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Chaparral House

1309 Allston Way, Berkeley, CA 94702 · Non profit - Corporation · 49 certified beds · (510) 848-8774 Medicare & Medicaid certified

Call the home — (510) 848-8774 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609) — most recent Jun 2026Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • 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)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
837 Addison St · (510) 981-4100 · Call to confirm hours
Pharmacy
1414 University Ave · (510) 647-3873 · Call to confirm hours
Grocery
2082 San Pablo Ave · (510) 540-8946 · Call to confirm hours
Park
2121 10th St · 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 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.

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 increased11.0%10.2%15.4%better
Long-stay residents who lose too much weight4.2%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 infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.8%7.3%6.5%better
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened11.7%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication6.6%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers3.6%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control6.5%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 table16.8%12.0%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%93.2%79.4%better
Short-stay residents rehospitalized after admission15.5%23.0%22.6%better
Short-stay residents with an outpatient ER visit14.6%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.592.251.67better
Long-stay outpatient ER visits per 1,000 resident days1.011.571.80better

* 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.

72.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 80 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

72.2%U.S. median 51.5%
Got home and stayed home
8.8%U.S. median 10.7%
Went back to hospital
69.2%U.S. median 56.6%
Met the expected recovery
0.34U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 69.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 94 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF72.2%CMS range 63.4–80.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.8%CMS range 5.9–13.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge69.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge62.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge70.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified12.3%98.7%Oct 2024–Sep 2025CMS 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 setting97.9%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 dischargenot 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 stay2.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.9%CMS range 4.6–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.91
RN hours/ resident / day
0.79
LPN hours/ resident / day
2.54
Aide hours/ resident / day
4.24
Total nurse hours/ resident / day
0.66
RN hoursweekends
48.0%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 49 beds and averages 47.1 residents a day — about 96% occupied, or roughly 2 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 4.24 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.91 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.83 hrs/resident/day on weekends vs 4.41 on weekdays — 13% thinner on weekends. RN hours go from 1.01 to 0.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% 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

10
deficiencies at the latest standard inspection (2024-09-27)
8
at the previous standard inspection (2023-04-20)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · D2026-06-30 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    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 notify Resident 1 of her Medicaid 'share of cost' in a timely manner and did not explain it in a way the resident could easily understand (Medicaid is a government-funded health insurance. Medicaid 'share of cost' is the specific dollar amount the insured resident is required to pay out-of-pocket for medical bills each month before Medicaid kicks in to cover the rest of the charges).This deficient practice compromised Resident 1's ability to make an informed decision, potentially leading to financial hardship and psychosocial issues. A review of Resident 1's Face Sheet (a one-page summary containing a resident's most critical demographic, financial, and medical information) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included epilepsy (a brain disorder that causes a person to have repeated, unprovoked seizures), insomnia (sleep disorder), and abnormalities of gait and mobility. During a review of Resident 2's MDS…

    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 · Dcited before2026-06-02 · 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 observation, interview, and record review, the facility failed to ensure timely reporting and thorough investigation of an allegation of misappropriation of resident property for one out of three sampled residents (Resident 1). Specifically, the facility did not notify law enforcement as required and document or maintain required lost-and-found logs.This failure resulted in the facility's inability to investigate the reported loss of $5,000, placing Resident 1 at risk for unreported financial exploitation.During a record review of facility's document titled, admission Record, printed 6/2/26, Resident 1 was initially admitted to the facility on [DATE] with multiple diagnoses including hyperlipidemia (high cholesterol in blood), and acute on chronic diastolic heart failure (a condition where the heart does not pump enough blood to meet the needs of the body).During a record review of Resident 1's Minimum Data Set (MDS, an assessment tool used to evaluate a resident's functional capabilities, health needs,…

