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 Piners Nursing Home during CMS and state inspections, most recent first.
A resident with dementia, chronic pain, COPD, and other comorbidities was converted from scheduled hydrocodone-acetaminophen to a fentanyl 25 mcg/hr transdermal patch despite not meeting FDA-defined opioid-tolerant criteria, and without documented risk assessment for advanced age and chronic lung disease. The resident’s actual morphine equivalent (ME) exposure was significantly below the 60 mg/day threshold required for initiating this fentanyl dose. Later, after several days without a patch and variable PRN opioid use, the fentanyl dose was doubled to 50 mcg/hr soon after the resident received Norco and lorazepam 0.5 mg for restlessness and anxiety, contrary to manufacturer titration guidance and the facility’s own policy to avoid or closely monitor opioid–benzodiazepine combinations. The resident subsequently developed acute shortness of breath, hypoxia, somnolence, slow shallow respirations, and pinpoint pupils, required naloxone by EMS, and was diagnosed in the ED with accidental opiate overdose and hypoxia.
A resident became upset during a Bingo activity, threatened another resident, and was escorted away while yelling, which drew the attention of the Administrator and DON. Later, while the resident was nearby in the lobby, the DON approached the nurses’ station in an emotional and aggressive manner, stating that the resident was out of control and needed to be sent out, within earshot of the resident. A confidential witness reported that the DON’s physically and verbally aggressive behavior felt like bullying, and the resident began sobbing. Progress notes documented the resident’s emotional distress, including facial redness, shaking, SOB, and crying, and the resident was sent to the ED for further evaluation. The facility’s policy requires staff to treat all residents with kindness, respect, and dignity.
A resident with dementia, traumatic brain injury, chronic pain, bipolar disorder, and other comorbidities had her fentanyl patch increased and her Seroquel regimen intensified, including a higher scheduled dose and a PRN order, without her representative being informed or providing consent, despite the medical director’s determination that the resident lacked decision-making capacity. Nursing documentation showed the discontinuation of a 25 mcg/hr fentanyl patch and initiation of a 50 mcg/hr patch, as well as increased Seroquel dosing, but no evidence of notification to the family or signed informed consent. The family member later discovered the changes after the resident experienced respiratory distress and appeared overly sedated, and staff interviews confirmed that the representative had not been notified, contrary to facility policies on resident rights, psychotropic medication use, and person-centered care planning.
A resident with dementia, bipolar disorder, anxiety disorder, epilepsy, chronic pain, and prior stroke had a PRN Seroquel 25 mg order for agitation related to anxiety that remained active well beyond the 14-day limit set by facility policy for PRN psychotropic medications. The MAR showed multiple PRN administrations, and observations later noted the resident in a wheelchair with eyes closed, chin on chest, and tongue hanging out. Nursing staff could not locate any documentation that the attending physician or a mental health provider had re-evaluated and documented the continued need for the PRN antipsychotic, and the MD was unsure about the 14-day documentation requirement. The pharmacist reported she had recommended discontinuation of the PRN Seroquel during a medication regimen review. This constituted a failure to prevent potential chemical restraint by not ensuring timely re-evaluation and documentation for continued PRN antipsychotic use.
A facility failed to investigate and report an alleged abuse incident involving a resident who reported physical abuse by a CNA, resulting in a hand discoloration. Despite the facility's policy requiring investigation and reporting, no documentation or investigation summary was provided to the State Department of Health, potentially delaying further investigation.
The facility failed to maintain the final rinse temperature of the dishwasher at the required 180 degrees Fahrenheit, compromising the sanitization of dinnerware and cooking utensils. Dietary staff confirmed the issue had been ongoing for several months, leading to the use of disposable plates and utensils as a temporary measure.
The facility failed to ensure hand hygiene for six residents before meals, did not conduct ongoing infection surveillance, and did not follow physician's orders for changing a resident's oxygen equipment weekly. Staff did not routinely offer hand hygiene, infection control documents were incomplete, and the resident's oxygen equipment was not labeled or changed as required.
The facility failed to consistently perform antibiotic stewardship, leading to potential inappropriate or unnecessary antibiotic treatment. The new Infection Preventionist (IP) had not seen previous documentation except for a folder on Antibiotic Stewardship, and the Director of Nursing (DON) stated that infection control documents could not be located. No antibiotic surveillance tracking was completed from August to December 2023, and the IP had not conducted in-services with staff on antibiotic stewardship.
