Bear Valley Community Hospital D/P SNF
41870 Garstin Rd, Big Bear Lake, CA 92315 · Government - Hospital district · 21 certified beds · (909) 866-6501 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- 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)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (63%) runs well above the national median (45%)
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 | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 28.0% | 10.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.0% | 4.0% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 2.5% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 5.9% | 1.2% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 6.1% | 7.3% | 6.5% | typical |
| 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 | 1.4% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 25.4% | 9.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 16.4% | 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 | 1.6% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 9.9% | 10.2% | 21.2% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 30.8% | 12.0% | 17.1% | 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 0.01 therapist hours per resident per day in 2026Q1 — more than 0% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 185% of this home’s weekday level — it runs therapy at close to weekday levels right through 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
| 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 data for this measure is missing or was not submitted. 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 data for this measure is missing or was not submitted. 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 data for this measure is missing or was not submitted. 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 data for this measure is missing or was not submitted. 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 data for this measure is missing or was not submitted. 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 | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality 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 data for this measure is missing or was not submitted. 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 data for this measure is missing or was not submitted. 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 | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The data for this measure is missing or was not submitted. 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 21 beds and averages 20.1 residents a day — about 96% occupied, or roughly 1 bed 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 6.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.36 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 5.42 hrs/resident/day on weekends vs 7.10 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.89 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Fcited before2026-06-04 · 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 ensure the kitchen was maintained in a clean and sanitary condition for 20 of 20 residents when, 1. Five bags of beef tenderloin, each weighing three pounds, were found on a refrigerator shelf stored in a plastic container without proper labeling or a date.2. Nine bags of tortillas with an expiration date of April 19, 2026, were found in the refrigerator (42 days expired).3. Two of two ovens were found with significant accumulations of burnt food particles, grease stains and dark residue across the interior surfaces, including oven floors, side panels and racks. These failures had the potential to lead to the growth of harmful microorganisms, including bacteria, viruses, and fungi, and cause food-borne illness (occurs when you consume contaminated food or beverages) to 20 residents served by the kitchen. Findings:1. During an observation on June 1, 2026, at 11:51 AM, in the kitchen, five bags of beef tenderloin, each weighing three pounds, were found on a refrigerator shelf stored in a plastic container…
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 · D2026-06-04 · tag F0577 — isolatedAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to post the results of the most recent survey of the facility in a place readily accessible for all 21 of 21 residents, family members, and legal representatives of residents to review. This failure had the potential to prevent residents, family members, and legal representatives from being informed about the facility's compliance with state and federal requirements, which could limit their ability to make fully informed decisions regarding the residents' care.Findings:During an interview on June 2, 2026, at 10:30 AM, in the Resident Council Meeting (an organized meeting of facility residents and family members who meet regularly to discuss and address concerns about quality of care in the nursing home), residents expressed concerns regarding the visibility and accessibility of the most recent survey results of the facility. Furthermore, multiple residents reported that they were unaware of the location where these results were posted.During an interview on June 2, 2026, at 11:00 AM, with the Director of Nursing (DON), the DON…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-04 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure that required daily nurse staffing information for licensed and unlicensed nurses was posted in a location readily visible and accessible to all 20 of 20 residents and visitors to review.This failure resulted in residents and visitors being unable to verify whether