Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northgate Postacute Care during CMS and state inspections, most recent first.
A resident with major depressive disorder, mild neurocognitive disorder with behavioral disturbance, anxiety disorder, severe memory impairment, and need for assistance with personal care was not protected from misappropriation of property when a staff member allegedly used the resident’s bank card without authorization. An Ombudsman reported that the resident’s bank had linked the card to a staff member’s phone number and identified thousands of dollars in charges. A bank employee stated that a joint account holder raised concerns about money being taken and that an internal investigation showed fraudulent withdrawals over about a year, totaling more than $4,000. Law enforcement and facility leadership confirmed that the staff member’s phone number was connected to the resident’s card transactions and that approximately $27,571.49 was missing from the resident’s account.
Surveyors found that the facility failed to complete a required criminal background check for an employee with direct access to residents. The personnel file showed that the 7-year county review portion of the background screening was closed as incomplete after the screening agency did not receive needed information from the applicant, and there was no documentation that this issue was ever resolved. In interview, the Administrator acknowledged there was no evidence the background check had been completed, despite facility policies requiring thorough background screening and prohibiting employment of individuals with histories of abuse, neglect, mistreatment, or misappropriation of property.
The facility did not ensure an RN was present for at least eight hours on four days, with some days having no RN coverage at all. This lapse was confirmed by the DON and Administrator, and was not in accordance with facility policy for staffing to meet the needs of a medically fragile population.
A medication error rate of 5 percent or greater was identified, indicating that the facility did not maintain medication administration accuracy within regulatory limits.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, or serve food according to professional standards, resulting in a deficiency related to food safety and handling.
Three resident bathrooms were found in disrepair, including a scratched toilet seat, a corroded door frame with exposed debris, and a separated baseboard with rust and wall discoloration. The DON acknowledged these issues during surveyor observations, confirming they did not meet facility standards for cleanliness and maintenance.
A LVN provided wound care to a resident with a skin tear, including the application of calcium alginate and A&D ointment, without obtaining a physician's order as required by facility policy. The absence of an active wound care order was confirmed through record review, and staff interviews indicated that the expected protocol was not followed.
A resident receiving hospice care for a dislocated hip prosthesis and Huntington's disease did not have updated wound care orders or care plans in the hospice binder. The hospice RN and DON confirmed the oversight, resulting in a lack of coordinated care and incomplete documentation as required by facility policy and hospice contract.
The facility did not complete required annual performance evaluations for two CNAs, as confirmed by record review and staff interviews. The Director of Staff Development and DON both acknowledged that these evaluations were missing, despite facility policy mandating annual reviews for all employees.
Surveyors found that used fentanyl patches were improperly stored in a medication cart by an LVN instead of being immediately disposed of according to facility policy. The DON confirmed that the patches should have been brought directly for proper disposal, and the pharmacist stated that patches must be rendered non-retrievable to prevent misuse.
A medication cart was left unlocked and unattended by an LVN, and an open bottle of Senna syrup without an expiration date or original packaging was found in a medication cart. Both issues were confirmed by the DON and pharmacist as not meeting facility policy, which requires medication carts to be locked when not in use and medications to be stored in their original packaging with expiration dates.
Garbage and refuse were not properly disposed of, with overflowing dumpsters left open and trash bags and boxes observed on the ground. The Certified Dietary Manager confirmed that this practice was unacceptable and contrary to facility policy, which requires sealed containers and closed lids to prevent pest attraction.
A hospice RN left a resident exposed from the waist down and visible to the public for over 20 minutes while delaying a wound change, and also exhibited unprofessional behavior by crying and yelling in the resident's presence, causing distress. The DON confirmed these actions did not meet professional standards or facility policy for maintaining resident dignity.
A resident with multiple open wounds, including a traumatic amputation and a sacral wound, was not placed on Enhanced Barrier Precautions (EBP) as required by facility policy. PPE and EBP signage were not present outside the room, and both the IP and DON confirmed the oversight during interviews.