A resident with dementia and dry eye syndrome had a large, bleeding growth on her nose that was not properly diagnosed or treated by the facility. Despite observations and interviews indicating the growth's consistent increase in size and bleeding, the facility only applied a band-aid and did not pursue further treatment or accurate monitoring. The resident's Responsible Person had declined further diagnosis based on age and perceived lack of pain, but had not seen the current state of the growth.
The facility failed to ensure that a resident received the RNA program as ordered by the physician, resulting in inconsistent delivery of prescribed exercises. Staffing shortages and reassignment of RNA staff to CNA duties contributed to this deficiency, which was confirmed by both the resident and staff.
The facility failed to ensure that resident meals were served with the appropriate dietary consistency. Licensed staff reviewed meal tray cards and dietary orders but did not check the actual food consistency before serving it to residents. Unlicensed staff were observed delivering meal trays without the required checks when the responsible licensed staff member was on a break. Interviews revealed a lack of formal documentation or training on this task, and the DON was unaware of the issue.
The facility failed to ensure a safe and functional kitchen environment due to unrepaired cracks and missing tiles on the floor. Cracked tiles were observed in front of the dry good storage, by the washing sinks, the exit door, and another dry good storage entrance. The Certified Dietary Manager acknowledged the non-compliance.
The facility failed to perform annual performance reviews for two CNAs. The Director of Staff Development acknowledged the reviews were behind due to a three-day work schedule, with 2023 reviews not yet completed for all unlicensed staff. Human Resource files confirmed the absence of reviews for 2023 and 2024.
Failure to Follow FDA Fentanyl Patch Dosing Guidelines Resulting in Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to follow FDA Black Box Warnings and manufacturer dosing specifications for a fentanyl transdermal patch in an elderly resident with COPD and multiple comorbidities. The resident, in her late 70s, had diagnoses including dementia, chronic pain, vertebral compression fractures, bipolar disorder, anxiety disorder, COPD, and cerebral infarction. Prior to fentanyl initiation, the resident was receiving hydrocodone-acetaminophen (Norco) 5-325 mg on a scheduled basis, with a regimen that allowed for up to five tablets per day, but the MAR showed multiple instances where doses were refused or held due to sedation. Based on the consultant pharmacist’s review and morphine equivalent (ME) calculations, the resident’s actual opioid exposure at the time fentanyl was started was approximately 20–25 mg ME per day, below the FDA-defined threshold of at least 60 mg oral morphine daily for at least one week to qualify as opioid-tolerant. The record contained no documented justification for switching from Norco to a fentanyl patch or any risk assessment addressing the resident’s advanced age, COPD, and sub-threshold opioid exposure in relation to the FDA Black Box Warning and manufacturer guidance. On 11/26/25, an order was written for a fentanyl (Duragesic) 25 mcg/hr transdermal patch to be applied every 72 hours for chronic pain, and Norco was changed to PRN two days later. The consultant pharmacist later confirmed that, according to the Duragesic dosing guidelines, a 25 mcg/hr starting dose should only be used in patients already receiving at least 60 mg oral morphine equivalents daily for a minimum of seven days, which this resident did not meet. The facility’s own pain management policy stated that pain medications should be selected based on pertinent treatment guidelines, that the lowest possible effective opioid dose should be used with ongoing monitoring, and that combining opioids and benzodiazepines should be avoided or closely monitored for respiratory depression. Despite these standards and the resident’s COPD and geriatric status, the fentanyl patch was initiated without documentation that the resident was opioid-tolerant as defined by the FDA labeling, and without a documented risk assessment. Subsequently, the resident’s fentanyl dose was increased from 25 mcg/hr to 50 mcg/hr on 1/30/26, after a period in late January when the 25 mcg/hr patch had been removed and not replaced for several days due to unavailability. During January, the resident’s PRN Norco use ranged from one to three tablets per day, with nine days of no Norco administration, and pain scores varied from 0 to 9. On 1/29/26, nursing documentation showed the resident was restless and unable to be consoled, leading to a new order for lorazepam 0.5 mg for anxiety, which was administered at 5:20 p.m., following a Norco dose at 4:00 p.m. The next day, the fentanyl patch dose was doubled to 50 mcg/hr. The consultant pharmacist verified that, at the time of this dose increase, the resident was receiving only 5–15 mg of supplementary morphine equivalents per day, far below the 45 mg ME per day that the manufacturer’s titration guidelines associate with a 12.5 mcg/hr increase, and that lorazepam and Norco had been administered shortly before the fentanyl dose escalation, creating a potential for respiratory depression. On 2/1/26, nursing notes documented that the resident began screaming for help and reported, “I can’t breathe, I can’t talk, I can’t swallow.” The nurse applied supplemental oxygen, but the resident’s oxygen saturation dropped to 77%, and her temperature was 100.1°F. The medical director was notified and ordered transfer to the emergency department. ED triage documentation indicated shortness of breath, slow shallow respirations, pinpoint pupils, and a positive response to naloxone administered by EMS, with the fentanyl patch removed by EMS. The ED history and physical described somnolence presumed due to opioid overdose and shortness of breath, and the ED physician’s note characterized the event as an iatrogenic occurrence requiring re-evaluation of the resident’s pain management strategy. The ED diagnoses included accidental or unintentional opiate overdose and hypoxia. Throughout interviews, the consultant pharmacist confirmed that both the initial fentanyl dose and the subsequent dose increase did not meet FDA and manufacturer criteria for opioid tolerance and dose titration, while the medical director stated he believed he had followed fentanyl dosing guidelines but could not identify the cause of the resident’s respiratory distress.
