The facility failed to maintain its infection prevention and control program when enhanced barrier precautions were not implemented and followed for two residents. One resident had wounds to the lumbar area and left buttocks, and another resident was admitted with a colostomy. During observation and interview, the resident with a colostomy reported that staff did not wear a gown when changing linens or providing toileting hygiene. The DON confirmed both residents required EBP signage to alert staff to use gloves and gowns for high-contact care activities, and stated that failure to follow EBP could lead to infection outbreaks. During a separate observation, the interim IP provided wound care to the resident with wounds without wearing a gown and acknowledged that EBP was not being followed. The interim IP also confirmed there was no EBP signage inside or outside either resident’s room. In addition, the facility’s Infection Prevention and Control policy and procedure binder showed the QA committee approved the policy on 1/31/24, and there was no review completed for 2025. The DON verified the policy had not been reviewed annually, and the MDSC stated the Infection Prevention and Control policy and procedure should be reviewed at least annually.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate at least one qualified infection preventionist (IP) responsible for the infection prevention and control program. Survey findings showed that the individuals performing the IP role had not completed specialized training or obtained certification in infection control and prevention. The facility's Infection Control Nurse job description, dated 2/2024, stated that the position's primary purpose was to plan, organize, develop, coordinate, and direct the facility's infection control program and its activities. During interviews, the DON confirmed the facility had not had a designated certified IP for approximately one month and stated that he and the interim IP were currently assuming the role even though neither was certified. The interim IP stated she was still training and was not a certified IP, and the MDS coordinator, who was certified as an IP, stated her job was focused on being the MDSC and that she was not organizing, developing, or directing the facility's infection control program. The MDSC confirmed the facility did not have a qualified IP for some time.
Cracked and Broken Kitchen Floor Tiles
Penalty
Summary
The facility failed to provide a safe and sanitary kitchen environment for all 63 residents when the kitchen had several cracked and broken floor tiles. During an initial tour of the kitchen, surveyors observed the damaged floor tiles and took photos to document the finding. During a concurrent review of the photos and interview with the Dietary Manager, the Dietary Manager confirmed that the kitchen had several cracked and broken floor tiles. The report cited 42 CFR 483.90(i), which requires the facility to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program for all 63 residents when cockroaches were observed in the kitchen under the dishwashing sink during the initial tour. Insects that looked like cockroaches were seen crawling under the sink, and a video was taken of the observation. During interviews, Unlicensed Staff A reported seeing a large cockroach in the hallway near the shower room the previous week and acknowledged awareness of cockroach activity in the kitchen. The Dietary Manager confirmed observing multiple cockroaches beneath the kitchen sink, on the floor behind the pipes, and around the grease trap, and stated the facility had been aware of the infestation, including from the previous year. Kitchen Staff B also confirmed seeing multiple crawling cockroaches underneath the dishwashing sink and stated this was a constant and daily occurrence. The Registered Dietitian, Resource Nurse, and County Environmental Health Program Manager all acknowledged the cockroach problem, and the PM confirmed seeing cockroaches during her inspection. The pest control company representative stated the facility had a severe infestation of German cockroaches and reported that treatments had been done only on an as-needed basis rather than every seven to 10 days as recommended. The facility policy stated it would maintain an effective pest control program to keep the facility free of insects and rodents.
Failure to Obtain Informed Consent for Antidepressant Medication
Penalty
Summary
The facility failed to ensure that Resident 10 was informed in advance of the risks and benefits associated with a proposed treatment before administering Trazodone for depression. Resident 10 was admitted in March 2023 with a diagnosis of major depressive disorder. Her September 2025 order summary showed that on 8/10/25 she was prescribed Trazodone HCl 50 mg, to be given as one-half tablet by mouth every evening for depression manifested by inability to sleep. During a concurrent interview and record review on 9/25/25 at 3:35 p.m. with the facility's Resource Nurse, the resident's medical records were reviewed and the nurse confirmed that the chart did not contain informed consent documentation showing that Resident 10 or her responsible party had been provided information regarding the risks and benefits of Trazodone. The report cited 42 CFR 483.10(c)(5), which states that residents have the right to be informed in advance of the risks and benefits of proposed care, treatment alternatives, and treatment options.