A broken, rust-covered laundry machine and a resident's bed with non-functioning locks were not promptly repaired or maintained, resulting in delays in laundry services and potential safety concerns. Staff and department heads confirmed the lack of regular maintenance and the importance of keeping equipment, such as laundry machines and bed locks, in safe working order, especially for residents with significant medical histories.
A handrail in the east wing hallway was observed to have a crack and was not firmly secured to the wall. Upon inspection by the MDR, the handrail separated from the wall, confirming it was unstable. Facility policy requires the maintenance department to keep equipment safe and operable at all times.
A resident was not given advanced written notice of two daily rate increases or a required security deposit, as required by facility policy. The resident and her representative did not receive an admission agreement or documentation of these financial changes, and billing statements lacked itemization for the security deposit. Staff interviews confirmed that notifications were not provided in writing and that required documentation was missing, resulting in financial hardship for the resident.
The facility did not maintain signed admission agreements for three residents and failed to provide a copy of the agreement to a resident who was cognitively intact and experiencing billing confusion. Admission agreements for two residents were signed long after admission, and one resident's agreement was missing entirely, contrary to facility policy requiring signed agreements and copies for all residents.
The facility failed to properly investigate and address allegations of misappropriation of property involving two residents, who reported missing debit cards and unauthorized transactions. The investigation was incomplete, lacking interviews with key staff, and the facility did not implement protective measures for other residents. Additionally, the facility failed to maintain a theft and loss log and did not incorporate these incidents into their QAPI program.
A resident with hemiplegia and hemiparesis following a cerebral infarction did not receive timely physician visits as required by the facility's policy. Despite the resident's MDS score indicating no cognitive impairment, there was no documented evidence of physician or nurse practitioner visits for several months. The resident reported not having a physician for a period, and the facility's Administrator confirmed the lack of documentation, potentially delaying necessary care.
The facility failed to maintain documentation and present evidence of its ongoing QAPI program. Unlicensed staff were unaware of the Quality Committee or QAPI projects. The Administrator could not initially find the QAPI binder, which later revealed only outdated documentation. The Director of Nursing mentioned a pest control project, but documentation was incomplete. The facility did not provide requested QAPI policies, attendance sheets, minutes, or agendas.
The facility failed to control a cockroach infestation in the kitchen and resident rooms, with live and dead roaches observed in food preparation areas and around residents' beds. Despite pest control measures, recommendations were not followed, and gaps in infrastructure allowed pest entry. Two residents were directly affected, with one refusing facility food after finding a roach on her meal plate and in her CPAP machine. The issue had been ongoing for about a year, with inadequate responses to pest control recommendations.
A resident with generalized anxiety disorder was not invited to participate in quarterly care conferences for 12 months. Despite the DON's recollection of the resident attending a meeting, there was no evidence in the clinical records to confirm the resident's participation or invitation to the conferences.
A facility failed to ensure a resident with generalized anxiety disorder was seen by a physician every 60 days. The resident's clinical record showed only two physician progress notes in the past year, and the DON could not provide evidence of regular visits or documented refusals. The resident confirmed not receiving regular physician visits.
Misappropriation of Resident Funds by Facility Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when a staff member made unauthorized charges to the resident’s bank card. The resident was admitted with major depressive disorder, mild neurocognitive disorder with behavioral disturbance, anxiety disorder, and a need for assistance with personal care. An MDS assessment indicated the resident had severe memory impairment and was only oriented to self. An Ombudsman reported to the DON that the resident’s bank had identified the resident’s bank card as being connected to a phone number belonging to a facility employee (Staff 1), with charges greater than $4,000. The facility’s abuse and neglect prohibition policy stated that misappropriation of property for all residents is prohibited. A police report documented that between mid-January and early November, the resident’s debit card had been fraudulently used by an employee of the facility, and the bank had accounted for approximately $27,571.49 missing from the resident’s account. In interviews, the Administrator and DON confirmed that Staff 1’s phone number was connected to the charges on the resident’s credit card, and the Administrator acknowledged that Staff 1’s employment had been separated based on this incident. A bank employee reported that a joint account holder had contacted the bank about money being taken from the resident’s account and that the bank’s investigation showed the fraud had been occurring for about a year and exceeded $4,000. A police officer stated that Staff 1 was definitely involved in the misappropriation of the resident’s property and confirmed the amount of the charges as $27,571.49, with the investigation ongoing.