Failure to Treat a Resident With Dignity and Respect During Behavioral Incident
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to be treated with kindness, respect, and dignity. A confidential witness (CW) reported that during an activities session in January 2026, a resident became upset during Bingo after observing another resident not covering a called number. According to a progress note dated 1/9/26 at 3:34 p.m., the resident stated that if someone did not know how to play, they should not be playing, and was informed by staff that assistance is provided to all residents. As the staff member removed the resident from the table, the resident threatened to slap another resident and threw two Bingo chips against the wall while being escorted down the hall, yelling loudly enough to draw the attention of the Administrator and the DON, who then took over the situation. The CW stated that later that afternoon, while at the nurses’ station, they observed the DON approach the nurses’ station in a very emotional and aggressive manner, saying that the resident was out of control and that something needed to be done, including that the resident needed to be sent out. This interaction occurred within earshot of the resident, who was only a few feet away in the lobby, and upon hearing the DON’s comments, the resident began sobbing. The CW described the DON’s behavior as physically and verbally aggressive and perceived it as bullying the resident. A subsequent progress note dated 1/9/26 at 5:20 p.m. documented that the resident had facial redness, shaking, shortness of breath, emotional distress, and crying, and was sent to the ED for further evaluation. The facility’s Resident Rights policy, last reviewed 3/31/26, states that employees shall treat all residents with kindness, respect, and dignity.
Failure to Inform Resident Representative of Pain and Psychotropic Medication Changes
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident’s family member of significant changes to the resident’s treatment plan for pain and behaviors, despite the resident lacking capacity to make healthcare decisions. The family member reported receiving a call that the resident was in respiratory distress after an increase in her fentanyl patch dose to 50 mcg/hr, and stated that he would not have agreed to this increase because the resident was already on multiple central nervous system depressants. He also reported that the resident’s Seroquel dose had been doubled in the hospital and continued upon her return to the facility without any discussion with him, even though the resident had delirium and was not at her baseline during the hospitalization. The family member described finding the resident slumped over in a chair and slurring her words, and later learned via text communication with the physician that there was also a PRN Seroquel order that he had not been informed about. Record review showed that the resident had multiple diagnoses including dementia with behavioral disturbance, epilepsy, chronic pain, traumatic brain injury, bipolar disorder, anxiety disorder, and cerebral infarction. The face sheet listed the resident as her own responsible party, but the medical director had previously informed surveyors that the resident did not have capacity to make healthcare decisions and confirmed that this had not changed and no county conservator had been arranged. Physician orders and MARs showed a fentanyl patch 25 mcg/hr ordered in November and discontinued in late January, with a new order for a fentanyl patch 50 mcg/hr dated 1/30 and administered on 1/30, as well as Seroquel 25 mg three times daily for agitation and later Seroquel 50 mg three times daily with an added PRN Seroquel 25 mg every six hours for agitation. Nursing progress notes documented discontinuation of the 25 mcg patch and initiation of the 50 mcg patch but contained no documentation that the family member was notified of this change. Interviews with facility staff confirmed the lack of family notification and informed consent. One licensed nurse stated that the family member was not informed of the decision to increase the fentanyl patch at the end of January. Another licensed nurse verified there was no informed consent signed for the increased Seroquel dose or the PRN Seroquel order and acknowledged that a new consent should have been obtained when the dose was increased and a PRN dose added in the hospital. The medical director confirmed that the resident still lacked decision-making capacity and stated that residents’ families have the right to participate in the plan of care and that he expected nursing staff to have informed the family member of the fentanyl dose increase. Facility policies on resident rights, psychotropic medication use, and comprehensive person-centered care planning required resident or representative participation in treatment decisions and care planning, informed consent for psychotropic medication changes, and documentation when resident or representative participation in care planning was not practicable, which did not occur in this case.
