Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vineyard Post Acute during CMS and state inspections, most recent first.
Licensed nurses failed to notify a resident’s representative of two significant changes in condition: an elopement and a subsequent fever. The resident had severe cognitive impairment, was deemed unable to make his own health decisions, and had a Wanderguard order for exit-seeking behavior. After the resident left the building and was returned by police, there was no documentation that the representative was informed. Later, when the resident developed a fever with respiratory symptoms and the MD was notified and treatment given, there was again no documentation of representative notification. The DON confirmed expectations and facility policies required notifying the resident’s representative and documenting these contacts, and one nurse admitted she did not know she had to report the fever.
A resident with dementia, severe cognitive impairment, atrial flutter on anticoagulation, and a history of repeated falls was assessed as high risk for wandering and elopement and had care plans and orders for close supervision and use of a Wanderguard device. Despite these measures, the resident eloped during early morning hours, leaving the building unnoticed, walking off premises to a nearby baseball field, and crossing a neighborhood intersection before being returned by police. Documentation indicated the Wanderguard was in place but did not alarm, the care plan for elopement had not been updated after the incident, and key staff, including the AD and HRD, were unclear about monitoring and replacement of the Wanderguard, while the Maintenance Director could not explain how the resident exited without triggering the door alarm.
Surveyors observed a medication cart left unlocked and unattended in a hallway outside a resident room. The NS locked the cart and stated that carts must always be locked when unattended so unauthorized individuals, including residents, cannot access medications. An RN responsible for the cart admitted leaving it unlocked and unattended, acknowledging that this violated facility policy requiring carts to be locked when not in use. The DON confirmed that only nurses are authorized to access medications and that leaving a cart unlocked while unattended is a safety issue, consistent with the written medication administration policy requiring carts to remain visible to staff and inaccessible to residents or passersby.
A resident with chronic kidney disease and a recent leg fracture had weekly CBC and BMP labs ordered, but one scheduled lab draw was documented as completed on the eMAR without any evidence in the EMR that it was actually obtained. Later, labs that were drawn showed flagged abnormalities in WBC, BUN, creatinine, and BUN/CREAT ratio, yet no SBAR was initiated and there was no documentation that the MD was notified of these abnormal results. Subsequent SBARs addressed edema, decreased urine output, abdominal pain, and urinary retention, and the resident was later sent to the ER with severe back pain and was found to have markedly elevated BUN and creatinine with diagnoses including UTI, AKI, and dehydration. Facility policies and staff interviews confirmed that ordered labs were to be obtained, abnormal results promptly reported to the MD, and changes in condition documented, which did not occur as required in this case.
Failure to notify the state mental health authority after a resident with dementia, MDD, psychosis, and anxiety showed a decline in mental status and behavior. Records showed depression, withdrawal, poor intake, medication refusal, weight loss, and worsening involuntary movements, while the PASRR process had not been updated to reflect the resident’s changed condition.
Bed rail consent was not properly obtained for a resident with dementia and severe cognitive impairment who had bilateral 1/4 side rails in use. Facility records showed consent forms with blank signature lines, while staff interviews and DON review confirmed the resident was not appropriate to sign her own consent and the RP did not sign the documents. The facility policy required informed consent before using bed rails.
A resident recovering from digestive system surgery experienced ongoing moderate to severe pain after nursing staff failed to administer physician-ordered morphine sulfate, instead providing only acetaminophen intended for mild pain. Despite documented increases in pain and minimal relief from acetaminophen, staff did not notify the physician or follow up on the morphine order, resulting in the resident enduring severe pain until hospitalization. The facility's policies for pain assessment and medication administration were not followed.
A resident with diabetes did not have sliding scale or blood sugar parameter orders for insulin administration, and staff failed to check blood glucose prior to giving insulin. This led to a hypoglycemic episode requiring hospitalization. Staff and the DON confirmed that required orders and monitoring were not in place before the incident.
A resident recovering from a stroke was unable to get uninterrupted sleep due to another resident's constant yelling and aggressive behavior. Despite notifications to the DON, the disruptive behavior persisted, affecting the homelike environment. Staff and other residents confirmed the ongoing issue, suggesting the facility might not be suitable for the disruptive resident's care needs.
The facility did not report an influenza outbreak to the LPHD for nearly three weeks, affecting 28 residents and staff. The outbreak began when two residents tested positive, and the IP, who was responsible for reporting, was away. The DON, DSD, and ADM all assumed others were responsible for notifying the LPHD, leading to a delay. The facility's policy required immediate reporting, but this was not followed, preventing the LPHD from providing necessary support.
A resident with a history of respiratory failure was found unresponsive and pulseless, but facility staff failed to initiate CPR promptly. Despite low oxygen saturation and the presence of an AED, CPR was not started until paramedics arrived, leading to the resident's death. Interviews revealed staff confusion about when to begin CPR.
A resident with severe cognitive impairment wandered into another resident's room, leading to a physical altercation. The second resident, feeling threatened, head-butted and restrained the first resident, resulting in a small injury. The facility's policy on abuse prevention was not upheld.