Incomplete Criminal Background Screening for Direct-Care Employee
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough criminal background screening for an employee, identified as Staff 1, prior to or during employment. Record review showed that Staff 1’s criminal background check results indicated the 7-year county review “need attention” and that the service was closed as incomplete because the screening agency attempted to obtain information from the applicant/client but did not receive the needed information. Despite this notation, there was no further documentation in Staff 1’s personnel file showing that the incomplete background check was ever resolved or completed. During an interview, the Administrator stated that he would not have moved an applicant forward until the background check matter had been satisfied, yet he confirmed there was no documentation in Staff 1’s file indicating completion of the background check. The facility’s Abuse and Neglect Prohibition Policy requires screening of potential hires for a history of abuse, neglect, mistreatment, or misappropriation of property and prohibits employment of individuals found guilty by a court of law of such conduct. The facility’s Background Screening Investigations policy further requires employment background screening, reference checks, and criminal investigation checks on all applicants with direct access to residents, and states that applicants with convictions for abuse, neglect, mistreatment, or misappropriation of property are not to be employed. The incomplete and unresolved background check for Staff 1 was inconsistent with these written policies.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for at least eight hours a day on four separate days in July 2025, as confirmed by review of the RN time sheet and interviews with the Director of Nursing (DON) and the Administrator. Specifically, on July 6 and July 20, the RN coverage was less than eight hours, and on July 12 and July 13, there was no RN present at all. The DON confirmed that neither she nor the MDS RN worked on those weekends and was unaware of the missed coverage. The facility's policy requires adequate RN staffing to meet residents' needs, but this was not met for a medically fragile population of 48 residents during the identified days.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct observation and review of medication administration practices, which revealed that the error rate exceeded the regulatory threshold.
Non-Compliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating non-compliance with established food safety and handling protocols. The report does not provide specific details about the individuals involved or the exact nature of the food procurement or handling issues observed.
Failure to Maintain Resident Bathrooms in Safe and Homelike Condition
Penalty
Summary
Surveyors observed that three out of thirteen resident bathrooms were not properly maintained, resulting in conditions that did not meet standards for a safe, clean, and homelike environment. During observations with the DON, one shared bathroom had a toilet seat with numerous scratches, which the DON acknowledged was abnormal and required replacement. Another shared bathroom had a door frame that was corroded at the baseboard, exposing a large black hole filled with debris, which the DON stated needed immediate repair. In a third shared bathroom, the baseboard was separated from the wall, exposing rust on the toilet plumbing and discoloration on the wall, with the DON noting the baseboard needed to be reattached. Review of facility policies confirmed requirements for maintaining cleanliness and repair of interior areas, which were not met in these instances.
Wound Care Provided Without Physician Order
Penalty
Summary
A Licensed Vocational Nurse (LVN) provided wound care to a resident without a physician's order. The resident, who had been admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and sepsis, was observed with a skin tear on her left hand. The LVN removed the resident's bandage, cleansed the wound, applied A&D ointment, placed a calcium alginate dressing, and covered it with an island dressing. Review of the Treatment Administration Record (TAR) confirmed there was no active wound care order for this resident at the time of the treatment. During interviews, the LVN acknowledged that a physician should have been contacted to obtain a new wound care order before providing treatment. The Director of Nursing (DON) confirmed that staff are expected to update the physician and obtain appropriate orders for wound care. The facility's wound care policy also requires verification of a physician's order prior to performing wound care procedures. The pharmacist noted that improper use of calcium alginate could delay wound healing.
