Anberry Nursing And Rehabilitation Center
1685 Shaffer Rd, Atwater, CA 95301 · For profit - Limited Liability company · 99 certified beds · (209) 357-3420 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 (29% vs 45% nationally) — better care continuity
- 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 (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 18% of its spending goes to commonly-owned related companies
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 |
| Short-stay residentsrehab / post-hospital | 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 held steady at 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.
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 | 3.1% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.8% | 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 | 1.4% | 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 | 0.6% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 5.1% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.6% | 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 | 2.6% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 0.5% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 30.1% | 12.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.0% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 17.0% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 8.4% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.57 | 2.25 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.86 | 1.57 | 1.80 | worse |
* 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.
Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| 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 | 100.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 99 beds and averages 95.3 residents a day — about 96% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. 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 3.485 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 is below 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 3.12 hrs/resident/day on weekends vs 3.63 on weekdays — 14% thinner on weekends. RN hours go from 0.30 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 29% 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 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.
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.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · F2026-01-23 · tag F0755 — failed to provide safe pharmacy services — widespreadProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 pharmaceutical services that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for five of nine sampled residents (Residents 7, 8, 52, 63, and 92) when the Controlled Substance Record (CSR) and the Controlled Drug Record (CDR) (a mandatory document used for tracking drugs from the moment they arrive at a facility until they are given to a patient or destroyed, acting as a security measure to prevent theft or misuse) were not completed by the Licensed Nurses upon receipt from the pharmacy.These failures had the potential to result in compromised resident safety including medication errors and drug diversion (the illegal transfer of prescription drugs-especially controlled substances from their intended legal recipient to someone else for personal use or sale).During a review of Resident 7's admission Records (AR) dated January 23, 2026, the AR indicated, Resident 7 was admitted 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 · Fcited before2026-01-23 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 store and prepare food in accordance with professional standards for food service safety when:A pot with food and debris in it was stored in the clean area.A black bean veggie patty bag with one patty in it, in the walk-in freezer, was open and undated.The walk-in freezer fan had ice buildup on it. A plastic container in the walk-in refrigerator with sliced pink fruit inside was unlabeled and undated. A box of mushrooms and a box of celery was open and exposed to air in the walk-in refrigerator.Mushrooms and white liquid were observed on the walk-in refrigerator floor.The sanitizer spray bottle used for cleaning food countertops, contained water in it instead of the sanitizer. These failures had the potential to cause cross-contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect) and the growth of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus,…
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 · F2026-01-23 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
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 essential kitchen equipment was in safe operating condition when:The food preparation sink did not have an air gap (a space between the drain spout and the in-floor drain inlet that prevents contaminated water from flowing back into a clean water supply). 2.The ice machine that supplies ice to the residents in the facility did not have an air gap. These failures had the potential to contaminate food sources for 90 of 97 residents who received food from the kitchen, causing foodborne illness in a vulnerable population and resulting in severe patient harm or death.Findings:1. During a concurrent observation and interview on 1/20/26 at 3:05 p.m. with the Dietary Manager (DM) in the kitchen, the food prep sink was piped directly into the wall. On the floor, under the food prep sink there was a drain without any piping going to it. The DM stated they were not using an air gap and the pipe from the food prep table went directly into the city sewer.During an interview on 1/23/26 at 1:54 p.m. with Maintenance…