A resident with end-stage renal disease missed scheduled medications on dialysis days, and the facility failed to notify the physician. The resident's MAR showed multiple instances of missed doses, and staff interviews revealed inconsistent communication with the physician. The DON and Administrator acknowledged the need for physician notification when medications are not administered.
A resident with ESRD in a facility experienced significant medication errors, particularly on dialysis days. Critical medications for low blood pressure, atrial fibrillation, blood clot prevention, and diabetes were often not administered as scheduled. Staff interviews revealed inconsistent communication and adherence to protocols, with medications either not given or administered outside prescribed parameters.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in the PASARR process. One resident with schizoaffective disorder and dementia, and another with psychosis and major depressive disorder, were not accurately represented in their MDS, missing their positive PASARR status for serious mental illness. Interviews revealed the MDS Coordinator overlooked this information, and the Administrator and DON acknowledged the assessments should have been accurate.
A resident with COPD and heart failure had a physician's order for 2L/min supplemental oxygen, but observations revealed the oxygen concentrator was set at 3.5L/min. The resident confirmed the correct setting should be 2L/min. An RN acknowledged the error and adjusted the setting, while the DON and attending physician confirmed the need to adhere to the prescribed oxygen level.
A resident with a history of allergic rhinitis, chronic pain, and COPD was found with multiple medications improperly stored in their room, contrary to facility policy. Despite having intact cognition, the resident self-administered some medications without informing staff. Interviews with staff confirmed that residents need an order to keep medications at the bedside, which was not in place for this resident.
A resident with a history of CHF and muscle weakness did not receive occupational therapy as ordered, due to staffing challenges. The resident was supposed to receive therapy three times a week, but only received it on three occasions over two months. Staff interviews confirmed the deficiency and the expectation for therapy to be provided as ordered.
A resident with diabetes and peripheral vascular disease experienced severe complications due to the facility's failure to provide timely foot care and communication. Nursing staff did not document daily skin assessments, leading to the resident's necrotic toe going unnoticed for a month. Miscommunication with the physician delayed appropriate intervention, and the facility delayed the resident's hospital transfer, resulting in sepsis and toe amputation.
A resident with PTSD threw water on another resident due to being disturbed by her continuous screaming, leading to the affected resident feeling unsafe. Both residents were cognitively intact, and the incident was confirmed by an LPN who found the affected resident's belongings damp. The facility's policy on abuse prevention was not upheld.
A resident with metastatic breast cancer was discharged from an LTC facility without her prescribed opioid medications, leading to severe pain and opiate withdrawal. The discharge process was rushed and unprepared, resulting in incomplete documentation and failure to provide necessary medications. The facility's policy lacked procedures for non-emergent discharges and medication provision.
A resident identified as a high fall risk fell from his wheelchair at the nurses' station, resulting in a bruise and hospital evaluation. Despite a fall risk assessment, no fall prevention care plan was developed. Staff interviews revealed the resident was agitated, and the facility's policy on managing fall risks was not followed, contributing to the incident.
A resident in a LTC facility did not receive his pain medication in a timely manner, leading him to feel helpless and unimportant. The delay occurred during a shift change, and the resident expressed feeling unsafe as staff seemed to prioritize their shift over patient needs. The resident was cognitively intact and on a scheduled pain medication regimen. A nurse acknowledged the importance of treating residents with respect and dignity, but the facility's policy was not followed in this instance.
The facility failed to administer scheduled medications within the required time frames for three residents, leading to delays of up to three hours. Despite the policy requiring administration within one hour of the scheduled time, multiple medications were given late. The DON acknowledged awareness of the time frame but did not routinely audit medication pass times, contributing to the issue.
Failure to Notify Resident Representative of Elopement and Fever
Penalty
Summary
Licensed nurses failed to notify a resident’s responsible party (RP) of significant changes in condition and status, including an elopement and a fever. The resident had dementia, bipolar disorder, a cognitive communication deficit, repeated falls, and an active order stating he was not capable of making his own health decisions, with his daughter listed as the RP and emergency contact. He also had an active order for a Wanderguard due to exit-seeking behavior. On 2/28/26, a change of condition note documented that the resident eloped from the facility sometime after he was last seen in bed at 4:00 a.m. and was found by police at a baseball field across from the facility and returned around 5:00 a.m. The note also indicated the Wanderguard was in place but did not alarm when the resident exited. There was no documentation that the RP was notified of this elopement. On 3/1/26, a progress note documented by a licensed nurse indicated a change of condition for fever, with the resident noted to be sneezing and congested, and temperatures of 100.4°F and later 101.1°F recorded, with acetaminophen administered and the MD notified for congestion medicine. There was no documented evidence that the RP was notified of the fever. In an interview, the RP stated she was not informed by the facility of the elopement and learned of it from a friend who heard the resident’s name on a dispatch call, and she later observed new coughing when visiting the resident. The DON stated she expected licensed nurses to complete change of condition reports for elopement and fever and to notify the RP, and confirmed there was no documentation of such notifications. One licensed nurse acknowledged she did not notify the RP of the fever because she did not know it was required. Facility policies on wandering/elopement and change in condition required notification of the resident’s legal representative or resident representative and documentation in the medical record when such events occurred.
