Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Ridgeway Post Acute during CMS and state inspections, most recent first.
Two residents with cognitive impairments were involved in a physical altercation, and the facility did not report the abuse allegation to the state agency within the required 2-hour timeframe. Staff and policy confirmed the reporting requirement, and the delay was acknowledged by the DON.
A resident was transferred to the hospital on two occasions without the required notification to the LTC Ombudsman. Staff interviews and record reviews confirmed that facility policy mandates Ombudsman notification for such transfers, but no documentation was found to show this occurred.
A resident with respiratory conditions repeatedly complained of headaches and throat irritation from a strong floral-scented air freshener used near their bedroom. Despite these complaints and the resident's request, the facility continued to use both spray and mechanical air fresheners in the hallway, and staff were unaware of the specific chemicals involved. The care plan acknowledged the resident's sensitivity but did not list it as an allergy, and the facility's policy on providing a homelike environment was not followed.
A nurse publicly told a resident that medication would be withheld until the resident took a shower, making the statement in front of other residents and staff. This action caused the resident to feel embarrassed and humiliated. Staff interviews confirmed the incident was inappropriate and not in line with facility policies requiring respect and privacy for all residents.
A resident with organ-limited amyloidosis was housed in a room with a damaged window sill, broken blinds, and peeling paint, conditions confirmed by both a CNA and the administrator. The resident reported discomfort and dissatisfaction with the environment, which did not meet the facility's policy for a safe, clean, and homelike setting.
A resident with a history of stroke and muscle weakness experienced pain and infection after staff failed to provide regular toenail care or arrange timely podiatry services, despite repeated complaints. The lack of documented foot care led to the development of cellulitis and ingrown toenails on all toes, ultimately requiring surgical removal of all toenails.
Two residents did not receive regular nail care, with long and dirty fingernails observed and no set schedule or documentation for nail trimming. Another resident did not receive scheduled showers or daily bed baths, with incomplete documentation of refusals and reasons. Staff interviews confirmed a lack of adherence to facility policies for personal hygiene and grooming.
A resident with a history of stroke and muscle weakness experienced significant pain from ingrown toenails and after a matrixectomy on all toes. Despite frequent reports of high pain levels and observable discomfort, staff did not develop or implement a pain management plan or use non-pharmacological interventions such as a bed cradle, resulting in ongoing pain and reduced mobility.
The facility failed to ensure residents wore their own clothing, affecting their dignity and well-being. A resident with dementia attended a family event in women's clothing, unaware due to his condition. Another resident felt disrespected seeing others in his clothes, which were gifts from his sister. Staff admitted to not checking clothing labels, violating the facility's dignity policy.
A facility failed to locate, replace, or reimburse personal items lost by three residents, including dentures and clothing. Despite notifying staff, the items were not recovered, and grievance reports were not updated. The facility did not adhere to its policies on safeguarding personal property and handling grievances, leading to unresolved issues for the residents.
A resident with multiple health conditions, including diabetes and peripheral vascular disease, did not receive proper wound care due to a failure in communication between the Wound Care PA and the Attending Physician. The PA's orders for bacitracin and a wound culture for a heel wound were not entered into the electronic medical system, and the Attending Physician did not review the wound care notes. This oversight was confirmed through interviews with the DON and licensed nurses, highlighting a deviation from the facility's standard procedure for handling verbal orders.
The facility failed to follow food safety and sanitation guidelines, with improper handwashing, inadequate temperature control, and cross-contamination risks observed. Staff did not use hair restraints, and food storage guidelines were not followed, with expired and undated items found. Equipment was unclean, and the kitchen environment was poorly maintained, increasing the risk of foodborne illness for residents.
The facility failed to ensure residents were treated with dignity and respect. A staff member was observed standing while assisting a resident with meals, contrary to the facility's expectation for a dignified dining experience. Additionally, three staff members were observed speaking Spanish in a resident care area, against the policy that staff should only speak a language other than English when communicating with residents in their native language. These actions were noted despite previous resident complaints about feeling ignored and uncomfortable.
The facility did not promptly address or resolve issues raised during resident council meetings, affecting 13 residents. Concerns about staff communication and delayed call light responses were documented without resolution. The Director of Staff Development failed to document training sessions adequately, excluding night shift staff. The facility's policy to track and address resident council issues was not followed.
The facility did not post the location of the survey results in an easily noticeable manner, affecting 76 residents' rights to examine them. The survey binder was found unlabeled and dusty in the entrance lobby, with no indication of its presence. It also lacked updates on complaints or incidents after January 2023. The Administrator confirmed the binder had not been updated since then and was in the process of labeling it. The facility's policy guarantees residents the right to examine survey results, which was not being honored.
The facility failed to maintain a homelike environment by using two shower rooms as storage, making them unusable for residents, and by allowing the smoking area to become dirty and unkempt. Residents reported issues with water temperature in the shower rooms and expressed dissatisfaction with the condition of the smoking area, which was cluttered with medical equipment and trash.