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 · D2026-01-23 · 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 Number of residents sampled: 6Number of residents cited: 1Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 10) was free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when the facility did not attempt or implement behavior monitoring for Resident 10's use of haloperidol (medications used to treat schizophrenia [a mental illness that is characterized by disturbances in thoughts]).This failure placed Resident 10 at risk for experiencing adverse effects from receiving medication without behavior monitoring. During a concurrent observation and interview on 1/20/26 at 2:45 p.m. Resident 10 was observed ambulating in the hallway using a front wheel walker, walked to the activity room and joined group activities other residents. Resident 10 stated she was not sure how long she had been in the facility. Resident 10 was observed with involuntary shaking of hands and did not…
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 · D2026-01-23 · 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 Number of residents sampled: 5Number of residents cited: 1Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for one of five sampled residents (Resident 2) when Resident 2 did not have a care plan for a diagnosis of dementia (a progressive state of decline in mental abilities).This failure placed Resident 2 at risk for harm by not identifying and monitoring signs and symptoms and care of resident with dementia. During a concurrent observation and interview on 1/20/26 at 10:15 a.m. during initial tour in Resident 2's room, Resident 2 was observed sitting at the edge of her bed, oxygen concentrator (medical device that takes in the air around you, removes impurities (mostly nitrogen), and delivers purified, high-concentration oxygen to breath) at bedside with nasal cannula (flexible tube with two small prongs…
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 · D2026-01-23 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 professional standards of practice for one of six sampled residents (Resident 48) when Resident 48's physician's orders had directions to give a total dosage of 150 milligrams (mg- a unit of measurement) of clozapine (medication used for reducing hallucinations, delusions, and risk of suicide) when Resident 48 was prescribed 175 mg.This failure had the potential to cause Resident 48 to receive less medication than what was prescribed.Findings:During a review of Resident 48's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 1/22/26, the AR indicated Resident 48 was admitted on [DATE] with diagnoses which included: schizoaffective disorder, bipolar type ( a mental health condition where a person has symptoms of psychosis [hallucinations and delusions] and strong mood changes like mania [very high energy] and depression [extreme…
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 · D2026-01-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: 5Number of residents cited: 2Based on observation, interview, and record review, the facility failed to ensure residents who were not able to carry out activities of daily living (ADLs- routine tasks/activities a person perform daily to care for themselves) were provided assistance to maintain personal hygiene and grooming for two of five sampled residents (Resident 4 and 56) when Resident 4 and Resident 56 had fingernails that were long, jagged and had colored particles under their fingernails.These failures resulted in poor personal hygiene and had the potential to result in serious health condition for Resident 4 and Resident 56. During a concurrent observation and interview on 1/20/26 at 10:45 a.m. during initial tour in Resident 56s room, Resident 56 was observed lying in bed with the TV on. Resident stated she had been in the facility since 2001 and had no issues or concerns. Resident 56 fingernails were observed and appeared long, jagged and with some discolored particles…
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 · D2025-02-18 · 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 ensure residents were free from unnecessary drugs for one of three sampled residents (Resident 1) when Resident 1 was prescribed and received an antipsychotic medication (Quetiapine-used for the treatment of mental illness) with a black box warning (serious warning from the FDA that appears on medication label indicating it has a significant risk or life threatening increased mortality in elderly patients with dementia related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death), for the treatment of Dementia (brain disorder that affects the ability to remember) with documented behaviors of restlessness, inability to sleep and voiced sadness on 2/11/25. This failure placed Resident 1 at risk for adverse reactions that included Dry Mouth, Blurred Vision, Tachycardia (increased heart rate), Urine Retention, Constipation (inability to defecate), Confusion, Delirium…
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 · D2024-10-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 ensure residents received adequate supervision to prevent accidents for one of three sampled residents (Resident 1), when on 10/23/24, Resident 1 eloped (leaves a facility without supervision or permission and may be a danger to themselves or others) from his bedroom through the sliding door that should have been securely locked in place. This failure resulted in Resident 1 allegedly removing the sliding door lock, opening the sliding door and eloped from the facility, resulting in Resident 1 ' s emergency room visit on 10/24/24. Findings: During a review of Resident 1's Interdisciplinary Team (IDT- team that consists of various staff that are involved with resident ' s care) Note, dated 10/24/24, the note indicated, . Resident eloped on 10/23/2024. Discussed and reviewed with IDT. After reviewing with staff, resident removed door lock and eloped through sliding glass door sometime after hourly check. Staff reported resident was last seen…