Failure to Prevent Elopement of High-Risk Resident Despite Wanderguard Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident at high risk for wandering and elopement, resulting in an actual elopement from the building. The resident had an Elopement and Wandering Risk Observation/assessment score of 12, which placed him at risk for wandering or elopement. His admission record documented diagnoses of dementia, bipolar disorder, cognitive communication deficit, atrial flutter, and a history of repeated falls. A BIMS score of 6 indicated severe cognitive impairment, and physician orders and care plans identified that he was not capable of making his own health decisions, was on anticoagulant therapy, and required safety measures and supervision, including a Wanderguard device and keeping him within supervised view as much as possible. The resident’s care plans included multiple risk areas: falls, elopement and wandering, and bleeding risk due to anticoagulant use. Interventions included identifying patterns of wandering, placing a Wanderguard on his right wrist, checking Wanderguard placement on the left ankle every shift, and providing supervision and reminders to ask for assistance. Orders also directed staff to monitor for signs and symptoms of bleeding every shift and to ensure the Wanderguard was functioning and replaced before expiration, with nursing staff instructed to notify the Activity Director for replacement. Despite these documented risks and interventions, a change of condition note recorded that the resident eloped in the early morning; he was last checked around 4:00 a.m. in bed and was found off premises by police near a baseball field and returned around 5:00 a.m. The note stated the Wanderguard was in place but did not alarm when the resident exited the facility. Interviews and observations further detailed the circumstances and gaps in supervision and monitoring. The resident reported leaving late at night to visit a friend who was a policeman and indicated he walked to a nearby baseball field, which required crossing a neighborhood intersection. The DON stated that nobody noticed the resident had left the facility and acknowledged the elopement care plan had not been updated to reflect the incident. The Activity Director stated she had been on leave and that she or anyone designated to cover her duties was responsible for tracking Wanderguard expiration dates, while the Human Resources Director did not recall being informed that the resident’s Wanderguard had expired. The Maintenance Director reported that door alarms were checked weekly, were loud when activated, and were monitored at two nurse stations, but he was unable to determine how the resident exited through the front door without triggering an alarm. The DON stated there was a potential for the resident to have fallen and sustained injuries when he eloped.
Unattended Unlocked Medication Cart Accessible in Hallway
Penalty
Summary
The deficiency involves failure to ensure that medications were stored securely and accessible only to authorized personnel. During an observation and concurrent interview, surveyors and the Nursing Supervisor (NS) saw medication cart #2 parked in a hallway outside a resident room, unlocked and unattended. The NS immediately went to the cart and locked it, stating that medication carts should always be locked when left unattended and that they needed to be secured so unauthorized people, including residents, could not access the medications. Shortly afterward, a licensed nurse (LN A) exited the nearby resident room and acknowledged responsibility for medication cart #2, admitting that she had left it unlocked and unattended. LN A stated that facility policy required medication carts to be locked when unattended for resident safety, particularly to prevent confused residents from accessing medications. In a separate interview, the Director of Nursing (DON) confirmed that medication carts must always be locked when unattended because only nurses are authorized to access the medications and that leaving a cart unlocked while unattended was a safety issue. Review of the facility’s “Administering Medications” policy indicated that the cart must be visible to the personnel administering medications and all outward sides must be inaccessible to residents or others passing by.
Failure to Follow Lab Orders and Report Abnormal Kidney Function Results
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of care and physician orders for a resident with a history of chronic kidney disease and a displaced bimalleolar fracture of the right lower leg. The resident was admitted in December 2025, and her MDS showed a BIMS score of 12, indicating moderately impaired cognition. A physician’s order dated 12/10/25 directed that CBC and BMP labs be obtained weekly on Wednesday mornings for four weeks. The December 2025 eMAR showed the CBC and BMP as completed on 12/17/25 and 12/31/25, but the EMR contained no evidence that the 12/17/25 labs were actually collected. The DON confirmed the order and the eMAR entries, but could not provide documentation that the 12/17/25 labs were obtained or that results were communicated to the physician. On 12/31/25 at 7:05 a.m., CBC and BMP labs were collected, and the results were reported to the facility on 1/02/26 at 11:51 a.m. The lab report was flagged and showed abnormal values, including an elevated WBC of 14.2 K/mm3, BUN of 42 mg/dL, creatinine of 1.34 mg/dL, and BUN/CREAT ratio of 31, all marked as high. Despite these abnormal and flagged results, the EMR contained no evidence that an SBAR was initiated on 1/02/26 or that the physician was contacted regarding these lab findings. The DON confirmed that these abnormal values should have been reported to the physician and included in an SBAR so the physician could implement interventions, and stated that if an elevated BUN is left untreated, it can cause kidney injury. Subsequent documentation showed that on 1/03/26 at 5 p.m., an SBAR was completed for increased edema to the resident’s bilateral lower extremities, and on 1/04/26 at 9 p.m., another SBAR documented decreased urine output, lower abdominal pain or tenderness, difficulty voiding, and a bladder scan showing approximately 1 liter of retained urine. On 1/07/26 at 11:31 a.m., a nurse’s note recorded the resident’s complaint of back pain rated 10/10 and that the resident was in distress, with an MD order for transfer to the ER for further evaluation. In the ED on 1/08/26, the resident’s BUN was 102 mg/dL and creatinine 1.67 mg/dL, and she was diagnosed with back pain, UTI, AKI, and dehydration. Facility policies required prompt physician notification of diagnostic test results, documentation of changes in condition, and that RNs and LPNs obtain ordered lab tests and notify the physician of changes in condition. Interviews with nursing staff and the DON confirmed that abnormal lab values were expected to be reported to the physician and documented, and that SBARs should be completed for out-of-range labs, which did not occur for the abnormal results reported on 1/02/26.