Failure to Re-Evaluate PRN Antipsychotic Order Within Required 14-Day Limit
Penalty
Summary
The deficiency involves the facility’s failure to comply with requirements for PRN antipsychotic medications, resulting in a chemical restraint concern for one resident. The resident, an older adult with dementia, epilepsy, chronic pain, bipolar disorder, anxiety disorder, and a history of cerebral infarction, had a physician order for Seroquel 25 mg to be given by mouth three times a day as needed for agitation related to anxiety disorder, starting on 2/3/26. The February MAR showed that the PRN Seroquel was administered on three occasions (2/11/26, 2/14/26, and 2/22/26). Observations on 3/12/26 documented the resident in a wheelchair in the lobby with eyes closed, chin resting on the chest, and later with the tongue hanging out of the mouth, while a musician performed nearby. Record review and staff interviews revealed that the PRN Seroquel order remained active from 2/3/26 through at least 3/26/26 without documented re-evaluation by the physician or a mental health provider, despite facility policy limiting PRN psychotropic orders to 14 days and requiring an evaluation and documentation to renew PRN antipsychotic orders. A nurse stated that the physician re-evaluated PRN antipsychotics during quarterly gradual dose reductions and monthly order recapitulations, but could not identify any documentation of a specific re-evaluation or rationale for continuing this PRN Seroquel order. The medical director could not recall if he documented a re-evaluation and appeared unaware that documentation every 14 days was required to continue a PRN antipsychotic. The facility’s pharmacist reported that, during a recent medication regimen review, she noted the PRN Seroquel order and recommended its discontinuation. This failure resulted in the resident having the potential to receive an antipsychotic dose beyond the 14-day limit without the required re-evaluation.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its abuse prevention policy and procedures when a resident reported an incident of alleged physical abuse by a certified nursing assistant (CNA). The resident claimed that the CNA pulled on her arms, resulting in a 2.5 cm x 2 cm discoloration on her left hand near the thumb. Despite this report, the facility did not conduct an investigation nor document any findings related to the incident. The resident's medical record contained a nurse's note documenting the alleged abuse, but there were no additional notes or interdisciplinary team (IDT) documentation addressing the incident. During interviews, facility staff confirmed the absence of documentation related to an in-house investigation or IDT notes regarding the incident. The facility's policy requires that all allegations of abuse be investigated and reported within the timeframes required by federal requirements. However, the facility did not provide a 5-day investigation summary to the State Department of Health, as required. This lack of action and documentation potentially delayed the Department's independent investigation of the incident.