the unit was staffed appropriately for the day.Findings:During a concurrent observation and interview on June 2, 2026, at 10:45 AM, with the Assistant Director of Nursing (ADON), in the skilled nursing facility's nursing station, the Direct Hours Per Patient Day (DHPPD-the average number of hours per day that licensed/unlicensed nursing staff spend providing hands-on care to each resident in a facility) was not visibly posted. The ADON acknowledged the DHPPD hours were not visible posted for residents and visitors to view but stated the DHPPD hours are kept inside a binder at the nursing station.During an interview on June 4, 2026, at 10:54 AM, with the Director of Staff Development (DSD), the DSD stated the staffing hours should be visibly posted and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-04 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to maintain the garbage storage area in a sanitary condition for 21 of 21 residents, staff, and the public when the facility's refuse (trash/garbage) was not properly disposed in the designated, covered outdoor container.This failure to properly dispose of refuse in the designated, covered outdoor container demonstrated noncompliance with established sanitation protocols, potentially increasing the risk of environmental contamination and pest infestation, and thereby compromising the health and safety of residents, staff, and visitors.Findings:During an observation on June 3, 2026, at 7:11 AM, a routine inspection was conducted at the outdoor trash disposal area located behind the facility's main building next to the emergency room parking lot. During this observation, one clear plastic bag filled with trash was found on the ground adjacent to the dumpster and was clearly visible from the parking area. Additionally, two more clear plastic bags filled with trash were discovered on the ground behind the same dumpster. The three…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-07 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 ensure resident was treated with respect and dignity for one resident (Resident 1) when the facility staff spoke to Resident 1 using language and tone as if one might address a child and refused Resident 1 to receive a shower at his preferred time.This failure resulted in Resident 1 feeling put down and embarrassed which could potentially affect his care from his lack of trust or doubt with the facility staff to participate in treatment plan.Findings:During a review of a Medical Doctor (MD) Progress Note, dated August 27, 2024, the MD progress note indicated Resident 1 has history of congestive heart failure (a serious condition in which the heart doesn't pump blood through the body as efficiently as it should), seizure disorder (a sudden burst of electrical activity in the brain and can cause changes in behavior, movements, feelings and levels of consciousness), stroke (a serious medical emergency that happens when blood flow to the brain is interrupted, either by a blockage or a rupture of a blood vessel),…
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 · F2025-05-08 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 food was stored to conserve nutritive value (measure of a well-balanced diet) and maintain professional standards of food safety for all 21 residents admitted in the facility when: 1. There was an unlabeled bag of minced beef in the refrigerator. 2. There was an open and unlabeled bag of tortilla flour in the refrigerator. These failures had the potential to cause unsafe food consumption for all 21 vulnerable residents in the facility from possible allergenic substances in food products and consume food beyond the use date (expired date), which can negatively affect resident's health from allergic reaction or foodborne illness (illness caused by ingestion of contaminated food or beverages). 3. For Resident 7, a serving of pureed cauliflower was not palatable or had comparable taste to regular serving of cauliflower. This failure had the potential to cause Resident 7, who was on pureed texture diet order, to experience a decrease in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-08 · tag F0810 — patternProvide special eating equipment and utensils for residents who need them and appropriate assistance.
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 special assistive devices during mealtimes for three of 21 sampled residents (Resident 3, 7 and 15) when: 1. Residents 3 and 7 were not provided with a plate guard (a clip onto the edge of a plate to prevent spilling of food) and [NAME] Anti Spill Cup (KCup-allows the cup to be easily filled, once the lid is screwed on, the liquid will not slip even if the cup is turned completely upside down) during lunch. 2. Resident 15 was not provided with KCup as ordered. These failures had the potential to cause Resident 3, 7, and 15 to experience a decrease in food intake without appropriate assistive devices which could lead to unintentional weight loss (not having enough food to eat) and resulting in actual physical harm and medical complications. Findings: 1a. During a review of Resident 3's admission Record (contain demographic and medical information), undated, the admission Record indicated, Resident 3 was admitted to the facility on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-08 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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, interview, and record review, the facility failed to ensure staff treated residents with respect and dignity to enhance quality of life for two of two residents (Resident 12 and 15) when the Certified Nursing Assistant (CNA) were observed standing over Resident 12 and 15 during mealtime. This failure had the potential to make Resident 12 and 15 to feel devalue and disrespected which could cause Resident 12 and 15 to distrust the health care provider and would negatively impact the treatment plan. Findings: a. During a review of Resident 12's admission Record (contains demographic and medical information), undated, the admission Record indicated, Resident 12 was admitted to the facility on [DATE], with diagnoses of anoxic encephalopathy (brain damage), dementia (a group of symptoms that affect memory), hypertension (high blood pression), depression and anxiety, insomnia (sleeping problems), and dysphagia (difficulty swallowing). During an observation on March 5, 2025, at from 12:09 PM…
