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Modoc Medical Center D/P SNF

225 W Mc Dowell Ave, Alturas, CA 96101 · For profit - Corporation · 84 certified beds · (530) 233-5131 Medicare & Medicaid certified

Call the home — (530) 233-5131 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Dec 2023Behavioral-health or dementia-care citations — no harm found (F0741, F0758)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (5/5) — 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)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2023
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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 (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (2/5)

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 5 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1034 Lake View Dr · (530) 233-3223 · Call to confirm hours
Pharmacy
120 S Main St · (530) 233-2947 · Call to confirm hours
Grocery
1077 N Main St · (530) 233-3822 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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 2 of 5
Long-stay residentspeople who live here 2 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 4 to 5 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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.8%10.2%15.4%typical
Long-stay residents who lose too much weight4.3%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection6.3%1.2%2.0%worse
Long-stay residents with depressive symptoms12.7%7.3%6.5%worse
Long-stay residents who were physically restrained2.6%0.4%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.6%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened16.5%9.8%16.1%typical
Long-stay residents on antianxiety or hypnotic medication14.8%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers9.2%4.3%4.7%worse
Long-stay residents with worsening bladder/bowel control17.1%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 table17.0%12.0%17.1%typical
Long-stay hospitalizations per 1,000 resident days2.172.251.67worse
Long-stay outpatient ER visits per 1,000 resident days4.731.571.80worse

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.

Staffing

0.48
RN hours/ resident / day
1.74
LPN hours/ resident / day
3.87
Aide hours/ resident / day
6.09
Total nurse hours/ resident / day
0.38
RN hoursweekends
44.1%
Total nursing turnover
71.4%
RN turnover

How full it usually is: this home is certified for 84 beds and averages 53.8 residents a day — about 64% occupied, or roughly 30 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 6.09 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.87 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 5.00 hrs/resident/day on weekends vs 6.53 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.52 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as 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

3
deficiencies at the latest standard inspection (2025-04-17)
2
at the previous standard inspection (2023-10-05)

Deficiencies are more than at the previous inspection — worsening. 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.

ABCDEFGHIJKL

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.

18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.

  • Potential for harm · D2026-01-14 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure there was a Licensed Nurse (LN) in the facility to provide care for 14 out of 14 residents when LN A left the facility for a lunch break. This had the potential to impact resident health status and could have caused a decline in psychosocial well-being. Findings:A review of the Facility Assessment Tool, dated 11/10/25, indicated the facility would staff two LNs on the night shift.A review of the undated Staffing Ratio for Revamping [changing or redoing] up Staffing, indicated, when the facility census (how many residents were in the facility) was less than 30, there would be one LN working the night shift.During an interview on 1/13/26 at 12:19 pm, Certified Nurse Assistant (CNA) B stated, one night, LN A went outside for a smoke break, and she drove away and was gone for an hour. CNA B confirmed, there was no LN in the facility or on the facility grounds while LN A was gone and stated, it was me and another CNA. CNA B stated a resident that was awake [Resident 1] was upset that the nurse left the facility.During an…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-14 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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