Failure to Notify State Mental Health Authority After Mental Health Decline
Penalty
Summary
The facility failed to notify the state mental health authority after Resident 70 experienced a decline in mental illness. Resident 70 was admitted with diagnoses including dementia, major depressive disorder, psychosis, and anxiety. The MDS dated 11/3/25 showed moderate cognitive impairment, need for assistance with self-care, and dependence on staff for transfers. A review of the state mental health authority’s correspondence dated 11/5/25 showed that, after reviewing the Positive Level I screening and speaking with facility staff, a Level II Mental Health Evaluation was not scheduled because the individual was determined to have no serious mental illness and no functional limitations in the past 6 months, and the facility would need to resubmit a new Level I screening to reopen the case. Records reviewed later showed changes in Resident 70’s condition and mental health status. Physician notes documented reports of depression, withdrawal, decreased appetite, refusal of meals and medications, weight loss, and worsening symptoms including jaw clenching, teeth grinding, mask facies, and tics, with concern for extrapyramidal symptoms. A behavior note stated the resident needed encouragement to complete ADLs and had a history of failure to thrive. During interviews, the MDS Coordinator stated the admissions department and IDT were responsible for completing PASRR screenings and Level II evaluations when necessary, and later acknowledged that Resident 70 was on multiple medications for mental illness, had behaviors interfering with ADLs, and had a recent new medication started for anxiety. The MDS Coordinator stated the IDT would restart the PASRR screening process.
Bed Rail Consent Not Obtained From Resident’s Responsible Party
Penalty
Summary
The facility failed to ensure informed consent was obtained for the use of bilateral 1/4 side rails for a resident with severe cognitive impairment. The resident was admitted with diagnoses including senile degeneration of the brain and delirium, and her son was identified as her responsible party. Her MDS showed a BIMS score of 1, indicating severe cognitive impairment. An active order placed for bilateral 1/4 side rails as an enabler for bed mobility and positioning was documented, and the care plan included interventions to discuss risks and benefits and obtain consent. Facility records titled Bed Rail and Entrapment Risk Observation/Assessment showed bed rails were in use and included check marks indicating the resident or resident representative had been informed of the risks and benefits and had provided informed consent, but the signature and date lines were blank. During observation, the resident was in bed with 1/4 side rails on both sides. Interviews with nursing staff and the DSD showed uncertainty about the facility's bed rail consent process, and the DON later confirmed the typed name on the consent was the resident's name, that the resident was not appropriate to sign her own consent, and that the documents were not signed by the resident's RP. The facility policy stated bed rails were prohibited unless criteria were met, including informed consent.
Failure to Administer Physician-Ordered Pain Medication for Severe Pain
Penalty
Summary
Licensed nursing staff failed to administer physician-ordered pain medication to a resident who was admitted following digestive system surgery and was experiencing moderate to severe pain. The resident's care plan specified that pain should be relieved to a tolerable level, with interventions including administering treatment as ordered, assessing pain every shift, and notifying the physician if pain became unmanageable. Despite these directives, the resident was only given acetaminophen, which was ordered for mild pain, even as her pain levels increased to moderate and severe levels as documented in the medication administration record (MAR). The physician had ordered morphine sulfate for moderate to severe pain, but the resident did not receive any doses of this medication during the period when her pain was documented as worsening. Progress notes indicated that acetaminophen provided minimal relief and that the resident reported nausea from acetaminophen. The MAR and interviews confirmed that the morphine order was not carried out, and there was no documentation that the physician was notified about the resident's escalating pain or the ineffectiveness of the prescribed pain management. The facility pharmacist confirmed that a clarification request was sent to the physician due to a listed morphine allergy, but there was no follow-up from facility staff or the physician, and no documentation of any adverse effects when morphine was eventually administered after the resident's return from hospitalization. Interviews with the resident revealed that she repeatedly requested additional pain medication and felt her pain was not believed or addressed by nursing staff. The DON confirmed that pain assessments and appropriate medication administration were not consistently documented or performed according to the care plan and facility policy. The facility's policies required timely administration of medications as ordered and immediate contact with the prescriber if pain was not controlled, but these procedures were not followed, resulting in the resident experiencing ongoing, severe pain.