    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 no plan of correction
  • Potential for harm · D2025-12-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to maintain a safe, comfortable and homelike environment when Resident 1's bedside table had scratched marks on top and had chipped edges. This failure resulted in Resident 1 feeling angry. On 12/26/25 at 10:40 a.m., an unannounced visit was made at the facility to investigate a complaint allegation. During a phone interview on 12/26/25 at 2:03 p.m., Resident 1 stated when she was living at the facility, her bedside table had scratch marks on top and peeled edges. Further stated she felt angry about this. During a review of Resident 1's Facesheet, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included depression (a mental health disorder characterized by persistently sad mood or loss of interest in activities, causing significant impairment in daily life) and was discharged from the facility on 9/9/25. Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 8/11/25…

    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 · D2025-12-26 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 one of three sampled residents (Resident 1) was free from significant medication errors when Resident 1 received the medication Percocet instead of Norco (Percocet is the brand name for oxycodone/acetaminophen and Norco is the brand name for hydrocodone/acetaminophen for pain. Both medications are for pain but have different opioid ingredients. Opioids are very powerful type of drugs used for pain relief). This failure exposed Resident 1 to the risk of adverse medication effects and discomfort. During a review of Resident 1's Face Sheet, it indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included right femur fracture (broken bone in right thigh bone). A review of Physician's orders dated 8/5/25, indicated an order of Norco or Hydrocodone-Acetaminophen oral tablet 10-325 milligrams (mg., a form of measurement), give one tablet by mouth every four hours as needed for severe pain. During an interview on 12/26/25…

    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 before2024-09-27 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 treat three of three sampled residents (Resident 21, 22, and 29) with dignity and respect when Residents 21, 22, and 29, who needed full assistance with meals, were not offered or fed their bread rolls during lunch. This failure had the potential to affect Residents 21, 22 and 29's psychosocial well-being and nutritional needs. Findings: During a dining observation on 9/23/24 at 12:53 p.m., in the dining room, Residents 21, 22, and 29 were being assisted by staff during lunch. Registered Nurse (RN) 3 asked Resident 29 if she wanted her bread roll to which Resident 29 replied, yes. RN 3 did not have gloves available to feed the bread roll and RN 3 offered water to Resident 29 instead. Residents 21, 22, and 29 did not receive their bread rolls from the staff who assisted them during feeding. During an interview on 9/25/24 at 3:07 p.m. with Director of Staff Development (DSD), DSD stated RN 3 should have accommodated and assisted Resident 29 when Resident 29 wanted to eat the bread roll. DSD further stated…

    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 · E2024-09-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic drugs (medications that can affect the mind, emotions, and behavior) for three of 38 sampled residents (Residents 8,7 and 10) when: 1. Resident 8 did not have the appropriate indications for the use of Seroquel (Seroquel is an antipsychotic medication; Antipsychotic medications are medications that are used to treat symptoms of psychotic mental disorder such as delusions, hallucinations, paranoia, or confused thoughts), 2. Resident 7 had no rationale for continued use of PRN Ativan beyond 14 days (PRN is short for pro re nata [a Latin phrase], meaning as needed, or as necessary; Ativan is a psychotropic medication used to treat anxiety; psychotropic medications are used to treat mental health disorders), and 3. Resident 10 was administered Trazadone (an antidepressant medication to treat major depressive disorder, some anxiety disorders and chronic pain conditions) for insomnia (difficulty…