Room Change Made Without Resident Choice
Penalty
Summary
The facility failed to provide Resident 46 with the opportunity to exercise her right to make a choice when her room was changed without her consent. Resident 46 was admitted in May 2020 with diagnoses including major depressive disorder, and her MDS dated 6/17/25 indicated she had no memory impairment. During an interview, Resident 46 stated she had to change rooms because the facility needed her room for a new admission, and she said the change upset her and made her feel like she did not have a choice. The DON confirmed that Resident 46 was moved to another room, but documentation requested to show the reason for the room change and evidence that the change was discussed and agreed upon with the resident was not provided. The facility's policy on Room Change/Roommate Assignment stated resident preferences are taken into account when room changes are considered, and the policy on Resident Self Determination and Participation stated residents are encouraged to make choices about aspects of their lives in the facility.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to ensure a written summary of the baseline care plan was provided to the resident and/or the responsible party for 3 of 16 sampled residents. Resident 1 was admitted with diagnoses of muscle weakness and dysphagia, Resident 7 was admitted with muscle weakness and difficulty walking, and Resident 9 was admitted with hypothyroidism and hyperlipidemia. For each of these residents, the Baseline Care Plan-Person Centered Care Planning-V3.1 form did not indicate that the baseline care plan summary was provided to the resident or their responsible party. Resident 7’s baseline care plan form was also completed by facility staff on 9/2/25, which was more than 48 hours after admission. During interviews, the DOR stated the baseline care plan should be completed timely and that failure to do so could result in staff miscommunication and delayed intervention for resident safety. The DON reviewed the forms and verified that the baseline care plan summary was not provided to Residents 1, 7, and 9 or their responsible parties, and verified that Resident 7’s baseline care plan was completed late. The facility policy stated that a baseline plan of care is to be developed within 48 hours of admission and that the resident and/or representative are to be provided a written summary, with documentation of that provision in the medical record.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure its medication error rate was less than 5 percent when surveyors identified two medication errors out of 33 medication administration opportunities, resulting in a 6.06% error rate. During a concurrent observation and interview, a Licensed Nurse administered Metoprolol Tartrate 25 mg and Amiodarone 100 mg to Resident 1 while the resident's blood pressure was 122/72 mmHg, and the nurse confirmed the medications were given at that time. A record review of the resident's order summary showed Metoprolol Tartrate was ordered to be held if DBP was less than 90 mmHg and Amiodarone was ordered to be held if SBP was less than 100 mmHg, with notification of the MD. In an interview, the DON confirmed the order indicated the medications were not to be given when SBP was less than 100 mmHg and acknowledged that administering medication outside ordered parameters could lower the resident's BP and potentially cause a hypotensive crisis. The facility policy stated that prior to administration of any medication, the physician's orders are checked for the correct dosage schedule and current directions.
Unsafe Bedside Medication Storage and Unauthorized Self-Administration
Penalty
Summary
Medication storage and self-administration were not managed in accordance with the facility’s stated requirements for one resident. The resident had an admission date in 12/2021 and diagnoses of COPD and essential hypertension. Her physician order summary, active as of 9/24/25, included ASA 81 mg daily, but there were no orders for antacid tablets or for self-administration of either medication. During a concurrent observation and interview on 09/23/2025 at 2:07 p.m., ASA 325 mg was found in the resident’s bedside drawer and antacid tablets 1000 mg were found on her overbed table. The resident stated she had no physician order for either medication, staff had not assessed her ability to self-administer them, and she had been using and storing them in her room for over a month without staff intervention. During a later interview and record review, the DON confirmed that only residents with a completed assessment may self-administer medications or keep them at bedside, and acknowledged that the resident had ASA 325 mg and antacid tablets at her bedside without such an assessment. The DON also confirmed the ASA order was for 81 mg, not 325 mg, and that the POS lacked orders for antacid tablets and self-administration.