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 · D2024-10-25 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 a safe environment for one of three sampled residents (Resident 1), when on 10/23/24, Resident 1 eloped (leaves a facility without supervision or permission and may be a danger to themselves or others) from his bedroom through the sliding door that should have been securely locked in place. This failure resulted in Resident 1 allegedly removing the sliding door lock, opening the sliding door and eloped from the facility, resulting in Resident 1's emergency room visit on 10/24/24. Findings: During a review of Resident 1's Interdisciplinary Team (IDT- team that consists of various staff that are involved with resident's care) Note, dated 10/24/24, the note indicated, . Resident eloped on 10/23/2024. Discussed and reviewed with IDT. After reviewing with staff, resident removed door lock and eloped through sliding glass door sometime after hourly check. Staff reported resident was last seen during hourly checks at 0700 (7:00 a.m.). At…
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 9 citations
- Potential for harm · D2024-08-23 · 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
Based on observation, interview, record review and facility policy review, the facility failed to ensure staff performed hand hygiene during wound care for 1 (Resident #55)of 1 sampled resident reviewed for pressure ulcer/injury. Findings include: A facility policy titled, Handwashing/Hand Hygiene, revised 10/2023, specified, Indications for Hand Hygiene. 1. Hand hygiene is indicated: f. before moving from work on a soiled body site to a clean body site on the same resident. The policy further specified, 4. Single-use disposable gloves should be used: a. before aseptic procedures. An admission Record revealed the facility admitted Resident #55 on 04/14/2023. According to the admission Record, the resident had a medical history that included a diagnosis of pressure ulcer of the sacral region, stage 4. Resident #55's Order Summary Report, revealed an order dated 08/09/2024, for staff to cleanse Resident #55's coccyx wound with wound cleanser, pat it dry, pack the wound with collagen powder, cover with calcium alginate and a foam dressing every day. During an observation of wound care…
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 · F2020-03-11 · tag F0727 — failed to provide required RN coverage — widespreadHave 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 meet the minimum requirement of a registered nurse on duty for eight consecutive hours per day, seven days per week when a registered nurse was not on duty for the minimum eight consecutive hours per day for six of 30 days sampled. This failure had the potential to result in residents not receiving services required to be provided by an RN. Findings: During an interview on 3/11/2020, at 8:20 a.m., with the Staffing Coordinator (SD), the SD stated, the facility was a 99 bed facility and the Director of Nurses (DON) served as the RN from Monday to Friday eight hours a day. The SD stated she was not aware she was required to schedule an RN seven days a week for eight hours a day. The SD stated she was directed by the DON to schedule an RN on Saturday and Sunday when the facility admitted residents who had intravenous (IV) therapy (therapy that delivers fluids and medications directly into a vein). The SD stated, the facility had a total of three Registered Nurses, the DON, one full time RN and one on-call RN (a person able 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 · Fcited before2020-03-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 facility document review, the facility failed to ensure food was stored, prepared and served in accordance with professional standards for food service safety for 91 residents when: 1. There was expired food in the refrigerators and freezer available for resident consumption. 2. Food items in the dry storage area were open and past the use by date. 3. Two kitchen staff members failed to properly cover facial hair while they performed kitchen duties. These failures had the potential for unsafe food handling in a highly susceptible resident population. Findings: 1. During a concurrent observation and interview on 3/8/2020, at 9:36 a.m., with [NAME] 1, in the kitchen, a jar of tartar sauce with an expiration date written on it of 12/7/19 and a container of ketchup with an expiration date of 12/19/19 written on it was found in the reach in refrigerator with the other condiments. [NAME] 1 stated condiments were to be thrown out within one month of being opened. During a concurrent observation and interview on 3/8/2020, at 9:36 a.m., with [NAME] 1, 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 · E2020-03-11 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure medications stored in the Central Supply Room were disposed of after the expiration date was reached. This failure had the potential to place ninety-one residents at risk of receiving expired medications. Findings: During a concurrent observation and interview on 3/10/20, at 10:20 a.m., with Director of Nursing (DON), in the Central Supply Room, five bottles of centirizine (medication used for allergy symptoms) 10 milligrams, (mg a unit of measurement) 90 tablets in each bottle, were found to have gone past their expiration date of 2/2020 and remained on the shelf with the non-expired medications. The DON confirmed the medication bottles were expired and should have been removed from the shelf. A review of the facility's policy and procedure titled, Medication administration dated 8/8/18, indicated, To ensue that all medications are handled and administered accurately and safely to each resident .bottles that are clearly marked .expiration date.