    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 · E2024-09-27 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure 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, interview, and record review, the facility failed to follow the menu for the soft and bite-sized (foods that are soft, moist, and easy to swallow) and easy to chew diet (soft, tender foods that are easy to chew) for 12 out of 12 residents (Residents 13, 23, 8, 6, 190, 29, 7, 12, 34, 18, 15 and 22) when Residents 13, 23, 8, 6, 190, 29, 7, 12, 34, 18, 15 and 22 did not receive two ounces of gravy for lunch with their chicken on 9/23/24. This failure had the potential for Residents 13, 23, 8, 6, 190, 29, 7, 12, 34, 18, 15 and 22 to have problems chewing and swallowing the food when the established menu was not followed accordingly and had the potential for poor nutrition and to further compromise the medical status of the residents. Findings: During the tray line (an assembly line preparation of meal trays in the kitchen to be delivered to residents) observation on 9/23/24, at 12:17 p.m., in the kitchen, the Dietary Services Supervisor (DSS) did not serve gravy to residents who were on the soft and bite-sized and easy to chew diet. During a record review of a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-27 · 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 ensure safe and sanitary food preparation and storage practices when: 1. Can opener had red discoloration on the blade that pierced the can, 2. Under the stove and steam tray line, the floors had a build-up of food crumbs, trash, dust, and grime, 3. The oven had build-up of black grime inside, 4. Dry storage floors had build-up of food crumbs, trash, and dead ants, and 5. Diet Aide 1 (DA 1) did not wear a bear net during meal preparation and service. These failures had the potential to expose 38 medically compromised residents who received food from the kitchen to foodborne illness due to cross-contaminations (the transfer for harmful substances or disease-causing microorganisms to food). Findings: 1. During an initial tour observation of the kitchen and interview on 9/23/24 at 9:32 a.m. with Dietary Service Supervisor (DSS), the can opener had red discoloration on the blade. DSS stated the can opener should have been cleaned. During a phone interview on 9/25/24 at 1:10 p.m. with the Registered Dietician 1…

    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 · D2024-09-27 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 Resident 8's Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care). PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting; and 3) receive the services they need in those settings.) completed when Resident 8 had diagnosis of brief psychotic disorder (mental disorder that can cause abnormal thinking and perception). This failure resulted in Resident 8 not being properly evaluated if he was receiving appropriate mental health services. (Cross Reference F758) Findings: During a review of Resident 8's admission Record, dated 9/25/24, the record indicated Resident 8 had diagnosis of brief psychotic disorder. During a review 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-27 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for two (Resident 10 and Resident 11) of thirteen sampled residents, the facility failed to implement its Care Plan, Comprehensive Person Centered policy and procedure when: 1. Facility did not develop care plan to address Resident 10's medical diagnoses of Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life ) and Insomnia (persistent problems falling and staying asleep), and there was no care plan to address Resident 10's use of Amitriptyline and Trazadone (antidepressant medications, antidepressants are medications used to treat major depressive disorder, some anxiety disorders and chronic pain conditions), and 2. Facility did not identify and address Resident 11's hairy mole on chin with a care plan and appropriate interventions. (Hairy moles are skin lesions that have both hair and pigmentation. They are usually present at birth.…

    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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2024-09-27 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 sampled resident's (Resident 14) long toenails received podiatry (foot care) treatment services as ordered by the physician. This failure had the potential to place Resident 14 at risk for injury and infection. Findings: During an observation on 9/23/24 at 1:45 p.m., Resident 14 laid in bed in her room. Resident 14 had contracted (tightened and may cause deformity) feet with long toenails. During a review of Resident 14's Minimum Data Set (MDS, Resident Assessment tool used to guide care), dated 9/12/24, the MDS indicated Resident 14 had short- and long-term memory problem. The MDS indicated Resident 14 was dependent on staff and required two or more helpers for putting on and taking off socks and shoes or other footwear and personal hygiene. The MDS indicated Resident 14's diagnoses included Peripheral Artery Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and Non-Alzheimer's Dementia (a loss of mental ability severe enough to interfere with normal…

    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
  • Potential for harm · D2024-09-27 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one (Resident 9) of two sampled residents received treatment services to address limitation in range of motion to right upper extremity when Resident 9 had contracture (a condition of shortening and hardening of muscles often leading to deformity and rigidity of joints) of right upper extremity and a resting splint (a device that supports and protects a broken bone or injured tissue) was not applied to right hand as ordered by the physician. This failure had the potential to cause Resident 9's decline in range of motion and risk of decreased muscle strength. Findings: During an observation on 9/24/24 at 10:53 a.m., Resident 9 laid in bed in her room. Resident 9 had right hand contracture. Resident 9's right hand upper extremity had no splint. During a review of Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 9/19/24. The MDS indicated, Resident 9 had short- and long-term memory problem. The MDS indicated Resident 9's had diagnosis of Non-Alzheimer's Dementia (a loss 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-27 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to have a written contract/agreement with Resident 189's outpatient dialysis provider (dialysis is the process of removing toxins from the kidneys and blood through a machine. The contract/agreement should include all aspects of how Resident 189's dialysis care and needs were to be managed by the dialysis provider outside of the facility). This failure had the potential to result in Resident 189's poor dialysis care management. Findings: During a review of Resident 189's admission Record, dated 9/26/24, the record indicated Resident 189 had diagnosis of acute kidney failure (a condition where the kidneys stopped working properly). Review of Resident 189's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 9/20/24, the MDS indicated Resident 189's cognition was intact. During a review of Resident 189's Physician's Orders dated 9/14/24, the order indicated Resident 189 had outpatient hemodialysis (a medical procedure that filters a person's blood when their kidneys are not functioning properly)…