    Based on interview and record review the facility failed to ensure that medication was stored securely when Licensed Nurse (LN) A left the medication keys at the nurse's station during a lunch break. This failure caused medication to be accessible to facility staff and residents and had the potential to cause a decline in resident health status. A review of the facility's policy and procedure (P&P) titled, Medication Cart, revised 8/1/24, indicated, the Pharmacists and LN would have access to the medication cart. The P&P indicated, If a nurse leaves the floor for any reason, they must turn over the keys to the cart to another nurse. During an interview on 1/14/26 at 11:41 am, Nurse Manager (NM) stated, I heard she [LN A] left one night for her lunch break and threw her medication keys on the counter at the nurse's station. One of the Certified Nurse Assistant's (CNA) called me. During an interview on 1/14/26 at 12:19 pm, CNA B confirmed that LN A had left the facility for a lunch break and left the medication keys unsecured at the nurse's station and Resident 1 had witnessed it. CNA…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0563 — failed to protect the right to visitors — isolated
    Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
    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 follow their visitation policy and procedure (P&P) for one out of three sampled residents (Resident 1) when Resident 1 was denied (not allowed) visitors of his choosing, the facility did not notify Resident 1 that his friend (Visitor) had been denied visits, there was no documentation present in the medical record, and rules and regulations regarding visitors were not posted for the public and residents to review. This failure violated Resident 1's right to receive visitors of his choosing and had the potential to cause psychosocial harm. Findings: A review of the facility's P&P titled, Visitation, Acute Hospital/SNF, revised 12/1/19, indicated, residents had the right to visitors of their choosing if they had the ability to make their own decisions. The P&P indicated, A visitor may also be prohibited [not allowed] if in the clinical judgement of the healthcare team, a visitor would negatively impact the health or safety of the patient,…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0909 — failed to maintain a comfortable temperature — isolated
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    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 bedframes were maintained for resident safety when the Medical Equipment Management Plan and manufacture recommendations were not followed for one of four sampled residents (Resident 1), when the footboard fell off of Resident 1's bed. This had the potential to subject all residents to injury from equipment that the facility had not regularly inspected and maintained for the safe use by residents. Findings: A review of the facility's policies and procedures (P&P) titled, Equipment Management Program, revised 3/1/18, indicated, electronically operated patient beds would be included in the Equipment Management Program. A review of the facility's P&P titled, Preventative Maintenance, revised 3/1/23, indicated, the facility maintained a comprehensive Preventative Maintenance Program for all equipment that included scheduled maintenance and documentation of maintenance. A review of the Medical Equipment Management Plan, dated 1/1/11, indicated, 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-17 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 interview, observation and record review, the facility failed to meet this requirement when a medication cart was observed to be left unlocked on two occasions. This had the potential to result in unauthorized access to medications that had the potential to cause illness and death. Findings: Review of the facility's policy titled Medication Preparation and Administration, last reviewed 2010, indicated, If the nurse leaves the medication cart, it must be locked. On 4/15/25 at 12:32 PM, a medication cart was observed to be unlocked and openable outside room [ROOM NUMBER]. Unsupervised medications were observed to include heart medication, blood pressure medication, antipsychotics (medications for mental health), and diuretics ('blood pressure pills), among many other drugs. No staff was observed nearby to secure the cart while it was open. On 4/15/25 at 12:33 PM, LVN (Licensed Vocational Nurse) was observed coming toward the unlocked cart from a distant hall in the facility. In a concurrent interview, LVN…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-17 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview and record review, the facility failed to meet this requirement when an expired food product was stored in the refrigerator and available for serving to residents. This had the potential to result in foodborne illness and poor food palatability (flavor, freshness). Findings Review of the facility's policy titled, Food Storage Policy and Procedure dated 2005 indicated, All food should be labeled and dated, and Refrigerated food should be stored upon delivery and careful rotation procedures should be followed. On 4/14/25 at 12:00 PM, a 15-ounce spray can of Redi Whip whipped topping was observed in the facility's foodservice refrigerator, with a use by date of 2/24/25 written per the facility's policy. It was observed that the product was nearly two months beyond this use-by date. In a concurrent interview on 1/14/25 at 12:00 PM, Dietary Manager (DM) confirmed that the whipped topping, Should have been thrown away. DM was observed disposing of the item.