Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spring Lake Village during CMS and state inspections, most recent first.
Failure to use EBP for two residents with open wounds. One resident had a new stage 2 PU on the coccyx, and another resident had an open wound on the left shin with watery exudate. Staff observed no EBP signage by the resident's door, and an LN and PA did not wear a gown during wound care. The LN and IPN both verified the residents should have been on EBP because their wounds required dressing changes.
A resident with muscle weakness, gait and mobility impairment, and severe cognitive impairment was observed sitting on a pommel cushion in a wheelchair without a physician order, prior assessment, or care plan documentation. The resident said the cushion was uncomfortable, while the DON and LPN confirmed it was being used for fall risk despite no documented monitoring or evidence that it was safe and necessary; the DOR later determined an anti-thrust cushion was more appropriate.
Failure to provide nail care and maintain grooming for two residents was identified when their fingernails were observed to be long and dirty with brownish material or dirt underneath. One resident with spinal stenosis and trochanteric bursitis and another resident with Alzheimer’s disease and major depressive disorder both had care plans directing staff to check, trim, and clean nails, yet staff verified the nails were not maintained as expected. Interviews confirmed the residents were dependent on staff for nail care and that long, dirty nails were not acceptable.
A resident at high risk for pressure injury developed an in-house stage 2 coccyx PU after staff did not consistently reposition her or check and change her for incontinence. Records showed she was only turned once per shift and incontinence checks were often limited to the start and end of shifts, while observations found her lying on her back in bed repeatedly. The RD and interim DON verified the wound was preventable and related to incontinence and prolonged supine positioning.
A resident accused a CNA of sexual abuse, and although the CNAs reported the allegation to an LPN, the LPN did not escalate the report to the DON or Administrator as required. The incident was not reported to the Department of Public Health within the mandated timeframe, resulting in a delay in notifying authorities and initiating an investigation.
The facility failed to implement Enhanced Barrier Precautions for residents with indwelling devices, as staff were unaware of the guidelines. Personal care items were improperly labeled and stored, increasing cross-contamination risks. A resident's urinal was unlabeled, and a nasal cannula was found on the floor, contrary to facility policies.
The facility did not maintain an effective infection control training program related to Enhanced Barrier Precautions (EBP). The Infection Preventionist RN and the Director of Staff Development were unaware of EBP, resulting in no policy, procedure, or staff training on the matter. This was contrary to CDC guidance and the California Department of Public Health's directive for skilled nursing facilities to implement EBP to reduce the transmission of multidrug-resistant organisms.
The facility failed to follow food safety and sanitation guidelines, with staff not wearing hair nets, cutting boards in poor condition, dented cans not discarded, and improper storage of dry goods. Expired and unlabeled food items were found, and expired sanitizer was used for washing vegetables, posing a risk to the medically fragile resident population.
The facility failed to meet the needs of two residents. A resident with Alzheimer's disease had a call light out of reach, contrary to facility policy. Another resident with congestive heart failure experienced delays in receiving assistance to get out of bed, impacting her ability to attend therapy. Staff acknowledged these issues, which were observed during the survey.
The facility failed to maintain a safe and homelike environment by not properly labeling and storing personal use items. Personal items were found in unlabeled wash basins in shared restrooms, and a resident's item was misplaced on a roommate's table. Staff interviews confirmed these practices were against facility policy, which requires labeling and proper storage to prevent cross-contamination.
The facility failed to implement care plans for two residents, one with Alzheimer's and another with dementia. A resident at risk for falls did not have fall mats on both sides of the bed, and another resident with heel redness had heels touching the mattress despite needing elevation. These oversights were confirmed by RNs during observations.
A facility failed to document weekly skin assessments for a resident with a right heel pressure ulcer, despite policy requirements. The resident, diagnosed with Parkinson's disease, had a Stage II pressure ulcer, but assessments were missing for several weeks, potentially delaying treatment. Interviews confirmed the expectation for weekly assessments, which were not documented in the electronic health record.
The facility failed to store shower disinfectant in a locked container as required by policy. An unlocked container with disinfectant was found in the shower room, despite signage indicating it should be locked. Interviews with staff confirmed the disinfectant should have been secured, and the facility's policy mandates that chemicals be stored in a locked area when not in use.