Failure to Honor Resident Privacy and Dignity During Room Entry
Penalty
Summary
Facility staff failed to treat a resident with dignity and respect by entering the resident's room without announcing themselves or being invited in. The resident, who had a diagnosis of Chronic Venous Hypertension with an ulcer and Chronic Post Traumatic Stress Disorder (PTSD), had an intact cognitive status as indicated by a BIMS score of 14. The resident's care plan identified risks for decreased psychosocial well-being, emotional distress, and ineffective coping skills, with interventions to encourage expression of emotions and to observe for signs of distress. Despite these documented needs, staff repeatedly entered the resident's room and opened the privacy curtain without knocking, announcing, or waiting for an invitation, even after the resident specifically requested that staff wait for permission to enter. The resident reported feeling anxious and unsafe due to these actions, particularly as he occupied the bed farthest from the door and could be using the commode when staff entered unannounced. Interviews confirmed that staff were educated to knock and announce themselves before entering, and that specific resident requests should be communicated during shift reports. However, the resident's request for privacy and control over room entry was not consistently honored, resulting in ongoing distress and a lack of privacy for the resident.
CNA Worked with Expired Certification
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) maintained a current and active certificate in accordance with state laws. A review of nine CNA certificate verifications revealed that one CNA's certificate had expired, yet the CNA continued to be scheduled and worked multiple shifts with the expired certification. The Director of Staff Development acknowledged that the CNA had been working without a valid certificate, and the daily nursing schedules confirmed the CNA worked several shifts during the period when the certificate was expired. The Administrator stated he was unaware of the expired certification until it was brought to his attention. Facility policy required all nursing staff to meet competency requirements as defined by state law.
Failure to Document and Monitor PICC Line Site as Ordered
Penalty
Summary
Nursing staff failed to carry out a physician's order for a resident who had a Peripherally Inserted Central Catheter (PICC line) in place for the treatment of acute osteomyelitis and a Methicillin Resistant Staphylococcus Aureus (MRSA) infection. The physician's order required monitoring the PICC line insertion site every shift for signs and symptoms of infection, including redness, drainage, and pain, and to alert the physician if any signs of infection were noted. However, a review of the resident's IV Administration Record showed that from 3/28/25 to 4/11/25, there was no documentation by licensed nurses that the PICC line site was monitored as ordered. Interviews with the Director of Nursing (DON) and the Infection Preventionist (IP) nurse revealed that the monitoring order was placed on the IV Administration Record instead of the Medication Administration Record (MAR), which led to the nursing staff not completing the required documentation. The facility's policy on preventing intravenous catheter-related infections also required observation and documentation of the insertion site every shift. The lack of documentation indicated that the monitoring was not performed as required by both physician order and facility policy.
Failure to Document IV Antibiotic Administration
Penalty
Summary
A resident with acute osteomyelitis of the right tibia and fibula and a MRSA infection was admitted to the facility and had a physician's order for daptomycin-sodium chloride IV solution to be administered every evening for a left lower extremity wound infection. On April 5, 2025, the Medication Administration Record (MAR) did not indicate that the ordered dose of the IV antibiotic was administered. Progress notes for the same date stated that the resident was currently receiving an IV antibiotic, but there was no documentation confirming the administration of the specific dose as required. During an interview, the DON confirmed that the missing documentation on the MAR made it difficult to verify whether the IV antibiotic had been given. The facility's policy requires that medications be administered as prescribed and that the person administering the medication records the administration on the MAR/eMAR immediately after giving the medication. The policy also states that the MAR/eMAR should be reviewed at the end of each medication pass to ensure all necessary doses are documented, and that no staff should leave duty without recording medication administration. In this instance, the required documentation was not completed, resulting in a significant medication error.