The facility failed to maintain safe water temperatures, with readings exceeding 120 degrees Fahrenheit in two showers and seven restroom faucets, posing a risk of scalds or burns. Despite repeated complaints from residents and staff, the issue persisted, with temperatures recorded as high as 136 degrees Fahrenheit. The facility's policy to keep water temperatures below 120 degrees was not followed.
A facility failed to provide proper pharmaceutical services, resulting in medication errors for three residents. An LPN did not verify a resident's identity before applying a Lidocaine Patch, which was not used according to instructions. Another LPN administered Metformin to the wrong resident and failed to document Tylenol administration. The facility's policies on medication verification and documentation were not followed.
The facility failed to manage and store medications properly, resulting in medication mix-ups among residents and non-compliance with temperature control standards. Medications for a discharged resident were not removed, and medications for four residents were stored incorrectly. Additionally, the medication room temperature exceeded the acceptable range, potentially affecting medication stability.
The facility failed to ensure adequate oversight in kitchen operations, resulting in deficiencies in food safety and sanitation. The CDM did not implement job-specific competency evaluations for new staff, leading to non-adherence to essential food safety practices. The RD's sanitation audits were incomplete, failing to address critical areas such as proper handwashing, monitoring of TCS foods, and cleanliness of equipment.
The facility did not adhere to standardized recipes, leading to unpalatable meals for residents. The preparation of Pacific Rim Pork Roast and Carrots with Parsley deviated from recipes, resulting in watery and improperly textured food. Residents reported the meals as tough, bland, and unappetizing. A test tray audit confirmed these issues, highlighting the facility's failure to ensure proper food preparation.
The facility failed to educate staff and visitors on safe food handling practices for food brought in from outside, as revealed through interviews with a Licensed Nurse, the DON, and the DSD. The facility's policy stated that outside food would not be reheated or stored, but there was no evidence of training on safe food handling. An in-service record lacked details on the material covered or competency assessment, and a document on food safety did not include safe handling information. These deficiencies could lead to unsafe food handling and foodborne illnesses for the 76 residents.
The facility failed to maintain a sanitary storage area for garbage and refuse, with an overflowing dumpster and littered surroundings, including dirty resident equipment. The Maintenance Supervisor confirmed the area was unclean, and the Administrator acknowledged the issue, suggesting a need for more frequent cleaning.
The facility failed to maintain the ice machine in proper working order, as observed during an inspection where black residue was found on its internal components. The Maintenance Supervisor admitted to not following the manufacturer's cleaning guidelines due to not knowing the model number. Additionally, the Registered Dietitian was unaware of how to inspect the internal components, only testing the ice bin's cleanliness. The facility's policy required monthly cleaning per the manufacturer's recommendations, which were not followed.
A resident was served pasta despite their known dislike for it, indicating a failure in honoring food preferences. The meal was initially delivered by unlicensed staff, and the CDM had to intervene to correct the meal. The CDM stated that both the diet aide and nurses are responsible for ensuring meal accuracy.
A resident in a long-term care facility was administered a new pain medication, MS Contin, without informing or obtaining consent from their medical decision-maker. This led to the resident becoming over-sedated and requiring naloxone to reverse the effects. The facility staff, including the DON, acknowledged the oversight, and the Medical Director confirmed the necessity of involving the resident's decision-maker in such decisions.
A resident with multiple medical conditions experienced increased confusion and blood in his urine, prompting a stat urinalysis and culture order. The specimen was rejected due to mislabeling, but the facility failed to collect a new sample or follow up, delaying diagnosis and treatment. The resident's condition worsened, resulting in hospitalization for septic shock and acute cystitis.
The facility failed to ensure an unlicensed staff member wore an N95 respirator while caring for COVID-19 positive residents. The staff member was observed wearing a surgical mask improperly, exposing her nose, despite the facility's policy and training requiring full PPE, including an N95 mask, for such situations. The Infection Preventionist confirmed the residents' COVID-19 status and the expectations for PPE use.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that an abuse allegation involving two residents was reported to the state licensing/certification agency within the required 2-hour timeframe. The incident involved two residents, both with moderately impaired thinking and memory as indicated by their BIMS scores of 10, and diagnoses including schizophrenia, major depressive disorder, and dementia. According to the SOC 341 form, one resident reported being punched in the face by their roommate, after which the resident retaliated by hitting the roommate on the right temple, and the roommate then hit back on the nose. The facility became aware of the incident at 5:10 a.m., but the SOC 341 form was not faxed to the state agency until 8:50 a.m., exceeding the 2-hour reporting requirement. Interviews with facility staff, including the MDS coordinator, Director of Staff Development, and Director of Nursing, confirmed that abuse allegations should be reported to the state within 2 hours of discovery, as outlined in the facility's policy and procedure. The Director of Nursing verified that the facility was aware of the abuse allegation at 5:10 a.m. and acknowledged that the report to the state was made late. The facility's policy defines "immediately" as within 2 hours for allegations involving abuse or resulting in serious bodily injury.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman when a resident was discharged and admitted to the hospital on two separate occasions. Interviews with facility staff, including the Minimum Data Set coordinator, Director of Staff Development, Director of Nursing, and Social Services Director, confirmed that notification of the Ombudsman is required by facility policy and is considered essential for resident safety. Record reviews verified that the resident was transferred to the hospital on two specific dates, but there was no documentation indicating that the Ombudsman had been notified of these transfers. The facility's policy and procedure on transfer and discharge notices, as well as state guidance, require that notice of transfer or discharge be provided to the Ombudsman. Despite this, the Social Services Director acknowledged that no documentation existed to show that the Ombudsman was notified for the resident's hospital transfers. This omission was confirmed through interviews and record reviews, establishing that the required notifications were not made as per policy.
