WINDSOR CARE CENTER OF PETALUMA

Nursing Home Inspector

523 HAYES LANE
PETALUMA, CA 94952
Sonoma County
Phone: 707-763-2457
Provider Number: 555703
Last Inspection: 02/17/2017

About the Nursing Home

Number of Beds: 79
Number of Residents: 69
Beds Available: 10
Percent Occupancy: 87%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

52

Facility
29

County
32

CA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

52

2017
29

2016
21

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

2/17/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 4/18/2017
 
Failed To: Assess in a timely manner the resident when the resident enters the nursing home. Isolated : Minimal 3 4/18/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 4/18/2017
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 4/18/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 4/18/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 4/18/2017
 
Failed To: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Pattern : Minimal 4 4/18/2017
 
Failed To: Provide bedrooms that don't allow residents to see each other when privacy is needed. Pattern : Minimal 4 4/18/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 4/18/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 4/18/2017
 
Failed To: Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. Widespread : Minimal 5 2/17/2017
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Pattern : Minimal 4 4/18/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Pattern : Minimal 4 4/18/2017
 

1/8/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 3/17/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 3/17/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Widespread : Minimal 5 3/17/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 3/17/2016
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Widespread : Minimal 5 3/17/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 3/17/2016
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Isolated : Minimal 3 3/17/2016
 

12/5/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 2/12/2015
 
Failed To: Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. Isolated : Minimal 3 2/12/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 2/12/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 2/12/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 2/12/2015
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Widespread : Minimal 5 2/12/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

8/1/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 9/1/2017
 

4/20/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 8/8/2017
 

9/8/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 11/1/2016
 

8/31/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 10/21/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg CA State Avg
Number of Residents 69 68.86 84.47
Registered Nurses 0.46 1.23 0.81
Licensed Practical / Vocational Nurses 0.75 0.79 1.06
Certified Nursing Assistants 2.14 2.73 2.59
Total Staff Hours 3.35 4.75 4.46

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% CA State Avg%
of high risk long-stay residents with pressure ulcers 9 2 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 99 97 96
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 93 95
of long-stay residents experiencing one or more falls with major injury 3 1 1
of long-stay residents who have depressive symptoms 4 1 0
of long-stay residents who lose too much weight 6 5 5
of long-stay residents who received an antianxiety or hypnotic medication 26 21 19
of long-stay residents who received an antipsychotic medication 22 15 11
of long-stay residents who self-report moderate to severe pain 8 2 3
of long-stay residents who were physically restrained 0 1 0
of long-stay residents whose ability to move independently worsened 22 15 15
of long-stay residents whose need for help with daily activities has increased 5 9 10
of long-stay residents with a catheter inserted and left in their bladder 2 1 2
of long-stay residents with a urinary tract infection 0 3 2
of low risk long-stay residents who lose control of their bowels or bladder 51 47 44
of short-stay residents assessed and appropriately given the pneumococcal vaccine 90 89 86
of short-stay residents who had an outpatient emergency department visit 7 11 11
of short-stay residents who made improvements in function 61 64 66
of short-stay residents who newly received an antipsychotic medication 2 1 1
of short-stay residents who self-report moderate to severe pain 35 11 8
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 90 83 84
of short-stay residents who were rehospitalized after a nursing home admission 14 13 21
of short-stay residents who were successfully discharged to the community 63 66 51
of short-stay residents with pressure ulcers that are new or worsened 0 0 0