Failure to Ensure Collaborative Hospice Care and Updated Care Plans
Penalty
Summary
The facility failed to ensure collaborative care with the contracted hospice agency for a resident who was admitted with a dislocated internal left hip prosthesis and Huntington's disease. During an observation and interview, the hospice registered nurse case manager was found without the necessary wound care orders and had not updated the hospice binder with the resident's wound care plans. The director of nursing confirmed that there were no wound orders or care plans for the resident in the hospice binder, which was an oversight and impacted the resident's comfort of care. Further review of facility policies and the hospice contract revealed that hospice providers are required to maintain updated and coordinated care plans, including the most recent hospice plan of care and all relevant physician orders. The facility is responsible for ensuring collaboration and that the hospice agency's nursing care plan is included in the resident's record. In this case, the lack of updated documentation and care plans in the hospice binder led to a breakdown in communication and coordination of care for the resident.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for two certified nursing assistants (CNAs), as required by its policy. During interviews and record reviews with the Director of Staff Development, it was found that neither CNA had a documented annual performance evaluation for the 2024/2025 period. The Director of Staff Development confirmed that these evaluations should have been completed. Additionally, the Director of Nursing was unaware that multiple staff members were missing evaluations and acknowledged that annual evaluations were necessary. The facility's policy, dated January 2018, specifies that performance evaluations must be conducted at the end of the 90-day probationary period and at least annually thereafter, with completed evaluations to be filed in the employee's personnel record.
Improper Disposal of Used Fentanyl Patches
Penalty
Summary
The facility failed to properly dispose of used fentanyl patches, a potent opioid medication, as observed during a survey. Nine opened and used fentanyl patches were found stored in a plastic cup inside a medication cart by an LVN, who stated that the patches were awaiting disposal by the DON. The DON confirmed that used fentanyl patches should not have been stored in the medication cart and should have been brought directly to the DON for proper disposal. The facility pharmacist explained that used fentanyl patches should be cut up and placed into a disposal bin containing liquid to ensure they cannot be reused, noting that residual medication on the patches could be dangerous if touched. Review of the facility's policy indicated that destruction of controlled substances must render them non-retrievable, permanently altering their properties so they cannot be used or diverted.
Unattended Unlocked Medication Cart and Improper Medication Labeling
Penalty
Summary
A medication cart was observed left unlocked and unattended in the hallway by an LVN, who walked away into a resident's room, leaving the cart accessible. The LVN later confirmed that the cart was left unlocked and unattended, acknowledging this was a mistake. The facility's policy and procedure require that medication carts be locked when not in use to prevent unauthorized access, and the DON confirmed that carts should always be locked when unattended. Additionally, an open bottle of Senna syrup was found in a medication cart without an expiration date and not in its original packaging. The LVN present stated that the Senna syrup needed to be discarded due to the missing expiration date and lack of original packaging. The DON and the facility's pharmacist both confirmed that medications should be kept in their original packaging with the expiration date visible, and the facility's policy supports this requirement.
Improper Disposal and Storage of Garbage
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as evidenced by observations in the garbage storage area where a trash dumpster was found with both lids unsecured and open due to overflowing garbage. Multiple bags and boxes of trash were also seen on the ground in the same area. During an interview, the Certified Dietary Manager acknowledged that leaving trash unsecured and on the ground was unacceptable because it attracts pests and rodents. A review of the facility's policy and procedure on garbage and trash indicated that all food waste must be placed in sealed, leak-proof, non-absorbent, tightly closed containers and disposed of as necessary to prevent nuisance or unsightliness, with no debris on the ground and lids closed. These requirements were not met during the observation.