Failure to Provide Homelike Environment Due to Air Freshener Use
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for a resident with significant respiratory diagnoses, including respiratory failure, acute bronchitis, and pulmonary hypertension. Despite repeated complaints from the resident about headaches and throat irritation caused by a strong floral-scented air freshener near his bedroom, the facility continued to use both spray and mechanical air fresheners in the hallway adjacent to his room. The resident had previously requested the removal of air fresheners, and while staff refrained from using spray air freshener in his bedroom, mechanical devices remained in use nearby. Staff interviewed were unaware of the specific chemicals in the air fresheners, and the maintenance assistant was not familiar with the devices or their contents. Observations confirmed a noticeable floral fragrance in the hallway outside the resident's room, and a mechanical air freshener device was found mounted on the wall near the ceiling, approximately six feet from the room. The care plan noted the resident's claim of being allergic to air fresheners, but this was not listed among his documented allergies, and no recent change in condition was recorded. The facility's policy emphasized providing a homelike environment with pleasant, neutral scents and minimizing institutional odors, but the continued use of air fresheners despite the resident's complaints and medical history constituted a failure to honor the resident's right to a safe and comfortable environment.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
A deficiency occurred when a licensed nurse made a humiliating comment to a resident in a public area of the facility, stating, "I am not going to give you your medication until you take a shower!" This statement was made in the presence of other residents and staff, resulting in the resident feeling embarrassed and humiliated. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic pain syndrome, osteoarthritis, hoarding disorder, and major depressive disorder, reported feeling disrespected and stated that the incident was deeply embarrassing. Multiple staff interviews confirmed that the nurse's actions were inappropriate and did not align with the facility's expectations for maintaining resident dignity and privacy. The Assistant Activities Director reported that the nurse had also expressed to her that the resident should not participate in activities until she showered, and confirmed hearing the nurse make the comment out loud in a public area. The Director of Nursing and the Administrator both stated that such matters should be addressed privately and that denying participation in activities or medication based on hygiene in a public setting is not acceptable. A review of the facility's policies and procedures on Resident Rights and Dignity indicated that all residents are to be treated with kindness, respect, and dignity, and that staff are expected to promote, maintain, and protect resident privacy. The policies specifically prohibit demeaning practices and require that residents be encouraged to attend activities of their choice. The nurse's public comment and actions were in direct violation of these established policies, resulting in a failure to honor the resident's right to dignity and respect.
Failure to Maintain Homelike Resident Room Environment
Penalty
Summary
The facility failed to provide a homelike environment for one resident when the window sill and blinds in the resident's room were found to be damaged, and there was peeling paint on the wall. Specifically, the window sill had two areas of missing or damaged wood, each about six inches in length, reportedly caused by staff moving beds in and out of the room. The horizontal blinds were missing approximately four inches from each strip along the right side, affecting two-thirds of the blind, which allowed more sunlight into the room and made it warmer. Additionally, there was a 12 x 12 inch area above the television with peeling paint, some of which had been painted over. The resident, who had organ-limited amyloidosis and no memory impairment, expressed dissatisfaction with the room's condition, stating it made him feel like he was "living in a dump." Both a CNA and the facility administrator confirmed the presence of the damage and agreed that the room was not homelike and required repair. The facility's policy required that residents be provided with a safe, clean, comfortable, and homelike environment, which was not met in this instance.
Failure to Provide Timely Foot Care Resulting in Pain and Surgical Intervention
Penalty
Summary
The facility failed to provide appropriate foot care, including timely toenail trimming, for one resident who was admitted with a history of intracerebral hemorrhagic stroke and muscle weakness. The resident repeatedly communicated to staff about discomfort and pain caused by long and ingrown toenails, which interfered with his ability to walk and wear shoes or socks. Despite these complaints, staff did not provide toenail care or arrange for timely podiatry services, and there was no documentation of nail care or cleaning being provided. The resident was not included in the list of those seen by the podiatrist during a facility visit, and staff interviews confirmed that daily nail care and regular trimming were not performed as required. The resident ultimately developed cellulitis and ingrown toenails on all toes, leading to a surgical procedure (matrixectomy) to remove all toenails. Interviews with staff, including the DON and Infection Preventionist, revealed that the facility did not attempt to arrange an earlier podiatry appointment or send the resident to an outside provider, and no documentation was provided to show such attempts were made. Facility policy required daily cleaning and regular trimming of nails, as well as documentation of care provided, but the facility was unable to produce records showing compliance with these requirements. The lack of timely and appropriate foot care resulted in the resident experiencing pain, infection, and the need for surgical intervention.