A resident with cancer under hospice care experienced unrelieved pain due to delays in administering prescribed pain medications. Despite having orders for Oxycodone and Morphine, the staff failed to provide timely relief, with significant delays noted in medication administration. Interviews revealed that the facility's pain management protocol was not followed, leading to the resident's ongoing discomfort.
A facility experienced a 12.2% medication error rate due to improper administration of medications. A resident received Pradaxa without sufficient water and Furosemide despite low blood pressure. Another resident's medications, including Aspirin, Oxybutynin, and Potassium Chloride, were administered late. These errors were against the facility's medication administration guidelines.
A resident with chronic hepatitis received excessive doses of acetaminophen, exceeding the prescribed 2,000 mg daily limit over several months. The DON and MD acknowledged the error, and the pharmacist had recommended order clarification, which was not acted upon. This failure to adhere to medication administration policies posed a risk of hepatotoxicity.
The facility failed to properly store and label drugs and biologicals. Controlled drugs were discarded in an unsecured Smart Sink, risking drug diversion. Additionally, a resident's oxygen humidifier bottle was opened and undated, contrary to facility policy, increasing the risk of bacterial growth.
The facility failed to ensure kitchen staff were competent in testing sanitizer levels in the 3-compartment sink, leading to incorrect readings outside the recommended range. The Executive Chef admitted to not properly demonstrating the procedure, and a Dishwasher was unable to correctly test the sanitizer mixture. This posed a risk of serving food on unclean dishes to 47 medically fragile residents.
The facility failed to label and date resident personal foods in the communal refrigerator, risking the consumption of expired food. During an observation, a pizza box and a package with crackers, cheese, and salami were found unlabeled and undated. An LVN confirmed the need for proper labeling, as per the facility's policy requiring outside food to be stored in labeled containers with the resident's name, room number, date brought, and use-by date.
The facility failed to ensure that one of two outside dumpsters had a lid, potentially attracting pests and rodents. During an observation with the Executive Chef, it was noted that the compactor dumpster was missing a lid and contained overflowing garbage with food and waste. The FDA Food Code and the facility's policy both require tight-fitting lids on outside receptacles.
Failure to Use EBP for Residents With Open Wounds
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were implemented for two residents with open wounds. Resident 29 was admitted with diagnoses including spinal stenosis and trochanteric bursitis, and a progress note dated 1/12/26 indicated she developed a new stage 2 pressure ulcer on her coccyx while at the facility. Resident 45 was admitted with diagnoses including dementia and syncope, and a progress note dated 1/21/26 indicated he had an open wound on his left shin present on admission with clear watery fluid exudate. During an observation on 1/20/2026, there was no EBP signage noted by Resident 45's door, and the LN and PA who treated his wound did not wear a gown when providing wound care. During a concurrent observation and interview on 1/21/2026, the LN verified Resident 29 was not on EBP but should have been because she had a stage 2 PU on her coccyx. The LN also verified Resident 45 did not have EBP signage by his door and stated he should have been placed on EBP because he had an open wound on his left lower leg requiring daily treatment and a dry dressing. The IPN stated both residents should have been placed on EBP because they had open wounds requiring wound dressing as part of wound treatment.
Unordered Pommel Cushion Used Without Assessment or Monitoring
Penalty
Summary
The facility failed to ensure one resident was free from the use of a physical restraint when the resident was observed sitting on a pommel cushion in the wheelchair without a physician order, without a prior assessment, and without documentation in the care plan. The resident had an admission diagnosis of muscle weakness and unspecified abnormalities of gait and mobility, and a BIMS score of 7 out of 15, consistent with severe cognitive impairment. The resident’s MDS indicated wheelchair use, but the physician order summary and care plans did not include a pommel cushion. During observation and interviews, the resident stated she was not sure why the pommel cushion was being used and reported it could be uncomfortable in the groin and inner thigh area. The interim DON stated the cushion was being used because the resident was at risk for falls, while the licensed nurse verified there was no physician order, no assessment before use, no care plan for the cushion, and no indication staff were monitoring the resident while it was in use. The DON acknowledged the facility could not provide documentation showing the pommel cushion was safe and necessary, and the DOR later changed the cushion to an anti-thrust cushion after determining that was more appropriate.