Failure to Ensure Resident Dignity and Professional Conduct During Hospice Care
Penalty
Summary
A deficiency occurred when a hospice registered nurse (HRN) failed to maintain a resident's dignity and privacy during care. The resident, who had a dislocated internal left hip prosthesis and Huntington's disease, was left exposed from the waist down and visible to the public for approximately 22 minutes while waiting for a wound change. The HRN was present in the room but did not begin the procedure, and the Director of Nursing (DON) confirmed the resident remained unclothed during this period, which was not in accordance with the facility's policy on accommodating resident needs and maintaining dignity. Additionally, the HRN displayed unprofessional conduct by crying and yelling unprovoked in the resident's room, causing the resident to appear confused and scared. The DON intervened and asked the HRN to leave the room, later confirming that the HRN's behavior was unprofessional and made the resident feel scared. The facility's policies and hospice contract require contracted hospice providers to meet professional standards and ensure resident dignity, which was not upheld in these instances.
Failure to Implement Enhanced Barrier Precautions for Resident with Open Wounds
Penalty
Summary
A deficiency occurred when the facility failed to identify the need to place a resident with multiple open wounds on Enhanced Barrier Precautions (EBP), an infection control strategy designed to prevent the spread of multidrug-resistant organisms (MDROs). The resident, who was admitted with a complete traumatic amputation of the left midfoot, had an open wound on the left foot with moderate serosanguineous drainage and a sacral wound with light serosanguineous drainage. During observation, there was no personal protective equipment (PPE) or EBP signage posted outside the resident's room, despite the resident receiving wound care for both the left foot and buttocks. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that the resident was not on EBP, even though facility policy required EBP for residents with wounds. The DON stated she was unaware that the resident was not on EBP and acknowledged that the resident should have been placed on these precautions due to the presence of wounds. Review of the facility's policy indicated that PPE should be available outside the resident's room and clear signage should be posted, neither of which was observed during the survey.
Failure to Maintain Safe and Operable Equipment
Penalty
Summary
The facility failed to maintain essential equipment in a safe and operable condition, as evidenced by two specific deficiencies. In the laundry room, one of the laundry machines was observed to be broken and covered in rust. The Maintenance Director (MDR) confirmed the machine was not functioning and acknowledged that maintenance was only performed when equipment was already malfunctioning, rather than on a regular schedule. The Housekeeping Staff stated that the broken machine had been out of service for an extended period, causing delays in the laundry process for residents. Additionally, the MDR was unable to locate the laundry machine manual, which was noted as important for troubleshooting. In a resident's room, Certified Nursing Assistants (CNAs) were unable to lock the bed due to malfunctioning bed locks. The MDR and the Director of Nursing (DON) both confirmed that the bed locks were not working and emphasized the importance of functioning bed locks to prevent falls and injuries. The resident involved had a history of left hip prosthesis dislocation, Huntington's disease, and a previous fall from a chair. Review of the facility's maintenance policy indicated that the maintenance department was responsible for ensuring all equipment was kept in a safe and operable manner at all times, including providing regularly scheduled maintenance.
Unsecured Handrail in Hallway
Penalty
Summary
During an observation in the east wing hallway, a handrail located between two rooms was found to have a crack along its seam and was not firmly secured to the wall. When the Maintenance Director inspected the handrail, it separated from the wall upon being tugged, confirming it was not properly attached. The Maintenance Director acknowledged that the handrail should have been secured and required reinforcement. A review of the facility's maintenance policy indicated that the maintenance department is responsible for ensuring that buildings, grounds, and equipment are maintained in a safe and operable manner at all times.