Failure to Provide Regular Nail Care and Scheduled Bathing
Penalty
Summary
The facility failed to provide adequate personal hygiene and grooming services to two out of three sampled residents. One resident, who had multiple sclerosis and muscle weakness and required assistance with activities of daily living, reported that staff did not trim her fingernails regularly despite repeated requests. Observations confirmed her fingernails were long, and she expressed discomfort and concern about accidental scratches. Staff interviews revealed there was no set schedule or reminder system for nail care, and documentation of nail care was lacking. Another resident was observed with long fingernails containing blackish material, which he identified as dirt. He stated that staff did not regularly offer to clean his hands or trim his nails, and he would have appreciated more frequent care. Staff and the Director of Staff Development acknowledged that long and dirty fingernails were unacceptable and could harbor bacteria, but were unaware of the facility's policy on nail care frequency and could not provide documentation of recent nail care for these residents. Additionally, the facility did not ensure that one resident received showers or bed baths as scheduled. Review of shower flow sheets showed that the resident received only a few showers and bed baths over a four-week period, with some refusals noted but without documentation of the reasons for refusal. The resident was observed to be unkempt and to have a urine odor, and he reported not receiving daily bed baths or regular showers. He also stated that staff had stopped asking if he needed assistance with bathing, and he did not complain because he assumed staff were too busy. Interviews with staff, including unlicensed staff, the DSD, and the DON, confirmed that residents were expected to receive showers several times a week and daily bed baths if showers were refused. Staff acknowledged that refusals and reasons should be documented, but this was not consistently done. Facility policies required daily cleaning and regular trimming of nails, as well as documentation of nail care and bathing, but these practices were not followed for the residents involved.
Failure to Develop and Implement Pain Management Plan for Post-Matrixectomy Resident
Penalty
Summary
The facility failed to develop and implement a pain management plan for a resident who was at high risk of experiencing pain due to ingrown toenails and following a matrixectomy procedure on all ten toes. The resident, who had a history of intracerebral hemorrhagic stroke and muscle weakness, was admitted in November 2024 and was previously able to ambulate with a walker. Documentation showed that the resident experienced significant pain, with reported pain levels ranging from 6 to 8 out of 10 on multiple occasions after the matrixectomy. Observations and interviews revealed that the resident experienced ongoing pain when blankets touched his bare nail beds, leading to grimacing, frustration, and feelings of depression. The resident reported that the pain from both the ingrown toenails and the post-surgical condition made it difficult to walk, resulting in a transition from using a walker to a wheelchair. Staff interviews confirmed awareness of the resident's pain and the potential for increased discomfort due to the lack of protective interventions, such as a bed cradle to prevent blankets from contacting the sensitive areas. A review of the resident's care plans indicated that no pain management strategies were documented for either the ingrown toenails or the post-matrixectomy period. The facility's own policy required assessment, recognition, and management of pain, including the use of non-pharmacological interventions when appropriate. Despite this, staff acknowledged that no such interventions were implemented, and the resident's pain was not adequately addressed through individualized care planning.
Failure to Ensure Residents Wear Their Own Clothing
Penalty
Summary
The facility failed to ensure that residents wore their own clothing, which compromised their dignity and sense of well-being. Resident 1, who has severe memory impairment due to dementia, was taken to a family Christmas party wearing women's clothing, which he was unaware of due to his condition. This incident was reported by a family member who had observed similar occurrences in the past. Upon inspection, it was found that Resident 1's closet contained clothing labeled with another resident's name, indicating a mix-up in the handling of personal items. Resident 6, who also has severe memory impairment, expressed feelings of disrespect and sadness when he saw other residents wearing his clothing. His clothing held sentimental value as they were gifts from his sister. During an observation, Resident 5 was seen wearing a shirt labeled with Resident 6's name, which he claimed to have bought from a thrift store. This was confirmed by a CNA who admitted to not checking the labels before dressing the residents. The facility's policy on dignity, which emphasizes the importance of respecting residents' private space and property, was not adhered to. The Director of Nursing acknowledged that CNAs are responsible for ensuring residents wear their own clothing, but this protocol was not followed, leading to the reported incidents. The failure to verify clothing ownership resulted in emotional distress for the residents involved.