Failure to Provide Nail Care and Maintain Grooming
Penalty
Summary
The facility failed to ensure two residents received grooming care when their fingernails were long and had brownish material or dirt underneath. Resident 29 was admitted with spinal stenosis and trochanteric bursitis, and the care plan for self-care and mobility deficit directed staff to check nail length and trim and clean nails on bath day and as necessary. Resident 16 was admitted with Alzheimer’s disease and major depressive disorder, and the care plan for self-care and mobility deficit also directed staff to check nail length and trim and clean nails on bath day and as necessary. During a concurrent observation and interview, Resident 16’s fingernails were found to be long, dirty, and with brownish material underneath, and Unlicensed Staff C verified the resident was dependent on staff for nail care. Later, Resident 29’s fingernails were observed to be long and dirty, and the resident stated no one had offered to clean or trim the nails and that the resident wanted someone to take care of it. The IPN verified Resident 29’s fingernails were long and had dirt underneath, and staff interviews confirmed that long, dirty fingernails were not acceptable and that residents’ nails were expected to be kept clean and trimmed.
Failure to Reposition and Manage Incontinence Led to a Coccyx Pressure Ulcer
Penalty
Summary
The facility failed to preserve skin integrity for one resident who was at high risk for pressure injury development. The resident had diagnoses including spinal stenosis and trochanteric bursitis, was assessed as having moderately impaired cognition, was totally dependent on staff for toileting hygiene, and required moderate assistance to roll in bed. A Braden score of 12 indicated high risk for pressure ulcers, and the resident did not have any unhealed pressure ulcers at the time of the MDS assessment. The resident later developed a new stage 2 pressure ulcer on the coccyx that was documented as acquired in-house. The interdisciplinary team noted the pressure ulcer was related to incontinence and lying on the resident's back. The care plan initiated after the wound was identified included avoiding flat supine positioning, using pillows to relieve pressure, and encouraging small frequent positional changes. Record review showed the resident was only repositioned once per shift and was checked for incontinence mostly at the beginning and end of shifts, with one interval of 10 hours between checks. During observations, the resident was repeatedly found lying on her back in bed, and the resident stated staff did not reposition her frequently and did not promptly change her briefs. The RD and interim DON both verified the wound was preventable and that the documentation showed the resident was not being repositioned or checked and changed for incontinence as often as required.
Failure to Immediately Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to implement its policy requiring the immediate reporting of abuse allegations when a resident accused a Certified Nursing Assistant (CNA) of sexual abuse. On 4/13/25, the resident informed staff of the alleged abuse, and both CNAs present reported the incident to a Licensed Nurse (LN). The LN removed the resident from the CNA's assignment but did not report the allegation to the Director of Nursing (DON) or the Administrator as required by facility policy. The incident was not reported to the California Department of Public Health until 4/15/25, which was outside the mandated reporting timeframe. Interviews confirmed that the CNAs followed internal reporting procedures by notifying the LN immediately after the resident's accusation. However, the LN failed to escalate the report to higher management or the appropriate authorities in a timely manner. The facility's policy, revised in August 2022, mandates that all employees report known or suspected abuse immediately, and that a report must be sent to the licensing agency within two hours of forming the suspicion. This lapse resulted in a delay in notifying the authorities and potentially delayed the investigation and protective actions for the resident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of adherence to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Four residents were identified as not receiving the necessary precautions, including the use of gowns and gloves during high-contact care activities. Staff members, including Licensed Vocational Nurses and Certified Nursing Assistants, were unaware of EBP guidelines, and there was no signage to alert staff of the required precautions. The Infection Preventionist and Director of Staff Development also confirmed their lack of knowledge about EBP, resulting in no policy or training being implemented. Additionally, the facility did not properly label and store personal care items, increasing the risk of cross-contamination. A resident's urinal was found unlabeled on a bedside table, contrary to the facility's policy that requires labeling and proper storage in a plastic bag. This oversight was acknowledged by a Licensed Vocational Nurse, who confirmed the urinal should have been labeled and stored correctly. Furthermore, another resident's nasal cannula was found on the floor instead of being stored in a plastic bag when not in use, as per the facility's oxygen therapy policy. A Certified Nurse Assistant admitted the nasal cannula should have been placed in a bag to prevent contamination. The Infection Preventionist confirmed the facility's policy for storing nasal cannulas to prevent infection was not followed.