Failure to Provide Written Notice of Rate Increases and Security Deposit
Penalty
Summary
The facility failed to provide a resident with advanced written notice of increases in the daily room and board rate on two separate occasions, as well as failed to provide written notice or documentation regarding a required security deposit. The resident, who was cognitively intact as indicated by a BIMS score of 13, experienced two rate increases—first from $412 to $525 per day, and then from $525 to $680 per day—without receiving the required 30-day written notice. The increases were communicated verbally, if at all, and there was no documentation to support that proper notification was given. Additionally, the resident was required to pay a security deposit without prior written notice or agreement, and the amount was not itemized or documented in billing statements or the admission agreement. The admission agreement for the resident was not completed at the time of admission and was only signed much later, with key financial sections such as the daily room rate and security deposit left blank or marked as not applicable. The resident and her power of attorney both confirmed that they did not receive an admission agreement or written notification of rate changes or deposit requirements. Billing records showed retroactive charges for the increased rates and a lack of itemization for the security deposit, further indicating a lack of transparency and proper communication regarding the resident's financial responsibilities. Interviews with facility staff, including the Medical Records Director, Accounts Receivable Director, Admissions Coordinator, and Administrator, revealed a lack of awareness and documentation regarding the notification process for rate increases and security deposits. Staff confirmed that written notice was not provided, and there was no documentation to show that the resident agreed to the new rates or the security deposit. Facility policies required written notification and itemized billing, but these procedures were not followed in this case, resulting in financial hardship for the resident.
Failure to Maintain and Provide Signed Admission Agreements
Penalty
Summary
The facility failed to maintain signed admission agreements for three out of five sampled residents and did not provide a copy of the admission agreement to one resident. Specifically, one resident, who was cognitively intact with a BIMS score of 13, reported not receiving information about a required security deposit and was unable to reference the terms of her admission, including the daily room rate and security deposit amount. The resident experienced confusion and difficulty regarding billing, as she was asked to pay a security deposit after being in the facility for over a year and did not receive clear answers from staff. Record reviews and staff interviews confirmed that admission agreements for two residents were signed years after their initial admissions, only after an audit was prompted by a surveyor's request. Additionally, the facility could not produce an admission agreement for a third resident, and the Admissions Coordinator acknowledged that copies of agreements were not consistently provided or documented as offered. Facility policy required a signed admission and financial agreement for every resident, with a copy to be given to the resident and another kept in permanent records, but this procedure was not followed.
Failure to Investigate and Prevent Misappropriation of Property
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of property involving two residents who reported missing debit cards and unauthorized transactions. The investigation conducted by the Administrator was incomplete, as it lacked interviews with key staff members, including the alleged perpetrator, the Social Services Director. The facility's policy required comprehensive interviews with all relevant staff, but this was not adhered to, resulting in an inadequate investigation process. Additionally, the facility did not implement measures to protect other residents from potential theft. The inventory of personal effects for the residents was not properly itemized, which is crucial for tracking and safeguarding residents' belongings. Despite an in-service training conducted to address this issue, the inventory process remained insufficient, as evidenced by another resident's inventory lacking detailed documentation of wallet contents. The facility also failed to maintain a theft and loss log for the past 12 months, which is a requirement according to their policy. This log is essential for tracking incidents and ensuring accountability. Furthermore, the incidents of misappropriation were not incorporated into the facility's Quality Assurance and Performance Improvement (QAPI) program, as they were not discussed in recent QAPI committee meetings. This omission indicates a lack of systematic review and improvement efforts regarding theft and loss prevention within the facility.
Failure to Ensure Timely Physician Visits for a Resident
Penalty
Summary
The facility failed to ensure timely physician visits for a resident diagnosed with hemiplegia and hemiparesis following a cerebral infarction. The resident, who was admitted to the facility with these conditions, had a Minimum Data Set (MDS) score indicating no cognitive impairment. Despite the facility's policy requiring physician visits upon admission and every 30 days for the first 90 days, followed by at least once every 60 days thereafter, there was no documented evidence of physician or nurse practitioner visits for the resident during the months of August, September, October, and November of 2024. During interviews, the resident expressed that there was a period when she did not have a physician and had gone a long time without seeing one. The facility's Administrator confirmed the expectation for physician visits but acknowledged the lack of documentation for the specified months. This oversight had the potential to delay the detection of declining health and the provision of necessary care for the resident.