Failure to Address Missing Personal Items
Penalty
Summary
The facility failed to ensure that three residents who lost personal items had their belongings located, replaced, or reimbursed. Resident 1, who had severe memory impairment due to dementia, lost his dentures approximately a year and a half ago. Despite notifying the Social Services Director (SSD) about the loss, the dentures were neither found nor replaced. Additionally, the inventory sheet for Resident 1 was not updated to reflect additional clothing brought by the responsible party, and it lacked the responsible party's signature. Resident 2, who had no memory impairment, lost all the clothing he was admitted with because he was not informed that his clothes needed to be labeled for identification. His clothes were never returned after being taken to the laundry, and he was unable to communicate effectively with housekeeping staff due to a language barrier. Despite notifying staff, his clothes were not located, reimbursed, or replaced. Resident 2 expressed that the loss of a blue jacket, a gift from his mother, was particularly significant. Resident 4, who also had no memory impairment, reported the loss of three dresses, two of which were reported missing six months prior. Despite filing a theft/loss report with the SSD, the dresses were not located, replaced, or reimbursed. The facility's grievance and missing items reports were not updated since April 2024, and there was no documented evidence of efforts to resolve these grievances. The facility's policies on safeguarding personal property and handling grievances were not followed, leading to unresolved issues and potential distress for the residents involved.
Failure to Communicate Wound Care Orders
Penalty
Summary
The facility failed to follow physician's orders for a resident when licensed nurses did not communicate the treatment orders written by a Wound Care Physician Assistant (PA) for a wound on the resident's left heel to the Attending Physician for approval and signature. This oversight was identified through interviews and record reviews, which revealed that the resident, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, Diabetic Polyneuropathy, and Peripheral Vascular Disease, had a stage 3 pressure wound on the coccyx and a suspected deep tissue injury on the left heel. The Wound Care PA had ordered bacitracin for the left heel wound and a wound culture, but these orders were not included in the Order Summary Report or the Treatment Administration Record (TAR) for the relevant period. Interviews with the Director of Nursing and licensed nurses confirmed that the orders from the Wound Care PA were not communicated to the Attending Physician, which was a deviation from the facility's standard procedure. The usual process involved the Wound Care PA communicating new orders to the treatment nurse, who would then relay them to the Attending Physician. However, in this case, the orders were not entered into the electronic medical system, and the Attending Physician did not review the wound care notes as part of his standard practice. The facility's policy on verbal orders required that such orders be documented and countersigned by the practitioner, but this process was not followed, leading to the deficiency in care for the resident's wound treatment.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by multiple observations and interviews. Staff members did not follow proper handwashing protocols, with one employee observed touching the trash can and wiping sweat from her face without washing her hands before continuing food preparation. Additionally, the cool down process for leftover foods was not documented, and the temperature control for safety (TCS) was not monitored, with cooked foods stored at improper temperatures. The facility's thawing process was also not followed, as meats were not labeled with pull and use-by dates. Cross-contamination risks were present, with personal items such as a glass of water and a pen found in food preparation areas, and incorrect cutting boards used for different types of food. Cleaning cloths were not stored in sanitizing solutions between uses, and hair restraints were not utilized by staff, increasing the risk of contamination. Food storage guidelines were not followed, with expired and undated items found in the refrigerator and dry storage areas. Equipment and utensils were not clean or in good working order, with dirty and worn items observed, and kitchen cleaning equipment was improperly stored. The kitchen environment was not maintained, with unclean walls, peeling paint, and dirty ceiling vents. Ice packs intended for personal use were stored with food, and the temperature log used was inappropriate for food storage. The manual dishwashing process was inconsistent with the facility's policy, as the immersion time for sanitizing dishes did not match the manufacturer's instructions. These deficiencies increased the risk of foodborne illness for the 76 residents consuming food prepared in the facility's kitchen.
Failure to Ensure Dignity and Respect for Residents
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect in two observed instances. In the first instance, a staff member was observed standing while assisting a resident with meals, which is against the facility's expectation that staff should be seated to provide a dignified dining experience. The staff member admitted to standing while assisting the resident and stated that they had not asked residents if they were comfortable with this practice. The Director of Staff Development confirmed that staff were expected to sit while assisting residents with meals and that in-services had been conducted on this expectation. In the second instance, three staff members were observed speaking Spanish in a resident care area, which was against the facility's policy that staff should only speak a language other than English when communicating with residents in their native language. This behavior was noted despite previous complaints from residents about staff speaking in languages other than English, which made them feel ignored and uncomfortable. The Director of Staff Development confirmed that staff were not allowed to speak a language other than English in resident care areas unless speaking to a resident in their native language, and that the Administrator had recently in-serviced staff on this requirement.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to promptly respond to and resolve concerns raised during resident council meetings, affecting a sample of 13 residents. During a meeting, a resident expressed that issues discussed were not addressed in a timely manner, often resolved only the day before the next meeting. The July 2024 resident council minutes documented complaints about staff speaking in their native language, which upset some residents. However, the facility's response form was left blank, indicating no action was taken. Similarly, the August 2024 minutes recorded concerns about the alarm system and delayed call light responses, with no documented resolutions. Interviews with the Activities Director and the Director of Staff Development (DSD) revealed that concerns were directed to appropriate departments, but responses were not documented. The DSD, new to her position, acknowledged the lack of documentation for staff training sessions intended to address these concerns. Training records showed incomplete information, with only a few staff members attending, and night shift staff largely excluded. The facility's policy required tracking and addressing issues raised by the resident council, but this was not adhered to, leading to unresolved resident care concerns.