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control training program concerning Enhanced Barrier Precautions (EBP), as per the Centers for Disease Control (CDC) guidance. During an interview, the Infection Preventionist Registered Nurse (IP/RN) and the Director of Staff Development (DSD) admitted they were unaware of what EBP entailed. Consequently, they had not developed a policy or procedure nor trained the staff regarding EBP. This oversight was identified during a review of an All Facilities Letter from the California Department of Public Health, which indicated that skilled nursing facilities should implement EBP as part of their infection control measures. The CDC Recommendations highlighted that EBP involves the use of gowns and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes, particularly for residents with wounds or indwelling medical devices.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as observed during a survey. Two kitchen staff members were found not wearing hair nets while in the kitchen, which is against the facility's policy requiring hair restraints for all kitchen personnel. Additionally, five green cutting boards were in poor condition, with deep grooves and grime buildup, making them unsuitable for use according to the facility's policy. Dented cans were found in the dry storage room, which should have been discarded as per the facility's guidelines. Furthermore, six boxes of dry goods were improperly stored directly on the floor, violating the policy that requires items to be stored at least six inches above the floor. The survey also revealed multiple expired food items in the dry storage room and refrigerators, which should have been discarded according to the facility's policy. Several food items were found unlabeled and undated, which is against the policy requiring all unused portions and open packages to be labeled and dated. Additionally, the sanitizer used for washing vegetables was expired, posing a risk to food safety. These deficiencies collectively posed a risk for foodborne illness among the facility's medically fragile resident population of 47.
Failure to Meet Residents' Needs and Preferences
Penalty
Summary
The facility failed to ensure that Resident 29's needs were met when the call light was not within reach. During an observation, it was noted that Resident 29, who has Alzheimer's disease and weakness, was lying in bed without the call light accessible. This was confirmed by a Registered Nurse who acknowledged that the call light should have been within reach. The facility's policy on the resident call system mandates that the means to call for assistance should be within the resident's reach. Additionally, the facility did not meet the needs of Resident 37, who has congestive heart failure and requires assistance with dressing, toileting, and transferring out of bed. Resident 37 expressed frustration over the delay in receiving assistance, which affected her ability to attend a scheduled therapy session. Observations confirmed that Resident 37 was still in bed wearing a gown, waiting for staff assistance. A Certified Nurse Assistant acknowledged Resident 37's complaints about the delay in getting out of bed. The facility's policy on ADL care requires nursing staff to provide daily care to meet each resident's individual needs.
Failure to Properly Label and Store Personal Use Items
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents by not properly labeling and storing personal use items. During observations, personal items such as toothbrushes, toothpaste, and combs were found in a shared restroom for multiple residents, stored in an unlabeled wash basin. This oversight was confirmed during an interview with a Certified Nurse Assistant (CNA), who acknowledged that the room number should be on the wash basin, but not the resident's name. This lack of proper labeling and storage had the potential to cause illness and cross-contamination among the medically compromised population. Additionally, a specific incident was noted where a resident's personal use item was found on their roommate's bedside table, contrary to the facility's policy. Interviews with staff, including another CNA and the Director of Staff Development (DSD), confirmed that wash basins should not be shared and should be labeled with the resident's first and last name. The facility's policy, reviewed during the investigation, clearly stated that bedside equipment should be labeled and stored in a plastic bag between uses to prevent cross-contamination. The failure to adhere to these procedures was identified as a deficiency in maintaining a safe and homelike environment for residents.
Failure to Implement Care Plans for Fall Prevention and Skin Integrity
Penalty
Summary
The facility failed to implement the care plan for Resident 29, who was at risk for falls due to Alzheimer's disease and weakness. Despite having a care plan intervention to place fall mats on both sides of the bed, an observation on February 10, 2025, revealed that Resident 29 was lying in bed without a fall mat on the right side. This was confirmed by Registered Nurse 5, who acknowledged the need for fall mats on both sides to prevent serious injury. Similarly, the facility did not adhere to the care plan for Resident 22, who had dementia and right heel redness requiring elevation of the heels while in bed to prevent further skin breakdown. Observations from February 9 to February 12, 2025, showed that Resident 22's heels were in contact with the mattress, contrary to the care plan's instructions. Registered Nurse 8 confirmed the need for heel elevation to prevent worsening of the skin condition.