Non-compliance in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to ensure that a qualified individual was designated as the Director of Food and Nutrition Services, as required by federal guidelines. The Dietary Manager (DM) was not a Certified Dietary Manager and did not meet the qualifications outlined in the facility's job description, which required graduation from an approved Dietary Manager's course. The Registered Dietician (RD) was not employed full-time and only visited the facility once a week, which did not provide the DM with consistent in-services and training. Interviews revealed that the DM lacked the necessary certifications and training, including not being a graduate of a Dietetic Technician Training Program or a College Degree Program with major studies in food or nutrition. The RD confirmed her status as a contractual staff member, not a full-time employee. Additionally, the Human Resources Department failed to provide a copy of the DM's file when requested, further indicating a lack of compliance with the required standards for staffing in the food and nutrition services department.
Failure to Complete Basic Care Plans Timely
Penalty
Summary
The facility failed to ensure that staff were aware of the Basic Care Plan (BCP) requirements and its completion timeframe, which should be within 48 hours of a resident's admission. This deficiency was identified through interviews and record reviews, revealing that staff members were either unaware of what a BCP was or did not know the timeframe for its completion. This lack of awareness among staff members, including Licensed Staff G, F, and T, as well as the Social Services Director and Director of Nursing, contributed to the failure in completing BCPs timely for several residents. The report highlights that the BCP was not completed for one resident and was completed late for seven other residents. These residents had various medical conditions, including hyperlipidemia, hypertension, type 2 diabetes, dysphagia, depression, schizoaffective disorder, muscle weakness, dementia, and anxiety. The BCPs for these residents were either incomplete or completed well past the 48-hour requirement, with some sections left blank or completed on different dates, indicating a lack of timely and coordinated care planning. The facility's policy and procedure, revised in December 2022, clearly stated that a baseline plan of care should be developed within 48 hours of admission. However, the failure to adhere to this policy resulted in potential risks to residents' safety and the possibility of them not receiving the necessary care. Interviews with staff and directors confirmed the importance of BCPs in ensuring safe and adequate care, yet the facility did not follow its own policy, leading to the identified deficiencies.
Failure to Monitor Tube Feeding and I&O for Resident
Penalty
Summary
The facility failed to periodically evaluate the amount of feeding being administered to Resident 265, who was receiving nutrition through a tube feeding. Observations revealed discrepancies in the amount of formula that should have been administered versus what was actually left in the feeding bag. For instance, during a 12-hour period, Resident 265 should have received 720 ml of formula, but there was over 500 ml left in the bag, indicating a significant shortfall in the administered amount. Licensed nurses were unable to calculate or verify the correct amount of formula that should have been administered, highlighting a lack of knowledge and monitoring. Additionally, the facility did not monitor Resident 265's input and output (I&O), which is crucial for evaluating fluid and electrolyte balance. Despite the presence of a dehydration care plan that directed staff to monitor I&O, this was not done, as confirmed by interviews with various staff members. The Registered Dietician and other staff acknowledged the importance of I&O monitoring for residents on tube feedings, yet it was not implemented for Resident 265, potentially putting the resident at risk for dehydration, malnutrition, and fluid imbalance. Interviews with staff, including the Nurse Consultant and Medical Director, confirmed that I&O monitoring should be a standard practice for residents on tube feedings, regardless of a physician's order. However, the facility's policy on I&O monitoring was not provided, and there was a lack of adherence to the policy on enteral tube feeding, which requires recording average fluid intake. This oversight in monitoring and evaluating tube feeding administration led to the deficiency identified in the report.