Failure to Post Survey Results Noticeably
Penalty
Summary
The facility failed to post the location of the survey results in an easily noticeable manner, which affected the rights of 76 residents to examine the facility's survey results. During an interview and record review, the Activities Director admitted that she did not discuss the location of the survey binder during regular resident council meetings. The survey binder was found on a shelf in the entrance lobby, covered with dust and unlabeled, with no postings indicating its presence. Additionally, the Director of Nursing confirmed that the survey binder did not include results of complaints or facility-reported incidents investigated after January 2023. The Administrator acknowledged that the survey binder had not been updated since January 2023 and was in the process of labeling it for easy identification. The facility's policy on Residents' Rights, last revised in February 2021, guarantees residents the right to examine survey results, which was not being honored due to these oversights.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a safe, functional, and comfortable environment for its residents by using two of the three shower rooms as storage spaces, which compromised their intended use. Residents reported issues with water temperature in the shower rooms, with one room having scalding hot water and another having cold water. The Chablis Hall shower room was cluttered with lifts and shower chairs, making it impossible to maneuver a resident in a shower chair for bathing. The Merlot Hall shower room was similarly crowded with equipment, leaving little room for residents. These conditions were confirmed by an unlicensed staff member who noted the difficulty in using the shower rooms due to the stored equipment. Additionally, the facility's smoking area was found to be dirty and unkempt, detracting from a homelike environment. Residents and staff observed that the smoking area, located in a wooden shed at the back of a patio, was filled with medical equipment, tarps, and dirty laundry. The area was covered with dust, spider webs, and trash, and the fire blanket was soiled and rusted. Residents expressed dissatisfaction with the condition of the smoking area, stating it did not feel like home. The facility's policy on providing a homelike environment was not upheld, as the smoking area and shower rooms were not maintained in a clean, sanitary, and orderly manner.
Unsafe Water Temperatures in Facility Showers and Faucets
Penalty
Summary
The facility failed to maintain a safe environment for its residents by allowing water temperatures in two showers and seven restroom faucets to exceed 120 degrees Fahrenheit, posing a risk of scalds or burns. This issue was highlighted during a Resident Council meeting where residents expressed concerns about the excessively hot water in the Merlot Hall shower. Despite repeated complaints from residents and staff over several months, the problem persisted, with water temperatures recorded as high as 136 degrees Fahrenheit in some areas. Observations and interviews conducted on 9/27/24 confirmed the ongoing issue, with multiple residents and staff members reporting dangerously high water temperatures in the Merlot Hall shower and other areas. The facility's policy, which mandates water temperatures not exceed 120 degrees Fahrenheit, was not adhered to, as evidenced by the recorded temperatures. The Maintenance Supervisor acknowledged the problem, and staff reported having to use alternative showers due to the unsafe conditions in Merlot Hall.
Medication Administration Errors and Documentation Failures
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for three residents, leading to medication administration errors. Licensed Nurse A did not verify the identity of a resident before administering a Lidocaine Patch, which was not applied according to the package instructions. The patch was left on for more than the recommended 12 hours, as the nurse was unaware of the correct application instructions. This oversight was confirmed by the Director of Nursing, who noted that the physician's order was unclear and needed revision. Additionally, Licensed Nurse B administered Metformin, a diabetes medication, to a resident for whom it was not prescribed, and failed to document the administration of Tylenol to the same resident. The facility's policy requires verification of resident identity and proper documentation of medication administration, which was not followed in these instances. The Director of Nursing confirmed the lack of documentation for the Tylenol administration, highlighting a breach in the facility's medication administration procedures.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications, leading to significant deficiencies. During an inspection of the medication cart, it was observed that medications belonging to a discharged resident were not removed and were stored among another resident's medications. Additionally, medications for four residents were found in incorrect compartments, which included Gabapentin, Tamsulosin hydrochloride, Metformin, and Pantoprazole being mixed up among different residents' medications. Licensed Nurse B confirmed these discrepancies but could not provide an explanation, suggesting that the evening nurse might have returned the medications to the wrong places. The facility's policy on discontinued medications was not followed, as medications were not removed from the cart in a timely manner after a resident's discharge. Furthermore, the facility failed to maintain the medication room temperature within the required range of 68 to 77 degrees Fahrenheit. During an observation, two thermometers in the medication storage room both read 81 degrees Fahrenheit, exceeding the acceptable temperature range. Licensed Nurse E and the Regional Nurse Resource confirmed the elevated temperature, which was not in compliance with the facility's policy and the United States Pharmacopeia standards. This failure to control the room temperature could potentially affect the stability and efficacy of the stored medications.