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 · D2025-05-08 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 or resident representatives (RP) were informed of psychotropic medication (medications that affect the mind, emotions, and behaviors) treatment for three of 12 sampled residents (Resident 2, 8, and 12) when: 1. Resident 2's informed consent (document signed by resident or representative to give permission for a proposed psychotropic medication and possible risks and benefits expected) was not updated and obtained for Resident 2's new order of Trazodone Deseryl (Trazodone-antidepressant medication) 50 milligram (MG-unit of measurement) and NF-Aripiprazole Av PAK (Aripiprazole-antipsychotic medication which is used to treatment of a wide variety of mood and psychotic disorders) 2.5 MG. 2. Resident 8's informed consent was not updated and obtained for Resident 8's new order of Risperidone (Risperdal-antipsychotic medication) 0.5 MG and Escitalopram (Lexapro-antianxiety medication to help you relax) 10 MG. 3. Resident 12's informed consent…
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 · D2025-05-08 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 comprehensive minimum data set (MDS-a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) assessment was completed and submitted to CMS in accordance with the required federal submission timeframe for one of eight sampled residents (Resident 12). This failure resulted in inadequate monitoring of progress or decline for Resident 12 and the lack of resident specific information to CMS for payment and quality measure monitoring. Findings: During a review of Resident 12's admission Record (contains demographic and medical information), the admission Record indicated Resident 12 was admitted to the facility on [DATE], with diagnoses of anoxic encephalopathy (brain damage), dementia (a group of symptoms that affect memory), hypertension (high blood pression), depression and anxiety, insomnia (sleeping problems), and dysphagia (difficulty swallowing). During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · D2025-05-08 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the quarterly Resident Assessment Instrument/Minimum Data Set (RAI/MDS- a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS] every 3 months or quarterly) was completed in accordance with federal submission timeframes, for two of four residents (Residents 16 and 19) when: 1. Resident 16's quarterly RAI/MDS assessment was completed on March 18, 2025 (52 days late). 2. Resident 19's quarterly RAI/MDS assessment was not completed on March 13, 2025 (92 days late) These failures had the potential to result in a delay in determining the resources necessary to competently care for the residents during the day-to-day operations and emergencies for Residents 16 and 19. Findings: 1. During a review of Resident 16's History and Physical (H&P -contains resident's medical history, physical examination and reason for admission to the facility), dated July 2024, the H&P…
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 · D2025-05-08 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the quarterly (every 3 months) Resident Assessment Instrument/Minimum Data Set (RAI/MDS- a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) was transmitted (submitted) to CMS in accordance with federal submission timeframes, for three of four residents (Resident 5,12, and16) reviewed for resident assessment when: 1. Resident 5's quarterly RAI/MDS assessment completed on February 14, 2025, has not been transmitted as of May 8, 2025 (69 days late). 2. Resident 16's quarterly RAI/MDS assessment dated [DATE], was transmitted on January 8, 2025 (7 days late) and quarterly MDS assessment due March 18, 2025, was not transmitted (37 days late from the due date). 3. Resident 12's comprehensive RAI/MDS assessment was due on March 30, 2025 but was not transmitted (81 days late) These failures resulted in inadequate monitoring of Residents 5, 12, and 16's progress or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan (an individualized plan that includes residents' health problems, preferences and goals) for one of three residents (Resident 12) when Resident 12 did not have a care plan developed or implemented to address an ongoing psychotropic (mind altering) medication. This failure had the potential for Resident 12 to have unidentified medical needs, delay in treatment and lack of coordinated care related to psychotropic drugs which can negatively affect Resident 12's mental state. Findings: During a review of Resident 12's admission Record (contains demographic and medical information), the admission Record indicated Resident 12 was admitted to the facility on [DATE], with diagnoses of anoxic encephalopathy (brain damage), dementia (a group of symptoms that affect memory), hypertension (high blood pression), depression and anxiety, insomnia (sleeping problems), and dysphagia (difficulty swallowing).