Failure to Document Weekly Skin Assessments for Pressure Ulcer
Penalty
Summary
The facility failed to conduct and document weekly skin assessments for a resident with a right heel pressure ulcer. The resident, who was admitted with Parkinson's disease, had a documented Stage II pressure ulcer on the right heel as of November 8, 2024. Despite the facility's policy requiring weekly monitoring of skin conditions, there was no documentation of assessments for several weeks, specifically on December 19, 2024, December 26, 2024, January 16, 2025, January 23, 2025, and January 30, 2025. Interviews with the Infection Preventionist/Registered Nurse revealed that the nursing staff was expected to perform head-to-toe skin assessments weekly and document the findings, including the appearance and measurements of the pressure ulcer. However, the electronic health record lacked evidence of these assessments during the specified weeks, which could have delayed necessary treatment and services to promote wound healing. The facility's policy, dated August 2022, emphasized the importance of monitoring any skin discoloration or breakdown at least weekly.
Failure to Securely Store Shower Disinfectant
Penalty
Summary
The facility failed to ensure that shower disinfectant was stored in a locked storage container, as required by their policy. During an observation in the shower room, an unlocked storage container was found on top of a cupboard, despite signage indicating it should be kept locked at all times. The container held a clear liquid labeled as shower disinfectant. Interviews with a Restorative Nursing Aide and the Director of Nursing confirmed that the disinfectant should have been stored securely. A review of the facility's policy on cleaning and disinfection indicated that chemicals must be stored in a locked container or area inaccessible to others when not in use or under staff observation.
Failure in Timely Pain Management for Hospice Resident
Penalty
Summary
The facility failed to effectively manage pain for a resident admitted with disseminated malignant neoplasm and under hospice care. The resident had orders for Oxycodone and Morphine Sulfate to manage pain, but there were significant delays in administering these medications. On multiple occasions, the resident reported severe pain and requested medication, but the staff did not administer the pain relief promptly. For instance, on one occasion, the resident reported pain at 7/10 and requested morphine, but it took over two hours for the medication to be administered. Interviews with the nursing staff revealed lapses in following the pain management protocol. A nurse admitted to not reevaluating the resident's pain after administering Oxycodone and acknowledged the delay in providing morphine. The facility's policy required immediate response to pain complaints, but this was not adhered to, resulting in the resident experiencing unrelieved pain. The care plan for the resident emphasized the need for timely administration of analgesics and anticipation of pain relief needs, which was not effectively implemented.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12.2% error rate. This was observed through five medication errors out of 41 opportunities. One unsampled resident was administered Pradaxa without a full glass of water, contrary to the medication's instructions, which could lead to potential complications such as ulceration. Additionally, the same resident received Furosemide despite having a systolic blood pressure below the prescribed threshold, which could have caused a further drop in blood pressure. Another resident experienced three separate medication timing errors. Aspirin, Oxybutynin, and Potassium Chloride were all administered past their scheduled times. The nurses involved acknowledged they were behind schedule, and the Director of Nursing confirmed that medications should be administered within a specific timeframe, which was not adhered to in these instances. The facility's policy and procedure for medication administration were not followed, as medications were not given as prescribed or within the required timeframes. The errors were identified through observations, interviews, and record reviews, highlighting a significant deviation from the facility's established guidelines for medication administration.
Excessive Acetaminophen Dosage Administered to Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of acetaminophen. The resident, who had a history of chronic hepatitis, was prescribed acetaminophen with a maximum daily dosage of 2,000 mg. However, the Medication Administration Records (MAR) revealed that the resident received dosages exceeding this limit, with instances of 3,500 mg and 4,500 mg administered on certain days. This excessive administration occurred over several months, with the Director of Nursing (DON) acknowledging the error and stating that the order should have been clarified. The Medical Director (MD) and the pharmacist both recognized the need for clarification of the acetaminophen order, especially given the resident's medical history. The pharmacist had recommended clarifying the order in the Monthly Medication Review, but this was not acted upon. The facility's policies on physician orders and medication administration required verification of orders for clarity and appropriateness, which was not adhered to in this case. The pharmacist noted that exceeding the daily limit of acetaminophen for an extended period posed a risk of hepatotoxicity for the resident.