Failure to Follow Professional Standards for Insulin Administration
Penalty
Summary
The facility failed to ensure that professional standards of practice were followed for a resident with diabetes mellitus, muscle weakness, and dysphagia. The resident was admitted with orders for both long-acting and short-acting insulin, but there was no documented order for a sliding scale or blood sugar parameters for insulin administration. Additionally, there was no evidence that blood sugar levels were checked prior to administering insulin lispro in the afternoon, as required by standard practice and facility policy. On one occasion, the resident experienced an episode of distress, with vital signs indicating low blood pressure and heart rate, and an oxygen saturation below normal. Paramedics found the resident's blood sugar to be 69 mg/dl, and the resident was subsequently sent to the hospital. The emergency department determined that the resident had experienced a hypoglycemic and mildly hypotensive episode, and recommended reducing insulin doses. Interviews with nursing staff confirmed that blood sugar checks were not performed prior to insulin administration, and that sliding scale and parameter orders were not in place as expected. Further review of facility policies indicated that nurses were required to check blood glucose per physician order or facility protocol and to notify providers of any discrepancies prior to administering insulin. The lack of sliding scale orders, blood sugar parameters, and failure to check blood sugar prior to insulin administration were confirmed by staff and the Director of Nursing. These omissions were not addressed until after the resident's hospitalization.
Disruptive Resident Behavior Affects Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment with comfortable sound levels for Resident 1, who was recovering from a stroke and required uninterrupted sleep for recovery. Resident 4, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, frequently yelled vulgar, offensive, and derogatory language, disrupting Resident 1's sleep. Despite Resident 1's notifications to the charge nurses and the Director of Nursing (DON), the situation persisted, affecting Resident 1's ability to rest and recover. Interviews with various staff members, including the DON, confirmed that Resident 4 exhibited aggressive behavior, which included yelling and physically attacking staff. The DON acknowledged that police intervention was required due to Resident 4's aggression, and Resident 4 was temporarily transferred to a hospital. However, upon return to the facility, Resident 4 continued to exhibit disruptive behavior, impacting the environment for other residents, including Resident 1. Other residents and staff also reported being affected by Resident 4's behavior. Resident 2 and Resident 3 expressed concerns about the noise and aggression, with Resident 3 suggesting that Resident 4's needs might be better met at a mental health facility. Staff members confirmed the ongoing issue with Resident 4's loud and offensive language, indicating that the facility might not be suitable for addressing Resident 4's care needs. The facility's policy on providing a homelike environment with comfortable sound levels was not upheld in this situation.
Delayed Reporting of Influenza Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not reporting an influenza outbreak to the local public health department (LPHD) for nearly three weeks. The outbreak began on January 29, 2025, when two residents tested positive for influenza, and by January 31, 2025, seven more residents had tested positive. In total, 28 residents and staff members were affected. The Infection Preventionist (IP) was away from work during the outbreak's onset and did not notify the LPHD until February 18, 2025. The Director of Nursing (DON) and the Director of Staff Development (DSD) both assumed that the Administrator (ADM) was responsible for reporting the outbreak, leading to a lack of communication and delayed reporting. The facility's policy and procedure, reviewed with the ADM, indicated that a single case of influenza should be reported to the health department. The ADM acknowledged that the IP was responsible for reporting but failed to ensure the LPHD was notified in the IP's absence. The LPHD's Infectious Disease Nurse emphasized the importance of timely notification to provide necessary support and resources to control the outbreak. The delay in reporting prevented the LPHD from offering education, guidance, and support to minimize the spread of the outbreak, as required by Title 17 of the California Code of Regulations.
Failure to Recognize Cardiorespiratory Arrest and Delay in CPR
Penalty
Summary
The facility staff failed to recognize a cardiorespiratory arrest in a resident who was a full-code, leading to a delay in performing CPR. The resident was found unresponsive, apneic, and pulseless by Complainant 5, who arrived at the facility five to seven minutes after being notified of the resident's condition. Despite the presence of an AED at the bedside, it was not used, and CPR was not initiated by the facility staff, resulting in the resident's death. The resident had a history of acute and chronic respiratory failure and was admitted to the facility with these diagnoses. On the day of the incident, the resident was found with low oxygen saturation levels and was initially placed on a nasal cannula, which was later changed to a non-rebreather mask. Despite these interventions, the resident's condition did not improve, and the oxygen saturation remained low. The staff called 911, but CPR was not started until the paramedics arrived. Interviews with the facility staff revealed a lack of recognition of the signs of cardiac arrest and confusion about when to initiate CPR. Licensed Staff A and B were present at the bedside but did not start CPR, as they believed the resident had not lost a pulse. The Director of Nursing stated that CPR should be performed when someone is unresponsive, not breathing, or has lost their pulse, but this protocol was not followed by the staff in this case.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident intentionally struck him in the head and held him down on the floor. Resident 1, who has severe cognitive impairment due to epilepsy, wandered into Resident 2's room and was perceived as a threat by Resident 2, who has moderate cognitive impairment from metabolic encephalopathy. Resident 2 reported that Resident 1 used profanity and attempted to swing at him, prompting Resident 2 to head-butt Resident 1 and force him to the ground. The incident was witnessed by Resident 3, who shared the room with Resident 2, and confirmed that Resident 1 was looking through their belongings and refused to leave when asked. The Director of Nursing and the Business Office Assistant also provided accounts of the altercation, with the latter finding Resident 2 holding Resident 1 in a headlock on the floor. Resident 1 sustained a small cut on his forehead as a result of the incident. The facility's policy on abuse prevention states that residents have the right to be free from physical abuse, which was not upheld in this situation.
