Atherton Baptist Home
214 South Atlantic Blvd., Alhambra, CA 91801 · Non profit - Corporation · 113 certified beds · (626) 289-4178 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.4% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.4% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 7.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 8.7% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 18.1% | 9.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.2% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.3% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.8% | 10.2% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.8% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 4.4% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 93.2% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.45 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.56 | 1.57 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
44.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 34% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 44.0%CMS range 28.6–58.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.0–15.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.3%CMS range 4.2–14.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.92 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 113 beds and averages 60.4 residents a day — about 53% occupied, or roughly 53 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.29 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.67 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.77 hrs/resident/day on weekends vs 4.50 on weekdays — 16% thinner on weekends. RN hours go from 0.43 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Ecited before2026-01-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide supervision for two of three sampled residents (Residents 12 and 18) under the accidents care area in accordance with facility policy when:1.Resident 12 was observed sliding off the wheelchair unattended in the activity room and unsupervised during a fall on 1/12/2026 in the resident's bedroom.2.Resident 18 was observed unattended in the activity room.This deficient practice placed Resident 12 and 18 at risk for accident and/or injury which had the potential to result in harm like fractures (break in bone), hospitalization, and death.Findings: 1. During a review of Resident 12's admission Record, the admission Record indicated the facility initially admitted Resident 12 on 3/29/2022 and was readmitted on [DATE] with diagnoses that included but not limited to dementia (a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life), repeated falls (an unintentional coming to rest on the ground or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-16 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician reviewed and took timely action on a medication regimen review (MRR, consists of a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) irregularity (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) identified by the facility's pharmacy consultant for two of five sampled residents (Resident 24 and 58) under unnecessary medications care area by failing to:1 a. Consider a gradual dose reduction (GDR, a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) with the goal of discontinuing Resident 24's Escitalopram (Lexapro, medication used to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-16 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its policy to ensure resident's drug regimen was free from unnecessary medication use for one (1) of five (5) sampled residents (Resident 2), under unnecessary medications care area, by failing to have a specific indication for Resident 2's use of Seroquel (quetiapine- an antipsychotic medication to treat mental condition by helping balance certain chemicals in the brain). This deficient practice had the potential to increase the risk for Resident 2 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medication (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), possibly leading to impairment or decline in the resident's mental, functional or psychosocial status.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan (a document that outlines a resident's care goals and the activities that will be performed to achieve those goals) for one (1) of 18 sampled residents (Resident 8) by failing to address Resident 8's central venous catheter (CVC, a type of access used for hemodialysis [HD-a procedure removing excess fluid and metabolic waste and products or toxic substances from the bloodstream]), in accordance with the facility's care plan policy.This deficient practice had the potential to not be able to provide specific interventions to address risk for having a CVC, such as accidental dislodgement (displacement/removal of a device thought to be securely in position), which could result in serious harm to Resident 8.Findings:During a review of Resident 8's admission Record, the admission Record indicated the facility initially admitted the resident on 6/25/2011 and was readmitted on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-16 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the care plan was implemented for one (1) of 1 sampled resident (Resident 47), under language and communication care area, by failing to put on the resident's hearing aid and provide a pencil and paper for communication.This deficient practice had the potential for Resident 47 from expressing her needs in a manner that the staff can understand, which could result in a delay in the provision of the resident's necessary care and services.Findings:During a review of Resident 47's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of dementia (a progressive state of decline in mental abilities), muscle weakness, and need for assistance with personal care.During a review of Resident 47's Minimum Data Set (MDS - a resident assessment tool), dated 10/20/2025, the MDS indicated the resident was severely impaired in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor, assess, and inform the physician regarding a skin discoloration (bruises - an injury appearing as an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) on the resident's left arm for one of one sampled resident (Resident 16) receiving anticoagulant medications (medications that prevent blood from clotting excessively) in accordance with professional standards of practice (authorized, authoritative guidelines established by professional bodies to define the expected behaviors, skills, ethics, and knowledge required for competent practice). This deficient practice had the potential to result in a lack of or delay in assessing for possible complications of Resident 16's skin discoloration which could lead to undetected bleeding and hospitalization. Findings:During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was