Inadequate Oversight in Kitchen Operations Leads to Food Safety Deficiencies
Penalty
Summary
The facility failed to ensure that the Certified Dietary Manager (CDM) and the Registered Dietitian (RD) adequately oversaw kitchen operations, leading to deficiencies in food safety and sanitation. The CDM did not implement job-specific competency evaluations for new kitchen staff, relying instead on general orientation and shadowing without documented competency assessments. This lack of oversight resulted in staff not adhering to essential food safety practices, such as proper hand hygiene, monitoring the cool down process for time-temperature control for safety (TCS) foods, following thawing guidelines, preventing cross-contamination, and using hair restraints. Additionally, cleaning cloths were not stored in sanitizing solutions between uses, and facility recipes were not consistently followed. The RD's oversight was also insufficient, as the sanitation audits conducted did not comprehensively address critical areas of concern. The audits failed to evaluate proper handwashing, monitoring of TCS foods, adherence to thawing processes, prevention of cross-contamination, and cleanliness of food preparation equipment. Furthermore, the audits did not ensure proper storage of kitchen cleaning equipment, accurate temperature monitoring of the resident nourishment refrigerator, or correct manual dishwashing procedures. The RD acknowledged that the sanitation audit was incomplete and required a more thorough approach to ensure food safety and sanitation standards were met.
Failure to Follow Recipes Results in Unpalatable Meals
Penalty
Summary
The facility failed to ensure that meals were prepared according to standardized recipes, resulting in unpalatable and improperly textured food for residents. Specifically, the preparation of Pacific Rim Pork Roast and Carrots with Parsley did not follow the prescribed recipes. The cook added an excessive amount of water to the pork roast, resulting in a watery mixture, and did not measure the instant mashed potatoes, leading to a chunky texture that was not suitable for a pureed diet. Additionally, the carrots were prepared without salt, contrary to the recipe instructions, which contributed to the lack of flavor. These deviations from the recipes were confirmed by the Registered Dietician (RD) and observed during meal preparation. Residents expressed dissatisfaction with the meals, describing the meat as tough and lacking flavor, and the food as bland and unappetizing. During a test tray audit, the Certified Dietary Manager (CDM) and RD confirmed that the carrots tasted watery and the pork roast was difficult to cut and chew. Residents also reported that the eggs were rubbery and the meat was undercooked. These findings indicate that the facility's failure to adhere to standardized recipes and ensure proper food preparation negatively impacted the quality and palatability of meals served to residents.
Lack of Safe Food Handling Education for Staff and Visitors
Penalty
Summary
The facility failed to ensure that both staff and resident visitors were educated on safe food handling practices, particularly concerning food brought in from outside for resident consumption. Interviews with facility staff, including a Licensed Nurse (LN L), the Director of Nursing (DON), and the Director of Staff Development (DSD), revealed that there was no training provided on safe food handling. LN L confirmed that outside food was never heated and had to be discarded if removed from the refrigerator. The DON was unable to confirm whether staff and visitors were educated on safe food handling practices. The DSD, who had been with the facility for two months, stated she had not conducted any in-service training on safe food handling and was unsure if the previous DSD had done so. The facility's policy on personal food storage indicated that individuals would be educated on safe food handling and storage techniques as needed, but there was no evidence of such training being conducted. The policy also stated that the facility would not store or reheat any outside food. A review of the in-service attendance record for a session titled "Storing Food in the Refrigerator" showed no instructor details, summary of material covered, or any method to assess employee competency. Additionally, a document titled "Food Safety for Your Loved One" lacked information on safe food handling practices. These deficiencies had the potential to lead to unsafe food handling and foodborne illnesses, affecting the 76 residents in the facility.
Improper Garbage and Refuse Storage
Penalty
Summary
The facility failed to maintain a sanitary storage area for garbage and refuse, as observed during a survey. One dumpster was overflowing with trash, preventing the lid from closing, and the surrounding area was littered with various items, including empty cardboard boxes, dirty mops, and resident equipment such as bedframes and wheelchairs. The Maintenance Supervisor confirmed that the trash area was not clean and that the resident equipment was stored outside waiting to be cleaned, which was scheduled to occur every Thursday. Additionally, the kitchen was found to have used soda cans stored in an open container under a counter. The Administrator acknowledged that the dirty resident equipment had been kept outside and suggested that the cleaning schedule might need to be more frequent. The report references the USDA Food Code 2022, which requires refuse to be stored in a manner that is inaccessible to pests and covered with tight-fitting lids. The facility's failure to adhere to these standards increased the potential for harboring pathogens and attracting pests.
Failure to Maintain Ice Machine Cleanliness
Penalty
Summary
The facility failed to maintain essential equipment in proper working order, specifically the ice machine located in the kitchen dry storeroom. During an observation and interview with the Maintenance Supervisor (MS), it was revealed that the ice machine had not been cleaned according to the manufacturer's guidelines. The MS stated that he cleaned the ice machine monthly, with the last cleaning occurring on 8/13/24. However, upon inspection, black residue was found on the internal components of the ice machine, including the ice harvester curtain and ice sensor. The MS confirmed these findings and admitted to skipping a crucial step in the cleaning process because he did not know the model number of the ice machine. Further interviews with the Registered Dietitian (RD) revealed a lack of awareness regarding the inspection of the internal components of the ice machine. The RD stated that she only wiped the inside of the ice bin to test for cleanliness and was not aware of how to inspect the internal components. The facility's policy and procedure for ice machine cleaning, dated 2023, indicated that the ice machine should be cleaned and sanitized monthly per the manufacturer's recommendations. However, the manufacturer's cleaning instructions were not followed, as the MS used an incorrect cleaning solution ratio and skipped steps in the sanitizing procedure.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, leading to a deficiency in dietary services. During a lunch meal observation, a resident who disliked pasta was served spaghetti with meat sauce, despite their known preference against it. The meal was delivered by an unlicensed staff member, who confirmed the resident's dislike for pasta. Upon notification, the Certified Dietary Manager (CDM) intervened and replaced the meal with an alternative that included rice instead of pasta. An interview with the CDM revealed that the diet aide was responsible for ensuring meal accuracy according to the meal ticket, and nurses were also expected to check meal trays for diet accuracy.