Failure to Notify Physician of Missed Medications for Dialysis Resident
Penalty
Summary
The facility failed to notify the physician when a resident consistently missed scheduled medications due to being out at dialysis. The resident, who had a medical history of end-stage renal disease and was dependent on renal dialysis, was admitted to the facility in October 2021. The resident's care plan included instructions to administer medications as ordered and collaborate with the physician for optimal medication dosing times. However, the resident's Medication Administration Record (MAR) for October and November 2024 revealed that medications scheduled between 7:00 AM and 10:00 AM were not administered on multiple days when the resident was out for dialysis. Interviews with facility staff, including Registered Nurse (RN) #15 and Licensed Vocational Nurse (LVN) #11, indicated that the physician was not consistently notified when medications were held due to the resident being unavailable for administration. The Medical Director confirmed that there should be communication regarding missed doses of certain medications, such as insulin and midodrine, but had not been notified of the missed doses for this resident. LVN #11 acknowledged coding the MAR to indicate the resident was out at dialysis and stated that attempts to clarify medication times with the physician had not been successful. The Director of Nursing (DON) and the facility Administrator both stated that the physician should be notified if a medication is not administered for any reason. The DON emphasized that medication timing should align with dialysis schedules, and if a medication is not given, it should be administered after dialysis or according to the physician's instructions. Despite these expectations, the facility did not have a specific policy for notifying physicians of changes in resident status, leading to a lack of communication regarding the missed medications.
Medication Errors for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease (ESRD) was free from significant medication errors, particularly on days when the resident was scheduled for dialysis. The resident, who had a medical history of ESRD and was dependent on renal dialysis, did not receive critical medications for low blood pressure, atrial fibrillation, blood clot prevention, and diabetes management on multiple occasions. The facility's policy required staff to be trained in the timing and administration of medications, especially before and after dialysis, but this was not adhered to. The medication administration records (MAR) for the resident showed that medications such as clopidogrel, apixaban, insulin, and midodrine were often not administered as scheduled on dialysis days. The MAR indicated that these medications were either marked as not given because the resident was out for dialysis or were administered outside the prescribed parameters. For instance, midodrine was given when the resident's blood pressure was above the physician's specified threshold, which could potentially exacerbate the resident's condition. Interviews with various staff members, including Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), the Medical Director, and the Nephrologist, revealed a lack of consistent communication and adherence to medication administration protocols. Staff members admitted to either not administering medications when the resident returned from dialysis or incorrectly documenting medication administration. The Medical Director and Nephrologist emphasized the importance of administering certain medications before or after dialysis, depending on the medication, to avoid adverse effects. However, there was a clear disconnect between the facility's practices and the medical guidance provided, leading to significant medication errors.
Inaccurate MDS Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the preadmission screening and resident review (PASARR) process. Resident #10 was admitted with a medical history of schizoaffective disorder and dementia, and their MDS indicated severe cognitive impairment. However, the MDS did not reflect the resident's positive PASARR status for a serious mental illness, despite the resident receiving antipsychotic medication and having active diagnoses of schizophrenia and non-Alzheimer's dementia. Similarly, Resident #7, who had a history of psychosis, major depressive disorder, and anxiety disorder, was also not accurately represented in the MDS. The MDS showed intact cognition and did not indicate a serious mental illness, even though the resident was receiving antipsychotic medication and had a positive PASARR status for a suspected mental illness. Interviews with facility staff revealed that the MDS Coordinator overlooked the PASARR information when completing the assessments for both residents. The Administrator and Director of Nursing acknowledged that the MDS assessments should have accurately reflected the residents' PASARR status. The failure to include this critical information in the MDS assessments highlights a lapse in the facility's adherence to its policy on certifying the accuracy of resident assessments, as revised in November 2022.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician orders for supplemental oxygen flow rates for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and heart failure. The resident, who was admitted on 04/24/2023, had a physician's order for continuous supplemental oxygen at 2 liters per minute via nasal cannula. However, during multiple observations on 11/18/2024 and 11/19/2024, the resident's oxygen concentrator was set at 3.5 liters per minute, contrary to the physician's order. The resident, who had intact cognition, confirmed that the oxygen concentrator should be set at 2 liters per minute. Registered Nurse (RN) #8 acknowledged the discrepancy and adjusted the oxygen concentrator back to the prescribed 2 liters per minute, noting that the resident's oxygen should not be set too high due to the COPD diagnosis. The Director of Nursing (DON) and the attending physician both confirmed that the oxygen should be maintained at 2 liters per minute as per the physician's order. There was no documentation to support any titration of the oxygen to 3.5 liters per minute, indicating a failure to follow the established physician orders and facility policy for oxygen administration.