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-17 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 follow infection control standards for 4 out of 5 residents (Resident 1, Resident 28, Resident 19, and Resident 29) during medication pass when staff did not disinfect medical equipment and when medication containers where brought into residents' rooms and handled by the residents. This had the potential to spread a communicable disease and cause cross-contamination. Findings: The facility's policy titled, Cleaning of Non-Critical Patient Care Equipment, dated 05/2017, indicated the purpose of this policy is to provide guidance on cleaning and disinfection of non-critical, patient care equipment. It is the policy for patient care equipment to be cleaned and disinfected to prevent the potential spread of infection and cross-contamination. The facility's policy titled, Medication Preparation and Administration, revised 2010, indicated this policy is to ensure the most complete and accurate implementation of a physician's medication orders…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-01 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 report an injury of unknown origin for one of one residents (Resident 1) sampled for abuse. Resident 1 was found to have significantly large suspicious bruising on both of her breasts from an unknown cause. The facility had not reported this to the California Department of Public Health (CDPH), Ombudsman (Resident advocate agency), or to their local Law Enforcement agency, in accordance with their Abuse Policy. This failure resulted in the inability for CDPH, Ombudsman and Law Enforcement to gather additional information surrounding Resident 1's injuries and conduct their own investigation, which could negatively impact Resident 1's physical, emotional and psychosocial well-being and quality of life. Findings: A review of facility's policy provided by Director of Nursing (DON) titled, Elder Abuse dated January 2012, indicated abuse as the, willful infliction of injury .resulting in physical harm, pain, or mental anguish. Facility policy further…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility did not protect residents' right to be free from sexual abuse for one of three sampled residents (Resident 1), when Certified Nursing Assistant (CNA) 1, offered to have sexual relations with her to relieve stress. This caused fear and anxiety for Resident 1, and had the potential to negatively impact her emotional and psychosocial well-being. Findings: A review of the facility's policy titled, Elder Abuse dated 6/2023, indicated, Abuse is the infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Abuse of a patient includes the deprivation of goods or services necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all patients, even those in a coma, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Instances include verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-06 · tag F0741 — failed to have staff trained for behavioral health — isolated
    Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
    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 one of seven sampled residents (Resident 1), received care according to Resident 1's comprehensive person-centered care plan. This happened when Certified Nursing Assistant (CNA) 2 and CNA 3 had a verbal disagreement in front of Resident 1; CNAs did not exit the room when Resident 1 became agitated; CNA 3 provided care quickly with no breaks between tasks; three CNAs were in the room at the same time and CNAs did not provide a sheet to cover Resident 1 during care. This failure resulted in Resident 1 becoming increasingly agitated and had the potential to cause Resident 1 physical and psychosocial harm. Findings: During a review of facility policy and procedure titled, Resident Right-Resident Behavior and Facility Practice, dated 10/2020, indicated the resident has the right to be free from verbal abuse and the facility must care for residents in a manner and in an environment that promotes maintenance or enhancement fo each resident's quality of life and enhances dignity and respect in full recognition…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 8 citations
  • Potential for harm · E2023-10-05 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide a Registered Nurse (RN) who was on duty, eight hours out of every day, seven days a week. This failure had the potential for RN assessment skills and supervision to not be available every day for residents and staff. Findings: Record review of the staffing schedules for the months of August and September 2023 showed there was no RN working on the following dates: 8/5, 8/6, 8/19, and 8/20; 9/2, 9/3, 9/9, 9/10, 9/16, 9/17, 9/23, 9/24, and 9/30. During an interview, on 10/3/23, at 9:18 am, the Administrative Assistant stated they did not have a full-time RN on the weekends during the months of August and September 2023. During an interview, on 10/4/23, at 10:23 am, the Director of Nursing stated they didn't have any policy about nurse staffing or RN staffing. During an interview, on 10/4/23, at 10:42 am, Licensed Nurse (LN) A stated RNs on the floor were sporadic, they came and went. During an interview, on 10/4/23, at 11:41 am, the Nurse Manager stated that for the last month they didn't have an RN working on 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-05 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 interview and record review, the facility failed to report a COVID-19 (a contagious virus that caused respiratory illness) outbreak which affected four residents (Residents 5, 19, 43, and 45) and four staff members to the California Department of Public Health (CDPH). This failure had the potential to expose further residents to illness, which could have threatened their health and well-being. Findings: A facility policy, titled, Outbreak Investigation, revised 1/1/12, was reviewed. An outbreak was defined as an excess level of endemic (constantly present in a specific location) disease or statistically (by the numbers) significant increase in endemic level. The time period would have varied according to the infection. The facility's threshold (required number of cases for an outbreak) was defined as greater than five percent of the resident population. If an outbreak was confirmed, it should have been reported to the local county Public Health Department and also to CDPH within 24 hours of the initial…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-16 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure 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