Failure to Maintain QAPI Documentation and Awareness
Penalty
Summary
The facility failed to maintain documentation and present evidence of its ongoing Quality Assessment and Performance Improvement (QAPI) program implementation and activities. During interviews, multiple unlicensed staff members were unaware of the Quality Committee or QAPI, and they did not know of any current quality improvement projects. The Administrator was unable to locate the QAPI binder initially and later provided one that only contained documentation from December 2024. She admitted to not knowing the current QAPI status or any performance improvement projects the facility was working on. The Director of Nursing stated that the QAPI Committee met monthly and at least quarterly, mentioning a project related to pests in the kitchen. However, a review of the facility's Quality Assessment and Assurance Committee Quality Assurance Performance Improvement Plan indicated incomplete documentation for a pest control plan dated December 3, 2024, with no data collection or results. The facility failed to provide requested policy and procedures for QAPI, attendance sheets, minutes, and agendas by the end of the survey.
Cockroach Infestation in Facility Kitchen and Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an infestation of cockroaches in both the kitchen and resident areas. Observations revealed live and dead cockroaches in the pantry and food preparation areas, with gaps and damages in the kitchen infrastructure that allowed pest entry. Food particles and uncovered garbage were also noted, contributing to the pest problem. Despite the presence of insect bait traps, the pest control measures were inadequate, and recommendations from pest service reports were not followed. Two residents were directly affected by the infestation, with cockroaches observed in and around their beds. One resident reported finding a cockroach on her meal plate, leading her to refuse facility-prepared food. The resident also discovered roaches inside her CPAP machine, which was confirmed by staff observations. The facility's administrator was unaware of the pest issues until a grievance was filed, and a log for pest sightings was initiated but remained blank. Interviews with staff and the pest control technician revealed that the roach infestation had been ongoing for about a year. The technician noted that the facility had not implemented his recommendations for repairs and cleaning. The Environmental Health Services conducted an inspection in response to the complaint, and the facility's policy on pest control was found to be ineffective in preventing the infestation.
Resident Not Invited to Care Conferences
Penalty
Summary
The facility failed to ensure that Resident 1 was invited to participate in quarterly care conferences, which are interdisciplinary meetings to review and revise residents' care plans. Resident 1, who was admitted with a primary diagnosis of generalized anxiety disorder, was not invited to participate in these meetings for the past 12 months. This was confirmed through a review of Resident 1's clinical records and interviews with both Resident 1 and the Director of Nursing (DON). Despite the DON's claim of having seen Resident 1 in one of the care conferences, there was no documentary evidence to support that Resident 1 was invited or attended any of the care conferences held on 3/14/23, 6/15/23, 9/14/23, 12/14/23, and 3/6/24.
Failure to Ensure Regular Physician Visits
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician at least every 60 days, as required. The resident, who was admitted with a primary diagnosis of generalized anxiety disorder, had only two physician progress notes documented in the past 12 months. During a review of the resident's clinical record, the Director of Nursing (DON) was unable to provide evidence of regular physician visits, offering only three additional progress notes over the same period. The DON claimed that the resident refused physician visits but could not provide documentation to support this claim. In an interview, the resident confirmed not receiving regular physician visits and could not recall the last time they were seen by a physician at the facility.
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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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Nursing homes near San Rafael
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Ridge Care Center | 0 mi | — | 24 | 0 |
| Professional Post Acute Center | 0 mi | — | 2 | 0 |
| Villa Marin | 0.8 mi | — | 11 | 0 |
| Smith Ranch Skilled Nursing & Rehabilitation Cente | 0.8 mi | — | 17 | 0 |
| Marin Post Acute | 1.2 mi | — | 24 | 0 |
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