Improper Storage and Labeling of Drugs and Biologicals
Penalty
Summary
The facility failed to properly store and label drugs and biologicals, leading to potential risks. Controlled drugs were being discarded in a Smart Sink, a container that was not secure or permanently affixed to the wall, which could result in drug diversion. During an observation, a Registered Nurse indicated that narcotic medications were disposed of in this manner when the Director of Nursing was not present. The Director of Nursing was unfamiliar with the Smart Sink's purpose and location, and the facility's policy on medication disposal required special handling and storage for controlled substances. Additionally, the facility did not properly label an oxygen humidifier bottle for a resident with pneumonia. The humidifier bottle was found opened and undated, which could increase the risk of bacterial growth and respiratory illness. A Registered Nurse incorrectly stated that humidifiers did not need to be dated, while the Director of Staff Development confirmed that they should be dated upon opening. The facility's policy on oxygen therapy required humidifiers to be labeled with the date opened.
Inadequate Training in Sanitizer Testing in Kitchen
Penalty
Summary
The facility failed to ensure that all kitchen staff were evaluated for competency in testing the sanitizer levels in the 3-compartment sink, which is crucial for cleaning and sanitizing dishes. During an observation, the Executive Chef (EC) tested the quaternary ammonium (quat) sanitizer and found the levels to be higher than the recommended range of 200-400 ppm, with readings of 600-800 ppm and 1000 ppm. The EC was unsure why the readings were high and admitted to not properly demonstrating the testing procedure to the staff. Further observations revealed that a Dishwasher (DW) was also unable to correctly test the sanitizer mixture, resulting in a reading of 400-600 ppm, which was outside the normal range. The EC acknowledged responsibility for training all kitchen staff and the facility's policy indicated that on-the-job training should include the use of specific hazardous substances. This lack of proper training and competency evaluation had the potential to result in residents being served food on unclean dishes, posing a risk of foodborne illnesses to the medically fragile population of 47 residents.
Failure to Label and Date Resident Personal Foods
Penalty
Summary
The facility failed to ensure that all resident personal foods were properly labeled and dated in the communal refrigerator, which could lead to the consumption of expired food and an increased risk of foodborne illness. During an observation in the Residents' communal refrigerator located in the Hydration Room, a pizza box and a package containing crackers, cheese, and salami were found unlabeled with resident names, room numbers, and undated. This was confirmed during an interview with an LVN, who acknowledged the need for labeling with the date and room number. A review of the facility's policy and procedure titled 'Use and Storage of Food Brought to Residents From the Outside' indicated that outside food must be stored in an appropriate container, labeled with the resident's name, room number, the date the food was brought to the resident, and the use-by date.
Dumpster Lid Missing at Facility
Penalty
Summary
The facility failed to ensure that one of two outside dumpsters had a lid, which could potentially attract pests and rodents. This deficiency was observed during a concurrent observation and interview with the Executive Chef in the outside loading dock area, where it was noted that the compactor dumpster was missing a lid and contained overflowing garbage with food and waste. The Executive Chef acknowledged that the dumpster should have a lid. A review of the U.S. Food and Drug Administration's Food Code from 2022 indicated that outside receptacles used with materials containing food residue should have tight-fitting lids, doors, or covers. Additionally, the facility's policy and procedure on Solid Waste Disposal, dated January 2025, stated that lids should be kept closed on all outside trash receptacles.
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 339 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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 Santa Rosa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summerfield Health Care Center | 1.4 mi | ★★★★★ | 4 | 0 |
| Park View Post Acute | 1.6 mi | ★★★★★ | 13 | 0 |
| Santa Rosa Post Acute | 2 mi | ★★★★★ | 29 | 0 |
| Blue Oak Post-acute | 4 mi | ★★★★★ | 33 | 0 |
| Northvine Postacute Care | 5 mi | ★★★★★ | 1 | 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.