Dishwasher Final Rinse Temperature Deficiency
Penalty
Summary
The facility failed to ensure the sanitization, safety, and functional environment in the kitchen when the temperature of the final rinse of the dishwasher was not maintained to adequately sanitize dinnerware and cooking utensils. During an observation and interview, it was noted that the final rinse temperature of the high-temperature dishwasher was only 150 degrees Fahrenheit, significantly below the required 180 degrees Fahrenheit. Dietary Aides E and F confirmed that the dishwasher frequently failed to reach the necessary temperature, and they had to run the dishwasher multiple times in an attempt to achieve the correct temperature. Despite these efforts, the dishwasher still did not consistently reach 180 degrees Fahrenheit, leading to the use of disposable plates and utensils as a temporary measure. A review of records revealed that the issue with the dishwasher's final rinse booster heater had been ongoing for several months. The monthly Consultant Dietitian Report Card indicated that the dishwasher was not holding temperature as early as January, with subsequent reports in February and March noting continued issues with the booster heater leaking and failing to maintain the required temperature. This prolonged failure to address the malfunctioning dishwasher compromised the facility's ability to properly sanitize dinnerware and cooking utensils, posing a risk of food contamination and potential foodborne illness among residents.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure hand hygiene was practiced by six of 15 sampled residents before meals. Observations revealed that staff did not offer or remind residents to wash or wipe their hands before eating. Interviews with staff confirmed that they did not routinely offer hand hygiene to residents, and moist wipes were not included on meal trays as previously done. The facility's policy on hand hygiene did not specify that staff should remind or offer hand hygiene to residents before meals, contributing to this oversight. The facility also failed to conduct ongoing analysis of infection surveillance. The newly appointed Infection Preventionist (IP) had not seen the infection prevention folders except for the one on Antibiotic Stewardship. Surveillance logs for the past 12 months were incomplete, and there was no documentation of data analysis or infection rate plotting. The Director of Nursing (DON) acknowledged that the infection control documents could not be located or had been misplaced, and the current IP had not started the process of overseeing infection surveillance. Additionally, the facility did not ensure that physician's orders were followed for one resident who was on oxygen therapy. The resident's nasal cannula and oxygen humidifier were not changed weekly as required, with the last documented change occurring nearly two months prior. Observations confirmed that the nasal cannula tubing and humidifier were not labeled with the date of the last change. Interviews with staff indicated that the responsibility for changing the equipment was not clearly assigned, and the DON admitted to not realizing the equipment had not been changed as scheduled.
Failure to Consistently Perform Antibiotic Stewardship
Penalty
Summary
The facility failed to consistently perform antibiotic stewardship, which had the potential to result in inappropriate or unnecessary antibiotic treatment. During an interview and records review, the Infection Preventionist (IP) stated she had only been working at the facility for three weeks and had not seen the previous IP's folders except for the one on Antibiotic Stewardship. The folder contained documentation on an antibiotic surveillance tracking form with residents' names who were treated with antibiotics from January to April 2024, but none for the past months. The Director of Nursing (DON) stated that infection control, surveillance, and monitoring documents could not be located or may have been misplaced after the previous IPs left. The DON had called the previous IP to help locate the folders. A review of the Infection Prevention and Control Line Listing Surveillance Logs indicated no antibiotic surveillance tracking was completed from August to December 2023, as there were no line listing surveillance logs for those months. The IP's job description indicated responsibility for the antibiotic stewardship program (ASP), including in-servicing, tracking, reporting, and educating families, employees, and physicians as needed. However, the IP stated she had not conducted in-services with staff on antibiotic stewardship. The facility's Antibiotic Stewardship policy, updated in January 2024, indicated that antibiotic usage and outcome data should be collected and documented using a facility-approved antibiotic surveillance tracking form. All clinical infections treated with antibiotics were supposed to undergo review by the IP or designee, but this was not consistently done, leading to the deficiency.
Failure to Diagnose and Treat Resident's Growth
Penalty
Summary
The facility failed to appropriately diagnose and treat a growth on the left side of Resident 29's nose. Resident 29, who has a history of dementia and dry eye syndrome, was observed with a large growth on her nose that had been bleeding. Unlicensed and licensed staff indicated that the growth had been consistently growing, and Resident 29 would scratch it, causing it to bleed. Despite these observations, the facility's staff only cleaned the area with saline solution and applied a band-aid, without pursuing further treatment or monitoring the growth's size and condition accurately. The Social Services Director (SSD) and various licensed staff members revealed that there had been a canceled plastic surgeon appointment and a dermatology appointment where Resident 29 became combative, preventing assessment. The Responsible Person (RP) for Resident 29 had decided against further diagnosis or treatment based on the resident's age and perceived lack of pain. However, the RP had not seen the current state of the growth, which had become larger and more prone to bleeding. The facility's weekly skin assessments failed to document the changing size and bleeding events of the growth accurately. The Director of Nursing (DON) was not aware of the growth's increase in size and its proximity to the lower eyelid. The facility's policies on charting, documentation, and skin and wound management were not followed accurately, leading to incomplete and inaccurate records. The lack of a comprehensive healthcare team approach and proper monitoring increased the risk of infection and discomfort for Resident 29.