initially admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-16 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the personal belongings were documented in the inventory list (a comprehensive, itemized record of all goods, raw materials, and finished products of the resident) in accordance with the facility's Policy and Procedure (P&P) for one (1) of 1 sampled resident (Resident 18) under personal property care area.This deficient practice has the potential to cause Resident 18 to lose his personal belongings and prevent the facility from being able to replenish them.Findings:During a review of Resident 18's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of age-related physical debility (a state of profound weakness, lack of energy, and diminished strength), unsteadiness on feet, and muscle weakness.During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool), dated 10/24/2025, the MDS indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-23 · tag F0697 — failed to manage pain — patternProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two (2) of 2 sampled residents (Residents 1 and 2) received proper pain management by failing to have pain scale parameters to pain medications ordered when: Resident 1, who had returned from the general acute care hospital (GACH) after a right hip hemiarthroplasty (a surgical procedure that involves replacing half of the hip joint), had a physician's order for Tramadol Hydrochloride (drug commonly used to treat severe pain) as needed (PRN) for pain without a pain scale parameter (mild, moderate, or severe pain). Resident 2 had a physician's order for Tramadol Hydrochloride and Tylenol Extra Strength (drug which reduces fever and relieves minor aches and pain) PRN for pain without a pain scale parameter.This deficient practice had the potential for Residents 1 and 2's pain not to be managed which could result in negatively affecting the residents' overall well-being. Findings: 1. During a review of Resident 1's admission Record, the admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide interventions to prevent accidents (any unexpected or unintentional incident, which results or may result in injury or illness ) for three (3) of 3 sampled residents (Resident 61, 29, and 24) by failing to: 1. Ensure a functional bed sensor pad (alerting device intended to monitor a resident's movement) for Resident 61's use, as indicated on the physician's order and failed to ensure resident's call light was within reach, as indicated on the fall care plan. 2. Identify and eliminate all foreseeable accident hazards and include care plan interventions to address underlying cause of fall for Resident 24 who had a history of falls on 5/25/2024, 7/13/2024, 8/30/2024, and 9/27/2024. 3. Ensure Resident 29's sensor pad alarm was properly positioned and turned on and worked at all times. These deficient practices placed Residents 61, 24, and 29 at risk for falls and injury which had the potential to result in serious consequences like…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to label food items in the kitchen with item name, opened and expiration date as indicated in the facility's policy and procedure. This deficient practice had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness such as food poisoning with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 11/7/2024 at 7:49 AM with dietary supervisor (DS) in the walk-in refrigerator of the main kitchen, the following were observed: a. Four trays of marinated fish fillet have no labels for the name of the food item, date, and time it was prepared and no label of use-by date. b. Three trays of prepared Jello have no lids to cover the trays of the Jello, there were no labels for the name of the food item, date, and time it was prepared and no label of use-by date. c. One loaf of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · Dcited before2024-11-07 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident received reasonable accommodation of needs for one of 22 sampled residents (Resident 9) by failing to ensure resident was in a comfortable position during meals. This deficient practice resulted in Resident 9 in feeling exhausted and uncomfortable while eating. Findings: During a record review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of spinal stenosis (a tightening of the spinal canal that causes nerve pain), osteoporosis (weakening of bones, leading to a decrease in bone density and an increased risk for fractures), and reduced mobility. During a record review of Resident 9's Minimum Data Set (MDS, a federally mandated resident assessment and tool), dated 10/29/2024, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its Change in a Resident's Condition or Status policy by failing to notify the physician regarding a significant weight loss for one of three sampled residents (Resident 31) as indicated on the care plan. This deficient practice had the potential to result in delayed provision of necessary care and services. Findings: During a record review of Resident 31's admission Record indicated Resident 31 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia (progressive brain disorder that slowly destroys memory and thinking skills) and left artificial hip joint. During a record review of Resident 31's Weight Tracking System Report, the record was as follows: - 5/29/2024 184 lbs - 6/3/2024 184 lbs - 6/6/2024 161 lbs (-23 lbs in three days, 12.5% weight loss) - 6/10/2024 160 lbs (-24 lbs, 13.0% weight loss) During a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain confidentiality of the resident's electronic health record (EHR) for one (1) of 22 sampled residents (Resident 45) by failing to turn off the computer screen and leaving it unattended, exposing the resident's EHR which included the resident's medical condition, list of medications, and other information regarding resident care to others not authorized to view. This deficient practice had the potential to result in the violation of Resident 45's privacy and confidentiality. Findings: During a review of Resident 45's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses which included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), benign prostatic hyperplasia (BPH, also known as an enlarged prostate, is a noncancerous condition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Restorative Nursing Services (a program available in nursing homes to help residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) as ordered by the physician to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) for one of three sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for decline in physical functions and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in the extremities (a limb of the body, such as the arm or leg) for not receiving the ordered exercises. Findings: During