Failure to Inform Resident's Decision-Maker of Medication Change
Penalty
Summary
The facility failed to honor the rights of a resident, identified as Resident 5, by not informing or obtaining consent from the resident's medical decision-maker, Family Member 2 (FM2), before administering a new pain medication, MS Contin (morphine sulphate). This oversight led to Resident 5 becoming over-sedated, necessitating the administration of naloxone to reverse the effects of opiate toxicity. The incident occurred after Resident 5, who suffered from arthritis and other medical conditions, was prescribed morphine by a new physician, Physician J, without FM2's knowledge or consent. Interviews and record reviews revealed that Resident 5 had been previously prescribed Norco for pain management, which was changed to oxycodone as needed. However, due to inadequate pain control, the facility's staff contacted Physician J, who ordered MS Contin without consulting FM2. The medication administration record showed that Resident 5 received multiple doses of MS Contin and oxycodone, leading to an opioid overdose and altered mental status. Despite the critical change in medication, there was no documentation of any discussion with FM2 regarding the risks and benefits of the new pain management regimen. Interviews with facility staff, including Licensed Nurses F and G, and the Director of Nursing (DON), confirmed that FM2 was not informed of the medication changes. The DON acknowledged that it was the responsibility of the nurse who took the medication order to notify the resident's responsible party. The Medical Director also verified that the resident or their decision-maker should be involved in decisions regarding changes to pain medication regimens. The facility's policy on resident rights emphasized the importance of involving residents and their families in care planning and treatment decisions, which was not adhered to in this case.
Failure to Follow Up on Stat Lab Order Leads to Resident Hospitalization
Penalty
Summary
The facility failed to follow up on a stat laboratory order for a resident, resulting in a delay in diagnosis and treatment. The resident, who had multiple medical diagnoses including schizoaffective disorder and cognitive communication disorder, exhibited increased confusion and blood in his urine. A stat urinalysis and culture and sensitivity test were ordered, but the specimen was rejected by the lab due to being mislabeled. Despite this, the facility did not collect a new specimen or follow up with the lab, leading to a delay in addressing the resident's condition. Interviews with staff revealed a lack of communication and follow-up regarding the lab results. The Infection Preventionist was preoccupied with COVID response testing and did not track the urine sample. Licensed nurses involved in the resident's care acknowledged the responsibility to follow up on lab results but failed to do so. The Director of Nursing was absent during the critical period, and the clinical interdisciplinary team did not adequately address the resident's change in condition or the missing lab results. The resident's condition worsened, leading to hospitalization where he was diagnosed with septic shock and acute cystitis. The facility's policy required prompt execution of diagnostic orders, but this was not adhered to, resulting in a significant health decline for the resident. The deficiency highlights a breakdown in the facility's processes for handling urgent medical orders and ensuring timely follow-up on critical lab results.
Failure to Use Proper PPE for COVID-19 Positive Residents
Penalty
Summary
The facility failed to ensure that an unlicensed staff member, referred to as Unlicensed Staff B, wore an N95 respirator while caring for COVID-19 positive residents. During an observation, Unlicensed Staff B was seen wearing a gown, gloves, and a surgical mask that was pulled low on her face, exposing her nose, while attending to residents who were confirmed to be COVID-19 positive. This was confirmed by Licensed Staff C, who also observed the improper use of a surgical mask by Unlicensed Staff B. The Infection Preventionist (IP) confirmed that the residents in the room were COVID-19 positive and stated that staff are expected to wear full Personal Protective Equipment (PPE), including an N95 mask, goggles, gloves, and a gown, when entering rooms with COVID-19 positive patients. The facility's policy, revised in September 2022, also mandates the use of an N95 mask in such situations. Despite in-service training provided to all staff on the proper use of PPE, the IP noted that some staff do not adhere to the training, which was evident in this incident.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 584 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Petaluma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Petaluma Post-acute Rehabilitation | 0.1 mi | ★★★★★ | 9 | 0 |
| Hillcrest Post Acute | 0.1 mi | ★★★★★ | 29 | 0 |
| North Bay Post Acute | 0.7 mi | ★★★★★ | 24 | 0 |
| Vineyard Post Acute | 2.6 mi | ★★★★★ | 28 | 0 |
| Novato Healthcare Center | 9.5 mi | ★★★★★ | 44 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.