Failure in Medication Regimen Review and Staff Knowledge
Penalty
Summary
The facility failed to adhere to its Medication Regimen Review (MRR) policy and procedure, resulting in significant deficiencies. The Director of Nursing (DON) was unable to provide complete pharmacy review documents for several months, specifically from September 2023 to March 2024. During this period, pharmacy recommendations were not forwarded to any facility physician, leaving them in a 'holding pattern.' This lack of communication and documentation meant that no actions were taken on pharmacy recommendations, potentially leading to unmanaged polypharmacy and lack of follow-up on dose reduction recommendations. Additionally, the facility did not ensure that staff were knowledgeable about a glycoprotein-colony stimulating factor (G-CSF) injection, which was being administered to a resident, Resident 14, weekly. The G-CSF injection was not listed on Resident 14's current medications, and the pharmacist was not notified of its administration. This oversight prevented the pharmacist from conducting a thorough and accurate MRR, which could have identified potential drug interactions and side effects. Interviews with licensed staff revealed a lack of understanding of the medication's purpose and potential side effects, further compromising the resident's safety. The facility also lacked a policy and procedure for G-CSF medication usage, and there was no documentation indicating that Resident 14 was being monitored for side effects or adverse effects while receiving the injections. The consultant pharmacist and medical director both emphasized the importance of notifying the pharmacist about all medications a resident is receiving, regardless of whether they are administered within the facility or externally. This coordination of care is crucial for ensuring resident safety and effective medication management.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food was palatable and served at appropriate temperatures according to resident preferences. Observations and interviews revealed that four out of five sampled residents reported that hot foods were served cold and lacked taste, with vegetables being overcooked and mushy. Additionally, the food temperature was not taken prior to serving to one resident, which could lead to potential safety hazards such as burns. The dietary manager and registered dietician confirmed that the food temperatures did not meet the guidelines, with pureed eggs and pancakes being served at temperatures below the recommended levels. The dietary manager noted that the texture of the pureed food was thick and pasty, which was not appropriate, and attributed this to the possible addition of thickener by the cook. The registered dietician emphasized the importance of checking food temperatures to prevent accidents and ensure the food is safe and palatable for residents. The facility's policy and procedure for food preparation and service, revised in November 2022, outlined specific temperature requirements for food safety, which were not adhered to in this instance. The dietary manager acknowledged that the test tray food temperatures were inappropriate and did not meet the guidelines, which could lead to food-borne illnesses and residents not consuming the food, potentially resulting in weight loss or malnutrition.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices, leading to unsafe and unsanitary conditions. During observations, it was noted that several food items in the refrigerator, freezer, and dry pantry were not marked with open and discard dates. Items such as cooking oil, chocolate mix, lemon juice, teriyaki sauce, veggie burgers, baking soda, peanut butter, and chicken bouillon were found without discard dates. The Dietary Manager and Dietary Aides confirmed that these items should have been labeled with open and discard dates to prevent the use of expired food, which poses a risk of food-borne illness. Interviews with the Dietary Manager, Dietary Aides, and a Registered Dietician highlighted the importance of date-marking food items to ensure resident safety. The lack of proper labeling could lead to the accidental ingestion of expired food, increasing the risk of illnesses such as diarrhea, salmonella, and listeria. The facility's policy for food storage and labeling was requested but not provided, indicating a potential gap in adherence to food safety protocols.
Kitchen Maintenance Deficiencies and Pest Control Issues
Penalty
Summary
The facility failed to maintain the kitchen walls and dishwashing sink counter in good repair, as observed during rounds. Cracks and holes were noted in the walls underneath the dishwashing sink and near the dish sanitizing machine, with a rusty dishwashing sink counter also observed. These conditions were confirmed by the Dietary Manager, who acknowledged the potential for pests and cockroaches to enter through these openings, posing a safety and infection control issue. The presence of a cockroach was noted during the inspection, indicating an ongoing pest problem. Further observations and interviews with staff, including Dietary Aide 2 and the Maintenance Assistant, corroborated the findings of holes and cracks in the kitchen walls and a rusty dishwashing sink counter. Staff expressed concerns about the potential for pests to contaminate food and utensils, leading to gastrointestinal illnesses among residents. The Maintenance Assistant recommended replacing the entire dishwashing sink due to its rusted condition, highlighting the need for immediate attention to these deficiencies. The Maintenance Director and Registered Dietician also confirmed awareness of the issues, emphasizing the importance of maintaining the kitchen environment free from structural damage and rust to prevent cross-contamination and ensure resident safety. The facility's policy and procedure for maintenance services, revised in 2008, indicated that the Maintenance Director was responsible for scheduling preventive maintenance, suggesting a lapse in adherence to these guidelines.