Improper Medication Storage for Resident
Penalty
Summary
The facility failed to ensure that medications were stored appropriately for one resident, leading to a deficiency. The facility's policy on self-administration of medications requires that residents have the right to self-administer medication if deemed clinically appropriate and safe by the interdisciplinary team. Medications authorized for self-administration should be stored securely, either in the resident's room or on a central medication cart, and any unauthorized medications found at the bedside should be returned to the nurse in charge. However, observations revealed that the resident had multiple medications, including a cough medication, diclofenac gel, hydrophilic wound gel, antifungal powder, muscle cream, and an inhaler, stored in their room in a wicker basket and on the over-the-bed table. The resident, who had a history of allergic rhinitis, chronic pain, and chronic obstructive pulmonary disease, was observed with medications not stored according to the facility's policy. The resident's care plan included interventions for managing a chronic fungal skin rash and impaired skin integrity, requiring specific treatments and monitoring. Despite the resident's intact cognition, as indicated by a BIMS score of 14, the medications were not stored securely, and the resident admitted to self-administering nasal spray and occasionally taking Tylenol without informing the staff. Interviews with facility staff, including LVNs and the DON, confirmed that residents need an order to keep medications at the bedside and should be assessed for their capability to self-administer. The DON stated that medications should be stored in the medication cart and provided upon request, and any medications found in the resident's room should be removed unless an order is in place. The deficiency arose from the failure to adhere to these protocols, as the resident's medications were not stored securely, and there was no evidence of an order allowing the resident to keep them at the bedside.
Failure to Provide Ordered Occupational Therapy
Penalty
Summary
The facility failed to provide occupational therapy as ordered by the physician for a resident who was readmitted with a medical history of congestive heart failure, generalized muscle weakness, and a need for assistance with personal care. The resident was supposed to receive occupational therapy three times a week for four weeks, as per the physician's order and the care plan. However, the service log indicated that the resident only received therapy on three occasions over a two-month period, which was significantly less than the prescribed frequency. Interviews with the resident, the occupational therapist, the Director of Rehabilitation, the Director of Nursing, and the Administrator confirmed the deficiency. The occupational therapist acknowledged that the resident was not seen at the required frequency due to staffing challenges, and all staff interviewed stated that the expectation was for therapy to be provided as ordered. The physician also emphasized the importance of following all physician orders, including those for occupational therapy, although it was unclear if the resident's condition declined due to the lack of therapy.
Failure to Provide Timely Foot Care and Communication Leads to Severe Complications
Penalty
Summary
The facility failed to provide appropriate foot care for a resident with a history of Diabetes Mellitus and peripheral vascular disease, leading to severe complications. The nursing staff did not document daily skin assessments as required by the resident's care plan, resulting in the necrotic condition of the resident's toe going unnoticed for approximately one month. This oversight allowed the condition to progress to wet gangrene, which is a life-threatening stage of necrosis. The nursing staff also failed to promptly notify the resident's physician about the black discoloration of the toe, initially reporting only swelling and discoloration without mentioning the black color. This miscommunication delayed the appropriate medical response and intervention, preventing timely diagnostic testing and treatment that could have mitigated the disease progression. The resident's family member had to intervene by contacting the physician's group directly to ensure the resident received the necessary emergency care. Furthermore, the facility delayed the resident's transfer to the hospital after the emergent condition was discovered, resulting in a significant delay in receiving treatment for sepsis. The resident was eventually transported to the hospital by an outside provider group, not the facility, and arrived in a septic state, necessitating the amputation of the affected toe. The lack of timely and accurate documentation and communication by the nursing staff contributed to the resident's deteriorating condition and subsequent complications.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse when Resident 4 threw water on Resident 3, leading to Resident 3 feeling unsafe. Resident 4, who has diagnoses including neurocognitive disorder with Lewy Bodies, bipolar disorder, and PTSD, was admitted to the facility in 2023. Resident 3, admitted in 2024, has anoxic brain damage and unspecified mood disorder. Both residents were assessed as cognitively intact. The incident occurred when Resident 4, disturbed by Resident 3's continuous screaming, entered Resident 3's room and poured water on her. Resident 4 later explained that the screaming triggered his PTSD, and he acted out of frustration. The incident was confirmed by Licensed Nurse 3, who observed Resident 3's gown and belongings were damp and noted that Resident 3 was on fluid restriction and unable to hold a cup. Resident 3 reported feeling unsafe, fearing further harm from Resident 4. The facility's policy on abuse prevention emphasizes protecting residents from abuse by anyone, including other residents, and maintaining a culture of compassion and care, which was not upheld in this situation.