Failure to Administer RNA Program as Ordered
Penalty
Summary
The facility failed to ensure that the Restorative Nursing Assistant (RNA) program was being administered according to physician orders for Resident 33. Resident 33, who was admitted with diagnoses including cerebral infarction, major depression disorder, and hemiplegia, had a care plan that included passive and active range of motion exercises to be performed 3 to 5 times per week. However, the records indicated that these exercises were not consistently provided, with significant gaps in the frequency of the sessions over multiple months. For example, in one six-week period, Resident 33 received the exercises only twice, whereas they should have been offered at least 12 times. Similar deficiencies were noted in subsequent periods, with the resident receiving the exercises far less frequently than ordered by the physician. This inconsistency in care delivery was corroborated by Resident 33, who expressed that promises to take him to the gym were not always kept and that he felt forgotten about. The Rehab Manager and the RNA staff confirmed that staffing shortages and the reassignment of RNA staff to CNA duties contributed to the failure to provide the ordered exercises. The facility's policies on restorative nursing services and resident mobility and range of motion were not adhered to, resulting in a failure to maintain or improve Resident 33's functional mobility and muscle strength as required by the care plan.
Failure to Ensure Appropriate Dietary Consistency in Resident Meals
Penalty
Summary
The facility failed to ensure that resident meals were served with the appropriate dietary consistency. During an observation, a licensed staff member was seen reviewing meal tray cards and dietary orders in the electronic medical record but did not check the actual food consistency before serving it to residents. The licensed staff member indicated that the meals were not uncovered to avoid touching the food. This process was common practice at the facility, and the staff member acknowledged the importance of checking meal trays to prevent residents from choking or aspirating on improperly prepared food. However, during another observation, unlicensed staff were seen delivering meal trays without the required checks, as the licensed staff member responsible was on a break and not available to perform the task. Interviews with various staff members, including the Director of Nursing (DON), revealed that there was no formal documentation or training on how to perform the task of checking meal trays for appropriate consistency. The DON was unaware that meals were not being checked by licensed staff before being served to residents and emphasized the importance of this safety measure to prevent aspiration. The facility's policy and procedure on tray line procedures indicated that assigned staff should deliver the cart to the nurses' station and announce its arrival, but it did not specify the need for checking meal consistency before serving.
Unrepaired Cracks and Missing Tiles in Kitchen
Penalty
Summary
The facility failed to ensure a safe and functional environment in the kitchen due to unrepaired cracks and missing tiles on the kitchen floor. During an initial tour of the kitchen, cracked tiles were observed in front of the entrance to the dry good storage. Further observations revealed more cracks and missing tiles by the washing sinks, the exit door to the back of the building, and the entrance to another dry good storage. The Certified Dietary Manager acknowledged the non-compliance when informed about the findings. The Food Code 2017 indicates that materials for indoor floor surfaces should be smooth, durable, and easily cleanable, which was not adhered to in this case.
Failure to Perform Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to perform annual performance reviews on two out of three sampled Certified Nursing Assistants (CNAs). During an interview, the Director of Staff Development (DSD) acknowledged that the annual performance reviews for Unlicensed Staff P and Unlicensed Staff Q were outstanding. The DSD indicated that the reviews were behind due to a three-day work schedule and that the facility was still working on completing the reviews for the current year of 2024, with 2023 reviews not yet completed for all unlicensed staff. A review of the Human Resource files for Unlicensed Staff Q and Unlicensed Staff P confirmed the absence of annual performance reviews for the year 2023 and, in the case of Unlicensed Staff P, also for 2024.
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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 Napa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Napa Valley Care Center | 0.8 mi | — | 0 | 0 |
| Napa Post Acute | 0.9 mi | — | 29 | 1 |
| The Meadows Of Napa Valley | 2.6 mi | — | 0 | 0 |
| Dept Of State Hospitals - Napa D/p Snf | 3.5 mi | — | 2 | 0 |
| Veterans Home Of California - Yountville - Snf | 6.4 mi | — | 16 | 0 |
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