Facility Lacks Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of cockroaches in the kitchen area. During observations and interviews, a cockroach was seen crawling underneath the dishwashing sink, and the Dietary Manager confirmed this was not the first occurrence. The Dietary Manager and other staff members acknowledged that the presence of cockroaches in the kitchen was an ongoing issue, posing a risk of contamination and illness to residents. Interviews with various staff members, including the Maintenance Assistant and Maintenance Director, revealed that the facility had been using pesticides and traps to address the cockroach problem. However, these measures were not effective in eliminating the issue. The Maintenance Director admitted that the facility did not have a structured pest control program or schedule for treatments between monthly visits from a pest control company. Additionally, there was uncertainty about whether the pesticides used were EPA registered. The Registered Dietician and Nurse Consultant expressed concerns about the lack of a pest control program and policy. The Administrator confirmed the use of a cockroach spray that was EPA exempt, but did not provide further details on the effectiveness or safety of the product. The absence of a comprehensive pest control program and policy contributed to the ongoing presence of cockroaches in the kitchen, raising concerns about potential health risks to residents.
Deficiencies in Resident Rights and Care
Penalty
Summary
The facility failed to honor the resident rights of 13 sampled residents, leading to significant deficiencies in care and dignity. Ten residents reported excessive call light response times, with delays of up to two hours, resulting in delayed care and loss of dignity. Observations noted staff, including licensed nurses and unlicensed staff, ignoring call lights and failing to assist residents promptly. This neglect led to residents being left in soiled briefs, increasing the risk of incontinence-related issues and psychosocial harm. Interviews with residents and staff confirmed the lack of timely response, and the facility's policy on call light response was not being monitored or enforced. Two residents were not provided with usable prescription glasses, impacting their ability to engage in daily activities and leading to feelings of neglect and vulnerability. Observations showed residents without glasses, unable to read or watch television, and staff failed to address the issue despite being informed. The care plans for these residents did not reflect their need for eyeglasses, and there was no documentation of efforts to repair or replace the broken glasses. The facility's policy on sensory impairments was not followed, contributing to the residents' sense of being unimportant. Additional deficiencies included a resident not being informed about a requested room change, leading to feelings of being ignored, and another resident not being provided with a facility phone for private calls, resulting in isolation and depression. Two residents had their urinary catheter drainage bags uncovered, violating their dignity. Furthermore, a resident was not provided with translated documents or translator services, hindering their ability to make informed healthcare decisions. These failures highlight a systemic issue in respecting and addressing resident rights, leading to potential psychosocial harm and miscommunication.
Facility Fails to Maintain Sanitary Environment and Infection Control
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents, as evidenced by multiple observations of unsanitary conditions and inadequate infection control practices. Hand hygiene was not consistently offered to residents before meals, and the facility's hand hygiene policy and procedure were not followed during medication administration. Additionally, cross-contamination risks were identified in linen storage and laundry processing areas, with insects observed in the clean utility room and other areas of the facility. The facility's housekeeping and maintenance practices were inadequate, with numerous areas observed to be dirty, stained, and in disrepair. The housekeeping closet, shower rooms, and utility rooms were found to have black and gray residues, insects, and unlabeled personal care items. The facility's pest control measures were insufficient, with no formal monitoring process or policy in place to address pest infestations. The facility's maintenance log was not effectively used, resulting in unresolved repair requests and unaddressed issues such as cracked wheelchair armrests and damaged flooring. Interviews with staff revealed a lack of awareness and understanding of infection prevention and control measures. The facility's infection preventionist did not have established goals for hand hygiene compliance and was unaware of environmental risks in laundry processing. The facility's policies and procedures for maintaining a homelike environment and handling soiled laundry were not adhered to, contributing to the unsanitary conditions observed throughout the facility.