    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
  • Potential for harm · D2024-09-27 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 two (Residents 15 and 21) of 38 sampled residents' call lights were within easy reach. This failure had the potential for the Resident 15 and Resident 21 to not to be able to use the call light when needing assistance. Findings: During an initial tour of the facility on 9/23/24 at 10:43 a.m., in Resident 15's room, Resident 15 was observed lying in bed, alert and was able to answer questions. The call button wire was observed to be hanging in right middle side of Resident 15's bed and the call button was almost touching the floor. Resident 15 attempted to reach for the call button but had a difficult time and failed. Resident 15 stated she could not reach her call button and further stated she needed the call light to call for help. During a concurrent observation and interview on 9/25/24 at 12:09 p.m., with Certified Nursing Assistant (CNA) 3 in Resident 15's room, CNA 3 confirmed that Resident 15 was not able to reach her call light. CNA 3 stated the call light should be within the resident's reach 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-20 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure four (Residents 4, 28, 41 and 43) of five sampled residents were free from unnecessary drugs when; - Resident 4 was administered two antipsychotic medications, Risperdal and Zyprexa, without adequate clinical indication for use and monitoring for adverse side effects. Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior. - Resident 28 was administered Clozapine an antipsychotic and Sertraline an antidepressant without adequate monitoring for target behavior and adverse side effects. Antidepressants are medications used to treat major depressive disorder, some anxiety disorders and chronic pain conditions - Resident 41 was administered Mirtazepine (anti-depressant) for sleep without adequate monitoring the hours of sleep. to determine effectiveness. -For Resident 43,the indication for use of Seroquel an antipsychotic was not monitored.…

    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 before2023-04-20 · 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, interviews, and record review, the facility failed to ensure storage of food under sanitary conditions when: - Dietary staff's lunch bag was kept in the kitchen refrigerator. - One container of low-fat cottage cheese was opened and not labeled or dated - One bottle of chili garlic sauce open date 2/28/23 - One bottle salad cream opened 8/3/22 - One bottle spicy sauce opened 2/28/23 - 1/2 sliced apple in cup not labeled or dated - Two bottles of jam opened 3/6/23 These failures had the potential to result in food borne illnesses. Findings: During the initial tour of the kitchen on 4/17/23 at 9:19 a.m., and accompanied by the Director of Food and Nutrition Services (DFNS), one staff lunch bag was stored in the refrigerator, One container of low fat cottage cheese opened not labeled or dated, one bottle of chili Garlic sauce opened 2/28/23, one bottle salad cream opened 8/3/22, one bottle spicy sauce opened 2/28/23, half sliced apple in cup not labeled or dated, two bottles of jam opened 3/6/23. During an interview on 4/18/23 at 9:36 a.m., [NAME] (CK) stated 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-20 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to develop and implement written policy and procedures to prevent abuse, neglect and exploitation of residents and misappropriation of resident property when: 1. Resident 31's statement that a nurse was Tearing [Resident 31] to pieces was not investigated and not reported. This failure had the potential to result in abuse by the same staff who continued to provide care to Resident 31. 2. Facility did not perform background checks for five of five employees. This failure had the potential for allowing potential employees who have been convicted of abuse, neglect and exploitation and misappropriation of resident property to care for the residents. Findings: 1. During review of the Resident Council Suggestion/Issue/Question/Concern dated 4/13/23 with Activity Director (AD), on 4/18/23 at 11:10 a.m., the record indicated Resident 31 claimed on 4/13/23 that a nurse was tearing me to pieces during a bath and while being changed. AD stated the information was passed on (shared) with the Nursing Department but could not identify…