a review of Resident 2's admission Record, the record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-07 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the physician addressed the medication regimen review (MRR/Drug Regimen Review - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to indicate a reason for disagreeing with the pharmacist recommendation for gradual dose reduction (GDR- the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Ativan (lorazepam- a medication used for anxiety [feeling of fear, dread, or uneasiness that can be mild or severe]) for one of 22 sampled residents (Resident 17) on 10/25/2024. This deficient practice had the potential to result in adverse medication outcome for potential unnecessary medications to Resident 17. Findings: During a review of Resident 17's admission Record, the admission Record indicated Resident 17…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the drug regimen for one (1) of five sampled residents (Resident 17) was free from unnecessary drugs by failing to assess the continued need for Tylenol (acetaminophen- used relieve mild to moderate pain from headaches, muscle aches, and to reduce fever) after it was not administered as needed for pain for more than ninety (90) days. This deficient practice had the potential for Resident 17 to suffer adverse reactions from unnecessary drug including bleeding easily and bruising. Findings: During a review of Resident 17's admission Record, the admission record indicated Resident 17 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included major depressive disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified pain, and anxiety disorder (fear characterized by behavioral disturbances). During a review of Resident 17's Minimum Data Set (MDS- a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to properly label the medications with the date opened of one (1) of 8 sampled residents as indicated on the facility policy. This deficient practice had the potential for adverse reaction if these improperly labeled medications were administered to Resident 45. Findings: During a review of Resident 45's admission Record indicated the resident was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses which included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), benign prostatic hyperplasia (BPH, also known as an enlarged prostate, is a noncancerous condition in which the prostate gland becomes larger than normal), and insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep) During a review of Resident 45's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide food that accommodated food preferences for one (1) of two sampled residents (Resident 40). This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included unspecified atrial fibrillation (afib- irregular and often very fast heartbeat that can lead to blood clots in the heart), heart failure (a serious condition in which the heart does not pump blood as efficiently as it should), and essential hypertension (high blood pressure). During a review of Resident 40's History and Physical examination (H&P), dated 5/16/2024, the H&P indicated Resident 40 did not have the capacity to understand and make decisions. During a review of Resident 40's Minimum Data Set (MDS- a federally mandated resident assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-17 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a resident centered care plan to address functional assistance needed with Activities of Daily Living (ADL) for one of two sampled residents (Resident 1) in accordance with the facility policy. This failure had the potential for Resident 1 not to receive interventions specific to the residents needs, which could result in injury and fall. Findings: A review of Resident 1's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included dementia (the impaired ability to remember, think or make decisions that interferes with doing everyday activities), difficulty in walking and fracture (break in the bone) of the right femur (thigh bone). A review of Resident 1's History and Physical Examination, dated 3/15/23, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-16 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to: 1. Label food in the kitchen with item name, opened and expiration date, and discard expired food as indicated on the facility's policy and procedure. a. Two opened packages of bread (English muffin and white loaf bread) in the working station were not labeled to indicate date food items were opened. b. Three trays of blueberry dessert, cornbread, and chocolate cake placed on a rack in the dry storage room were not labeled with item name and date when they were made. c. An opened box of cinnamon streusel coffee mix and corn flakes crumbs were not labeled to indicate date when it was opened. d. A container with brown grains in the dry storage did not have a label to indicate the food item. e. Four packages of mandarin orange sauce were not labeled to indicate expiration date. f. A package of chocolate chip cookies was not labeled to indicate expiration date. g. A tray of expired left over Boston cream pie dated 6/23/2023 was not discarded. 2. Ice cream freezer log did not have a documentation for temperatures…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that the call light (device used by residents to call staff) was within reach for one of 19 sampled residents (Resident 75). The call light was observed on the floor, out of reach (more than the arm's length) of Resident 75. This failure had the potential to put Resident 75 at risk for fall that could lead to a serious injury and/ or death. Findings: A record review of Resident 75's face sheet (admission records) indicated Resident 75 was admitted in the facility on 3/11/2023 with admitting diagnoses of generalized muscle weakness (weakness of the muscle that affects the entire body), unsteadiness of the feet, and history of falls. A review of Resident 75's Minimum Data Set (MDS - a standardized assessment tool that measures the health status in nursing home residents), dated 9/1/2023, indicated, Resident 75 requires assistance with activities of daily living, including bed mobility (how resident moves while in bed such as turning from side to side), transferring, walking, dressing (how resident puts…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-16 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were provided a homelike environment for three of 19 sampled residents (Resident 53, Resident 76, and Resident 57) by failing to provide a working wall clock with the correct time. This deficient practice had the potential to negatively impact the resident's quality of life and further confuse the residents. Findings: A review of Resident 53's admission record indicated Resident 53 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (another term for a cancerous tumor) of unspecified site of right female breast, muscle weakness and difficulty in walking. A review of Resident 53's History and Physical dated 12/14/2022 indicated Resident 53 does not have the capacity to understand and make decisions. A review of Resident 53's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 8/23/2023, indicated Resident 53 needs extensive assistance with a one-person assistance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a resident-specific care plan addressing the Preadmission Screening and Resident Review II (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are appropriately placed in nursing homes for long term care) recommendations for one of 19 sampled residents (Resident 27). This deficient practice had the potential for Resident 27 to not get the appropriate care and interventions for her mental needs. Findings: A review of Resident 27's Profile Face Sheet (admission record) indicated Resident 27 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia (a brain disorder that results in memory loss, poor judgment and confusion), psychosis (mental disorder characterized by a disconnection from reality), and anemia (condition where the blood does not carry enough oxygen to the rest of the body). A record review of Resident 27's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-16 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross Reference with F692 and F726 Based on interview and record review, the facility failed to review and revise a care plan to address a significant weight loss (weight loss of five percent in one month) for one of 19 sampled residents (Resident 35). This deficient practice placed Resident 35 at risk for further decline in nutritional status and continued weight loss, which could result in serious harm. Findings: A review of Resident 35's admission Record indicated Resident 35 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD- disease that causes obstructed airflow from the lungs), thyrotoxicosis (an abnormal high blood levels of triiodothyronine (T3) and thyroxine (T4) which are your body's thyroid hormones), and hypertension (high blood pressure). A review of the Resident 35's History and Physical (H&P, the initial clinical evaluation and examination of the patient), dated 7/20/2023, indicated the resident did not have the capacity to understand and make…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross Reference with F657 and F726 Based on interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one of one sampled resident (Resident 35) in accordance with the facility policy by failing to: a. Notify the resident's physician of Resident 35's significant weight loss (weight loss of five percent in one month) of 5.5 percent (%) in a month . b. Conduct an Interdisciplinary Team Nutrition Alert meeting (a systematic and interdisciplinary approach to identify, track, intervene, monitor, and follow-up with residents at high risk for significant weight changes, dehydration (harmful reduction in the amount of water in the body), and any other nutrition-related concerns) to address Resident 35's significant weight loss. c. Obtain and implement interventions to prevent further weight loss. This deficient practice placed Resident 35 at risk for further decline in nutritional status, which could result in harm. Findings: A review of Resident 35's admission Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-16 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Cross Reference with F657 and F726 Based on interview and record review, the facility failed to ensure Restorative Nursing Aide 1 (RNA 1) had the appropriate skill sets and proficiencies to provide nursing services for resident in response to a change in condition of significant weight loss (five percent weight loss in one month) for one of 19 sampled residents (Resident 35). This deficient practice had the potential to place Resident 35 and other residents who may be at risk for decline in nutritional status, suffer from unplanned weight loss. Findings: A review of Resident 35's Weight Tracking System indicated as follows: - On 10/12/2023, the resident's weight was 127 pounds (lbs., unit of measurement). - On 11/03/2023, the resident's weight was 123 lbs. - On 11/11/2023, the resident's weight was 120 lbs., (-5.51% weight loss in 30 days). During a concurrent record review of Resident 35's Nursing Notes and interview with Licensed Vocational Nurse 1 (LVN 1) on 11/15/2023 at 11:22 AM, LVN 1 stated Resident 35 lost seven (7) lbs. from 10/12/2023 to 11/11/2023. LVN 1 stated a 7 lb.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor the effectiveness of psychotropic medications (a type of medication that affects brain activities associated with mental processes and behavior) for one of five sampled residents (Resident 76). This failure had the potential to put the resident at risk for not receiving the appropriate treatment. Findings: A review of Resident 76's face sheet (admission record) indicated the resident was admitted on [DATE] with admitting diagnoses of dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), psychosis (mental disorder that affects how a person thinks, feels, and behaves), and cognitive communication deficit (loss of ability to communicate). A review of Resident 76's Minimum Data Set (MDS - a standardized assessment tool that measures health status in nursing home residents), dated 9/1/2023, indicated the resident has impaired cognition (an individual's ability…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-16 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for one of one sampled resident (Resident 2) when the oxygen tubing observed touching the floor. This deficient practice had the potential to spread respiratory infection to Resident 2. Findings: A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 2's diagnoses included chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, acute respiratory failure (occurs when you do not have enough oxygen in your blood) with hypercapnic (happens when you have too much carbon dioxide in your blood) and chronic bronchitis (is inflammation and irritation of the bronchial tubes[these tubes are the airways that carry air to and from the air sacs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ATHERTON BAPTIST HOMES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | NO DATE PROVIDED |
| MEREDITH, BRETT | Individual | CORPORATE OFFICER | — | since 10/01/2024 |
| PASCUAL, MA JOCELYN | Individual | CORPORATE OFFICER | — | since 05/01/2002 |
| MEDINA, JOELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/14/2025 |
| NASSIF, TAREK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2016 |
CMS files one row per role, so the 8 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555272. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.