Failure to Provide Prescribed Pain Medications Upon Discharge
Penalty
Summary
The facility failed to ensure that a resident with metastatic breast cancer was discharged with her physician-prescribed controlled opioid medications, which were necessary for managing her moderate to severe pain. The resident was discharged without her controlled pain medications, leading to severe pain, nausea, and vomiting. This resulted in the resident calling emergency services and being taken to a General Acute Care Hospital (GACH) one day after discharge, where she was diagnosed with opiate withdrawal due to not taking her medications for over 24 hours. The resident was admitted to the facility with diagnoses including malignant neoplasm of the left breast and secondary malignant neoplasm of bone. Her discharge orders specified that she should be discharged with a seven-day supply of narcotics, including oxycodone and morphine. However, the facility's documentation was incomplete, and the section for medications on the post-discharge plan of care was left blank. A handwritten note referenced an attached medication list, which was not provided to the surveyor, and the facility failed to provide evidence that the resident was discharged with the prescribed medications. Interviews with staff and the resident revealed that the nurse responsible for the discharge was not prepared and unaware of the scheduled discharge, leading to a rushed process where the resident's pain medications were not provided. The facility's policy on transfer or discharge did not include procedures for non-emergent discharges or mention the provision of medications upon discharge. The Director of Nursing confirmed that discharging staff should document the medications and quantities provided to residents, which was not done in this case.
Failure to Implement Fall Prevention Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a plan of interventions to address the risk of falls for a resident who was identified as a high fall risk. This resident fell from his wheelchair at the nurses' station, resulting in a bruise on his forehead and a trip to the hospital for evaluation. The incident occurred when the resident, who was agitated, removed the wheel brakes of his wheelchair and attempted to move, causing the wheelchair to get stuck on the railing and the resident to fall. The resident's medical record indicated a fall risk assessment score that identified him as a fall risk, yet there was no care plan with interventions to prevent falls. The Licensed Nurse responsible for the resident's admission assessment confirmed that she completed the fall risk assessment but could not explain why a fall prevention care plan was missing. The interdisciplinary team, which reviews admissions and care plans, also failed to identify the omission of a fall prevention plan. Interviews with staff revealed that the resident was agitated on the day of the fall and that interventions for fall prevention were typically communicated through nurse reports to CNAs. However, the facility's policy on managing fall risks was not followed, as it required staff to identify and implement interventions based on the resident's specific risks. The lack of a fall prevention care plan and the failure to implement appropriate interventions contributed to the resident's fall and subsequent injury.
Resident's Dignity and Timely Care Compromised
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as well as provided timely access to care, which negatively impacted the resident's quality of life. Specifically, Resident 2 did not receive his pain medication in a timely manner, leading him to feel helpless and unimportant. During an interview, Resident 2 expressed that he did not feel entirely safe in the facility, citing an instance where he waited for an hour for his pain medication because the nurses were engaged in a shift change. This delay made him feel that the staff prioritized their shift change over the needs of the patients. The medical records review indicated that Resident 2 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 13, and he was able to understand and communicate effectively. He was also on a scheduled pain medication regimen. During an interview, a Licensed Nurse (LN C) acknowledged the importance of treating residents with respect and dignity, ensuring their privacy, and responding promptly to their calls for assistance. However, the facility's policy on resident rights, which emphasizes treating residents with kindness, respect, and dignity, was not adhered to in this instance, as evidenced by the delay in providing necessary medication to Resident 2.
Medication Administration Delays
Penalty
Summary
The facility failed to administer scheduled medications within the required time frames for three residents, as per the facility's policy on medication administration. The policy stated that medications scheduled more frequently than daily should be administered within one hour before or after the prescribed time, and those scheduled daily, weekly, or monthly should be administered within two hours before or after the prescribed time. However, 12 scheduled medications were administered as late as three hours after their prescribed times for the residents involved. Resident 1 was observed receiving medications significantly later than scheduled. Levetiracetam and Potassium Chloride, both scheduled for 8:00 AM, were administered at 10:15 AM, and Topiramate, scheduled for 9:00 AM, was given at 10:18 AM. Similarly, Resident 2 received Bumetanide and Acetaminophen, both scheduled for 8:00 AM, at 11:00 AM, and Sertraline HCL, scheduled for 8:59 AM, at 11:01 AM. Keflex, scheduled for 9:00 AM, was administered at 10:59 AM. Resident 3's medications, including Aspirin, Finasteride, and Lithium Carbonate, scheduled for 9:00 AM, were administered between 11:15 AM and 11:30 AM. The Director of Nursing acknowledged that all nurses were aware of the time frame for medication administration, which was one hour before and after the scheduled time. Despite this, the facility did not routinely audit medication pass times, which contributed to the late administration of medications. Complaints from residents about late medication administration were noted during Resident Council Meetings, indicating a pattern of delayed medication administration within the facility.
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What surveyors actually found near you
We read the 549 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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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) |
|---|---|---|---|---|
| North Bay Post Acute | 2 mi | ★★★★★ | 24 | 0 |
| Hillcrest Post Acute | 2.5 mi | ★★★★★ | 29 | 0 |
| Petaluma Post-acute Rehabilitation | 2.5 mi | ★★★★★ | 9 | 0 |
| Ridgeway Post Acute | 2.6 mi | ★★★★★ | 2 | 0 |
| Valley Of The Moon Post Acute | 9 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.