    Based on interview, and record review, the facility's pharmacy consultant failed to identify drug irregularities which included the diagnoses and necessary indications, including target behaviors, for each psychotropic drug (any drug that affects brain activities associated with mental processes and behavior), or antipsychotic drug (drugs that work by altering brain chemistry to help reduce psychotic symptoms including hallucinations, delusions, and disordered thinking), and the Centers for Medicare and Medicaid Services (CMS) requirement to limit as needed (PRN) psychotropic medications to 14-days, unless there was a documented rationale which included why the medication needed to be extended past 14-days, and the duration, for three of eight sampled resident records reviewed for unnecessary medications (Residents 3, 37, and 25). This failure resulted in, or had the potential to result in residents receiving unnecessary medication with adverse side effects, some of which could be permanent. The facility failed to ensure their pharmacy consultant provided documentation for each…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-16 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement 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

    Based on interview, and record review, the facility failed to ensure 4 of 8 sampled residents (Residents 3, 8, 25, and 37) who received psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior), or antipsychotic drugs (drugs that work by altering brain chemistry to help reduce psychotic symptoms including hallucinations, delusions, and disordered thinking) had adequate diagnoses and clinical indications for use including monitoring of target behaviors to assess effectiveness, monitoring of adverse side effects, and documentation by the physician that included the rationale, and duration for as needed (PRN) psychotropic drugs that exceeded 14-days. This resulted in or had the potential to result in residents receiving unnecessary medication with adverse side effects, some of which could include permanent neurological side effects, and a deterioration in the clinical condition of these residents. Findings: 1. A review of Resident 3's medical record indicated she was admitted with diagnoses that included lung disease, anxiety disorder,…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-06-16 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 make sure that the ice machine dispenser area was free of mineral deposits and debris. This failure had the potential to promote the growth of mold which could have cross contaminated the ice and led to foodborne illness among those residents, staff, and visitors who consumed it, which could lead to negative outcomes. Findings: The facility's policy titled, Food Safety: Ice, revised 11/1/21, was reviewed, and indicated that the facility's ice supply would remain free of all possible contaminants. The Food Code of the United States Public Health Service, and Food and Drug Administration, dated 2017, was reviewed, and indicated in Section 4-602.11 the cleaning of equipment such as ice machines: 4-602.11 Equipment Food-Contact Surfaces and Utensils. (E) Except when dry cleaning methods are used as specified under § 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At any time when contamination may have occurred; (4) 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-16 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to develop and implement a plan of action to correct deficiencies related to unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior). As a result of this failure, a pattern of deficiencies was present regarding unnecessary psychotropic medications control that had the potential to harm all residents who received these drugs. (Refer to F 756, and F 758). Findings: During an interview, on 6/16/22 at 9:45 am, the Chief Nursing Officer (CNO) reported that the QAA Committee was working on falls, skin, pain, and psychotropic medication issues. Specifically, he said there was a high percentage of psychotropic use for the residents in the skilled nursing facility. The CNO said they discuss gradual dose reductions (GDR) during their GDR meetings. He was asked if the QAA committee identified any issues with psychotropic drugs being given without diagnosis or clinical indication, inadequate monitoring of behaviors and…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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

    Based on observation, interview, and record review, the facility failed to ensure adequate supervision and implement all interventions in the care plan including having a sitter, to prevent one of 16 sampled residents (Resident 3), who was a high risk for elopement (leaving the building without permission), from leaving the building. This had the potential to result in a serious injury to Resident 3, which could lead to negative clinical outcomes. Findings: The facility's policy titled, Resident Elopement, revised 3/18, was reviewed, and indicated that facility will have a system in place for the early identification of residents at risk for elopement and will have the implementation of interventions to prevent elopement, and harm as evidenced by the assessment and care planning procedures. The facility reported to the California Department of Public Health on 6/1/22, that Resident 3 had left the faciity on 5/27/22, and was found about 150-feet away by a staff member who lived in the area. The staff member brought her back to the facility, and there were no injuries. The facility…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2022-06-16 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview, and record review, the facility did not have the required membership at its Quality Assessment and Assurance (QAA) meetings, when the Medical Director missed the meetings for one quarter. This failure had the potential for unidentified resident care issues to occur, as well as a lack of medical oversight, which could lead to negative clinical outcomes. Findings: On 6/16/22 at 9:23 am, the attendance sheets for QAA meetings from 6/10/21 through 6/9/22, were provided by Administrative Assistant (AA). A review of these documents indicated there had been a total of nine meetings during that period. The Medical Director was present during a meeting on 12/9/21, and 5/12/22, but did not attend meetings held on 1/13/22, and 4/14/22, so he missed one quarterly QAA meeting. During a concurrent interview, and document review, on 6/16/22 at 9:34 am, the Director of Nurses (DON) confirmed that the Medical Director had missed one of the quarterly QAA meetings.

    Administration Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
LAST FRONTIER HEALTHCARE DISTRICTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 01/01/2010
RICHERT, EDWARDIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
JOHNSON, EDWARDIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
KRAMER, KEVINIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2013
BOULADE, ROSEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
DOLBY, PAULIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
MADISON, CAROLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
MASON, MIKEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
WEBER, KEITHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 23 rows in the source record cover these 9 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.

What families pay in CA

Paying with Medicaid

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.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

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 555420. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, 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.

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