- Potential for harm · D2020-03-11 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 written Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN-a notice to provide information to residents/beneficiaries if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume responsibility) and Notice of Medicare Provided Non-Coverage (NOMNC) for one of three sampled residents (Resident 57) when the Medicare coverage was terminated. This deficient practice resulted in not protecting Resident 57's (and the resident representative) right to appeal the termination of Medicare Part A and possibly denying Resident 57 needed services. Findings: During a concurrent interview and record review on 3/10/2020, at 1:44 P.M., with Director of Social Services (DSS), the DSS reviewed the facility document titled, Skilled Nursing Facility Beneficiary Protection Notification Review which indicated Resident 57's Medicare Part A Skilled Services Episode start date was on 1/8/2020 and the last covered day of Medicare Part A Services was on 1/17/2020. The DSS stated she did…
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 · D2020-03-11 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 a baseline care plan was developed and implemented within 48 hours of admission to the facility for one of three sampled residents (Resident 45), when Resident 45 did not have a care plan for his customary routines and activities. This failure had the potential to result in Resident 45's activity needs to go unmet. Findings: During a review of Resident 45's clinical record titled, admission RECORD (a document containing resident profile information) undated, the admission record indicated, Resident 45 was admitted to the facility on [DATE]. During a review of Resident 45's Minimum Data Set (MDS- assessment of healthcare and functional needs) dated 1/11/2020, the MDS assessment indicated Resident 45's Brief Interview for Mental Status (BIMS- an assessment of cognitive status) had a score of 2 of 15 points which indicated Resident 45's cognition was severely impaired. The MDS Preference for Customary Routines and Activities indicated 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 · D2020-03-11 · 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 Based on interview, and record review, the facility failed to revise a person centered comprehensive care plan in a timely manner for one of three sampled residents (Resident 87) when Resident 87's care plan did not accurately reflect the current physician's ordered settings for Resident 87's Bi-Pap machine (Bi-level Positive Airway Pressure-a machine used to provide a non-invasive form of therapy for patients suffering from obstructive sleep apnea- OSA a potentially serious sleep disorder in which breathing repeatedly stops and starts.). This failure had the potential to result in respiratory complications and failure for Resident 87. Findings: During a concurrent interview and record review, on 3/11/2020, at 10:42 a.m., with LN 4, she reviewed Resident 87's care plan dated 3/11/2020 which indicated, focus- [Resident 87] is at risk for alteration in respiratory function related to COPD (chronic obstructive pulmonary disease-a group of lung diseases that makes it harder to breathe) .OSA . revision 8/14/19 . Goal…
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 · D2020-03-11 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to timely notify the ordering physician for a laboratory result that fell outside of the normal reference range for one of two sampled residents (Resident 65) when Resident 65's urinalysis (UA-urine sampled to test for the presence of bacteria) result was positive for bacteria that was resistant to the physician ordered antibiotic (a medication to treat infections) regimen. This failure resulted in the administration of antibiotic treatment to Resident 65 that she was resistant to from 1/18/2020 through 1/25/2020 and placed her at risk for further complications from the Urinary Tract Infection (UTI). Findings: During an interview on 3/9/2020, at 9:35 a.m., with Resident 65, Resident 65 stated she recently had a urinary tract infection and was in isolation. Resident 65 stated she was not sure what the infection was, but believed she may have had Methicillin-resistant Staphylococcus aureus (MRSA- a bacteria that causes infections) in the urine. During an interview on 3/10/2020, at 11:05 a.m., with the licensed vocational nurse…
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 · D2020-03-11 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview and document review, the facility failed to ensure the nutritional needs were met for residents on a small portions diet when the lunch meal on 3/9/2020 was not plated in accordance with menu guidance for one of two sampled residents (Resident 34). This failure had the potential to result in weight gain, further compromising the medical status. Findings: During a concurrent observation, interview and record review on 3/9/2020, at 12:36 p.m., with [NAME] 1 and Director of Dietary Services (DD), in the kitchen during tray service, all portions of chicken were observed in the same pan with no separation of portion sizes. [NAME] 1 stated she checked the portion sizes when she prepared the chicken and separated the small and regular portions within the tray. [NAME] 1 stated the small portions were at the top side of the pan and the regular portions were at the bottom side of the pan. [NAME] 1 placed a large piece of chicken on Resident 34's plate. When the plate was at the end of the tray line [NAME] 1 removed the chicken from plate and weighed 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.
“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.
Part of a chain
This home belongs to GENERATIONS HEALTHCARE — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.1 | +0.9 vs chain |
| Health inspection | 4 of 5 | 3.6 | +0.4 vs chain |
| Staffing | 4 of 5 | 3.7 | +0.3 vs chain |
| Quality measures | 5 of 5 | 4.6 | +0.4 vs chain |
The other 26 homes this chain runs (chain average 4.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ENS, CASSANDRA | Individual | W-2 MANAGING EMPLOYEE | since 04/01/2023 |
| MASTROCOLA, LOIS | Individual | CORPORATE OFFICER | since 04/01/2023 |
| OLDS, THOMAS | Individual | CORPORATE OFFICER | since 04/01/2023 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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.
About 89% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $269K paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 555244. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-23, 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.