    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 · Dcited before2023-04-20 · 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

    Based on interview and record review, the facility failed to implement their Abuse policy and procedure to investigate and report injuries of unknown origin for one (Resident 4) sampled resident. Resident 4's laceration to the left pinky toe was not investigated for the source of the injury and reported to the required agencies. This failure resulted in Resident 4 being transferred to the emergency room (ER) for sutures and had the potential to place residents at risk for mistreatment, neglect and /or abuse. Findings: Review of Resident 4's Significant change in status-Minimum Data Set, Resident Assessment and Care Screening, dated 1/4/23, indicated Resident 4 had unclear speech with slurred or mumbled word, rarely/never understood. Resident 4 had short and long term memory problem. Resident 4 had no behavioral symptoms. Resident 4's diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). Review of the nurses notes dated 2/12/23 indicated Resident 4 laid on his floor mattress, and noted…

    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 · D2023-04-20 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 to meet the needs of the residents when: 1. For Resident 99, Metformin (diabetic medication), a condition where blood sugar levels are too high) was not available for medication administration. 2. For Resident 149, Fluticasone propionate nasal suspension (for management of nasal symptoms of perennial nonallergic rhinitis in adults, rhinitis is inflammation that causes nasal congestion, runny nose, sneezing and itching) was not available for medication administration. [Reference:https://dailymed.nlm.nih.gov] These failures had the potential to result in an ineffective medication regimen. Findings: 1. Review of Resident 99's admission Record indicated Resident 99 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus. During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 2 on 4/18/23 at 8:42 a.m., LVN 2 did not administer Metformin 500 milligrams…

    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 · D2023-04-20 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 observations, interviews, and record reviews, the facility failed to be free of medication error rate of five percent or greater when three medication errors were observed out of 31 opportunities. The medication error rate was calculated as follows; three divided by 31, then multiplied by 100, which was equal to 10 percent. This failure had the potential to result in ineffective medication regimen for the affected residents (Residents 99 and Resident 149). Findings: 1. Review of Resident 99's admission Record indicated Resident 99 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (when blood sugar levels are too high). During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 2 on 4/18/23 at 8:42 a.m., LVN 2 did not administer Metformin (treats diabetes) 500 milligrams (mg) tablet to Resident 99. LVN 2 stated Resident 99's Metformin was not available for administration. Review of Resident 99's Medication Administration Record (MAR) for April…

    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 · D2023-04-20 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to promptly follow-up on a denture evaluation and acquiring full dentures for one (Resident 8) sampled resident in a timely manner. This failure resulted in emotional distress. Findings: Review of the significant change in status- Minimum Data Set (MDS), Resident Assessment and Care Screening tool used to guide care, dated 4/2/23, indicated Resident 8's Basic Interview of mental status (BIMS) score was 15 (meaning cognitive intact). Resident 8 had a clear speech, able to express ideas and wants. Resident 8 had no natural teeth. Resident 8 had diagnoses that included stroke. Resident 8's insurance was Medicaid. During an interview on 4/17/23 at 10:24 a.m., Resident 8 stated he felt so depressed because he had no dentures to eat food. Review of the care plan revised 2/3/23 indicated Resident 8 had several teeth extracted and new dentures are on hold. During an interview on 4/17/23 at 12:06 p.m., the Social Services Designee (SSD) stated Resident 8 had all his teeth extracted sometime ago and had no dentures. SSD stated there…

    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
  • Potential for harm · D2023-04-20 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to coordinate care planning in collaboration with the resident, family and hospice care (provisions for the terminally ill) provider for one (Resident 41) sampled resident. This failure had the potential for residents to not receive person-centered care at the end-of-life. Findings: Review of Resident 41's significant change in status-Minimum Data Set, Resident Assessment and Care Screening, dated 3/3/23, indicated Resident 41 had unclear speech with slurred or mumbled word, rarely/never make self understood or understand others. Resident 41 had short and long term memory problem. Resident 41 had no behavioral symptoms. Resident 41 had trouble falling asleep and little energy. Resident 41 diagnoses included Alzheimer's Disease, Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language), depression and on hospice care (is a type of care that focuses on interdisciplinary approach to specialized nursing care for people with life limiting illnesses, available…