Inadequate Infection Control and Maintenance in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by numerous observations of unsanitary conditions and cross-contamination risks. Dirty and stained carpeting, broken floor surfaces, cracked wheelchair armrests, exposed wall plaster, rust, and chipped paint were observed in patient care areas. These conditions were noted in various locations, including resident rooms, hallways, and utility rooms. Interviews with staff revealed a lack of awareness regarding the infection prevention concerns associated with these issues, and there was no evidence of a systematic process for reporting and addressing maintenance needs. Cross-contamination risks were also identified in the laundry processing and storage areas, clean utility room, and resident ice storage room. Observations included the presence of insects, such as cockroaches, and gray particulate matter on surfaces that were supposed to be clean. The facility lacked a formal pest control policy and procedure, and there was no monitoring process to track insect sightings or pest control measures. Staff interviews indicated a lack of knowledge about proper cleaning procedures and the use of approved cleaning solutions. The facility did not monitor vaccination rates of staff and residents or hand hygiene compliance. The infection preventionist admitted to not having established goals for hand hygiene compliance and was unaware of the facility's compliance rate. Observations showed multiple instances where staff failed to perform hand hygiene before and after resident contact, and there was no formal infection control committee to review and support the infection control program. The lack of monitoring and oversight in these areas posed a significant risk for cross-contamination and infection among residents.
Failure to Provide Accessible State Agency Contact Information
Penalty
Summary
The facility failed to ensure that residents were aware of and had access to State Survey Agency contact information, which is necessary for filing complaints. During a Resident Council Meeting, several residents expressed that they did not know how to file a complaint with the State Agency or where to find the contact information. An interview and observation with a Licensed Nurse (LN F) revealed that the nurse mistakenly pointed to the Ombudsman posting when asked about the State Agency contact information. Further investigation showed that the State Agency contact information was posted on a small paper at the end of a hallway, away from resident activities, and not easily accessible or visible to residents. LN F acknowledged that residents typically contacted the Ombudsman and were unaware of the State Agency information.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to post the results of the most recent State Survey in a location that was readily accessible to residents, family members, and/or legal representatives. During a Resident Council Meeting, several residents expressed that they did not know where to access the survey results. An observation revealed that an outdated binder labeled 'Survey Results' was placed in a hallway, but it only contained information from 2012 to 2016. The Administrator admitted that the binder with the most recent survey results, dated 2019, was given to a family for review and was later found in the Administrator's office. The Administrator stated that residents or their family members had to request the binder from him to view the survey results.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss experienced by a resident, identified as Resident 25. The resident, who was admitted with diagnoses including essential hypertension, dysphagia, and anxiety, experienced a weight loss of 19.8 pounds over five months, equating to a 16.5% reduction in body weight. Despite this significant change, there was no documentation indicating that the physician was informed, which is a requirement for managing such health changes. Interviews with various staff members, including licensed and unlicensed personnel, confirmed that the weight loss was significant and should have been reported to the physician to prevent further health deterioration. The Medical Director and the Director of Nursing both acknowledged the significance of the weight loss and the necessity of notifying the physician. The absence of a documented notification to the physician was verified by a nurse consultant. The facility's policy and procedure for handling weight changes were requested but not provided, indicating a potential gap in protocol adherence or documentation. This oversight had the potential to compromise the resident's medical status further, as the physician was not given the opportunity to assess and address the underlying causes of the weight loss.