    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 · Ecited before2019-06-12 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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, interviews and record review, the facility failed to provide six of 12 Residents (Resident 35, Resident 13, Resident 28, Resident 8, Resident 16, and Resident 9) with dignity and respect when they were not served their lunches at the same time as others seated at their dining table. For Resident 13, utensils were not provided in a timely manner. These failures had the potential to result in Resident 35, Resident 13, Resident 28, Resident 8, Resident 16, and Resident 9 having a decreased quality of life. Findings: 1. A record review of the face sheet dated 6/12/19 indicated Resident 35 was admitted to the facility on [DATE] with multiple diagnoses including, Major Depressive Disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life) and Alzheimer's Disease (a progressive mental deterioration). 2. The record review of the face sheet dated 6/12/19 indicated Resident 13 was admitted to the facility on [DATE] with multiple…

    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 · D2019-06-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 Based on observation,, interview and record review, the facility failed to ensure two (Resident 19 and Resident 5) of two sampled residents, who were dependent on staff for meals, were not assisted to eat in a timely manner. Resident 19 did not receive meal assistance for ten minutes and had interrupted meal assistance when offered, and Resident 5 did not receive assistance for 35 minutes. This deficient practice resulted in Resident 19 and Resident 5 receiving delayed meal assistance and had the potential for foods to be served cold. Findings: 1. According to the face sheet dated 6/12/19, Resident 19 was admitted to the facility on [DATE] with multiple diagnoses including, Cachexia (weakness and wasting of the body due to severe chronic illness), and Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury). The record review of the Minimum Data Set (MDS-a resident assessment tool) dated 4/12/19, Resident 19 was unable to complete the Brief Interview for Mental Status…

    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
  • Potential for harm · Dcited before2019-06-12 · 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 — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was stored properly when food items were left unlabeled and undated in the kitchen refrigerator, and the dishes and utensils were not cleaned under sanitary conditions when the high temperature dishwasher's final rinse did not reach 180 degrees Fahrenheit (F) according to the policy. These deficient practices placed the residents at risk for developing foodborne illness. Findings: During the initial observation of the dietary department on 6/10/19 at 8:14 a.m., the kitchen refrigerator had one container of cream cheese, one package of cinnamon french toast, one loaf of bread, four hamburger buns, four English muffins, and one bag of pita bread left opened, unlabeled and undated. There was one five-pound container of low-fat cottage cheese that had a use-by date of 6/9/19. During a concurrent interview with the Cook, she stated all items in the refrigerator should be labeled and dated when opened, and all expired food items should be discarded. A record review of the policy, Refrigerated…

    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

“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
CHAPARRAL FOUNDATIONOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/08/1971
BAKER, ELIZABETHIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 07/24/2025
DILLINGHAM, BEATAIndividualCORPORATE DIRECTORsince 01/29/2025
LAWRENCE, MICHELEIndividualCORPORATE DIRECTORsince 06/27/2024
MATEO, ONOFREIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 06/27/2024
MCNENNY, HOWARDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 07/01/2020
MIYAZAKI, JUNICHIIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 07/24/2025
OUTIS, ROBERTIndividualCORPORATE DIRECTORsince 05/22/2025
RICHARDSON, ASHLEIGHIndividualCORPORATE DIRECTORsince 07/01/2022
STROH, SUZANNEIndividualCORPORATE DIRECTORsince 06/27/2024
JAMALI, MEHRANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/21/2025
LY, SONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024

CMS files one row per role, so the 18 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.4M
Net patient revenuemost recent cost report
+1.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 30%Medicare 18%Other / private 52%

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$587per resident / day
operating cost
$17,843per month
≈ monthly operating cost
$595per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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

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 555872. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-27, 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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