Failure to Provide Usable Prescription Glasses for Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident 16 and Resident 200, had usable prescription glasses, which impacted their ability to perform activities of daily living and engage in activities that brought them joy. Resident 16 was observed without glasses, with her eyeglass case containing a pair of frames missing a lens. She reported difficulty reading and doing needlework, experiencing headaches when attempting these activities without proper eyewear. Similarly, Resident 200 was found without glasses and unable to see the television, expressing a desire for her glasses to be able to watch TV and eat properly. Unlicensed staff members were observed serving meals to the residents without ensuring they had their glasses, which was part of their responsibility. The staff was unaware of the residents' needs for glasses, as this information was not included in the morning report. The Social Services Manager and other staff members were not informed about the broken glasses, leading to a lack of follow-up and repair. The care plans for both residents did not reflect their need for eyeglasses, and there was no documentation of their glasses in the inventory lists. The Director of Nursing acknowledged that the care plans were not individualized to address the residents' vision impairments. The facility's policy on sensory impairments was not followed, as staff failed to optimize the residents' ability to see by ensuring they had corrective lenses.
Improper Labeling of Insulin Pens in LTC Facility
Penalty
Summary
The facility failed to properly label insulin pens with resident information, which is a violation of accepted professional principles for drug labeling. During an observation, a Licensed Nurse (LN G) administered insulin to two residents using insulin pens that were not labeled correctly. The insulin pens were obtained from the Emergency Medication Supply (E Kit) and were either labeled on the cap or the outer plastic storage bag instead of the shaft, which is the correct location for labeling. This improper labeling was confirmed by the Director of Nursing (DON), who acknowledged that the labels should have been placed on the shaft of the insulin pens. Further observations revealed that three insulin pens on the Medication Cart for Hallway Two were also improperly labeled. One pen was labeled on the outer plastic storage bag, another with a sticker on the cap, and the third with a black marker on the cap. The Institute for Safe Medical Practices (ISMP) has established best practices for labeling, which include featuring two forms of patient identification, proper storage condition information, drug ID information, and expiration date. The facility's failure to adhere to these practices had the potential to expose residents to infectious agents and cause serious adverse effects if insulin was administered incorrectly.
Lack of Plant-Based Menu for Vegan Residents
Penalty
Summary
The facility failed to develop a plant-based menu, which is necessary to meet the nutritional needs of residents on vegan diets. During an observation and interview, the Dietary Manager (DM) admitted that the facility did not have a plant-based menu and relied on existing food items to substitute for vegan meals. The DM found a Ziploc bag labeled 'Veggie burger' in the freezer, which lacked information on dietary content, such as calories or protein. This lack of information raised concerns about ensuring adequate nutrition for residents on vegan diets. The DM acknowledged the importance of having a plant-based menu to prevent malnutrition and ensure residents receive adequate proteins and nutrients. Interviews with various staff members, including Dietary Aides and the Registered Dietician (RD), confirmed the absence of a plant-based menu. They emphasized the importance of having such a menu to ensure residents on vegan diets receive adequate nutrition, including micronutrients and protein. The facility's policy and procedure on menus, revised in 2017, indicated that menus should meet residents' nutritional needs and provide a variety of foods. However, there was no specific policy or procedure addressing plant-based menus, highlighting a gap in the facility's ability to cater to residents with specific dietary requirements.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 39 citations issued within 25 miles in the last 12 months — 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ukiah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ukiah Post Acute | 0.3 mi | ★★★★★ | 9 | 0 |
| Lakeport Post Acute | 16.5 mi | ★★★★★ | 1 | 0 |
| Rocky Point Care Center | 16.6 mi | ★★★★★ | 13 | 0 |
| Northbrook Healthcare Center | 20.9 mi | ★★★★★ | 16 | 0 |
| Cloverdale Healthcare Center | 25.7 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.