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe oxygen administration was provided in accordance with the facility's policy and procedure (P&P) for one of two sampled residents (Resident 8) when Resident 8's oxygen tubing (a device which delivers oxygen) was not labeled to indicate the date it was changed. This failure had the potential to result in a respiratory infection leading to a decline in Resident 8's health status. Findings: During a review of Resident 8's clinical records, Progress Note, April 2025, the Progress Note indicated, Resident 8 was admitted on [DATE], with diagnoses which included dementia (loss of ability to think or remember), diabetes (high blood sugar), and osteoarthritis of multiple joints (a condition that causes the hands, legs, hips to become stiff and painful). During an observation on May 5, 2025, at 11:09 AM, Resident 8 was in his room, lying in bed, and receiving oxygen via oxygen tubing running at three liters per minute. The oxygen tubing…
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 · D2025-05-08 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
Based on interview and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for one of two medication carts (Medication Cart 1). This failure had the potential for drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 21 residents. Findings: During a concurrent interview, and record review on May 7, 2025, at 6:20 AM, with a Licensed Vocational Nurse 2 (LVN 2), at the nurse's station, the Medication Cart 1's Controlled Medication Shift Count (CMSC-form used by the facility to verify counting of controlled medications at the change of shift by oncoming and off going licensed nurses), dated April 23 2025, through May 4, 2025, was reviewed. The CMSC indicated that there were two missing signatures on April 26, 2025, for the night shift (7:00 PM to 7:00 AM). LVN 2 confirmed two missing signatures and stated the expectations for the CMSC to be counted by two…
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 · D2025-05-08 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for drug storage for one of one medication refrigerator in the medication storage room when the daily medication temperature log for the refrigerator was missing two staff signatures for two shifts. This failure had the potential for medications to be less effective due to the temperature of the medications being out of range. Findings: During a concurrent observation and interview on May 07, 2025, at 9:30 AM, with the Director of Nursing (DON), in the medication storage room, across from the nursing station, one medication refrigerator was observed with a document titled, Daily Temperature Log for Refrigerator, with two missing signatures. The DON verified there were missing signatures for the refrigerator temperature checks on March 12, 2025, and March 30, 2025. During a concurrent interview and record review on May 07, 2025, at 10:32 AM, with the DON, the facility's P&P titled, Drug Storage Temperatures, undated, was reviewed. The P&P indicated, . All refrigerators…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-08 · 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, and record review, the facility failed to ensure proper and safe infection control practices were followed for all 21 residents in the facility when two cups with brown liquid were found on the folding table/desk in the laundry room. This failure had the potential to result in spilling which can cause contamination to from uncleaned cloths and wetness can create mold and mildew to further compromised all 21 vulnerable residents in the facility. Finding: During a concurrent observation and interview on March 7, 2025, at 7:01 AM, with an Environment Service (EVS) and Environment Service-Trainee (EVS-T), the laundry room across from the Nurse's station in Unit B was observed. There was a brown cup with a sippy lid and a clear cup, containing brown liquid inside, located on the folding table. EVS and EVS-T acknowledged the two brown liquid cups on the folding table inside the laundry room. EVS stated he was informed that the coffee cup was allowed. During an interview on March 7, 2025, at 8:10 AM, with the Director of Facilities (DOF), the DOF 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.
- Potential for harm · D2024-03-19 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 for one of one sampled resident (Resident 4) Percutaneous endoscopic gastrostomy (PEG- a tube placed in the stomach to provide food, water, and medications) tube placement and residual were checked before administering medications. This failure had the potential to affect the health and well being for Resident 4. Findings: During a review of Resident 4's clinical record, the history and physical (a document that contains basic information) indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included PEG tube. During a concurrent medication pass observation, and interview on March 13, 2024, at 8:01 AM, with Licensed Vocational Nurse (LVN 1), the LVN 1 was administering medications through the PEG tube. LVN 1 did not check Resident 4's PEG tube placement and residual before administering the medications. When asked why she did not check Resident 4's tube placement and residual, she stated knows she has…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed follow their policy and procedure for one of three sampled residents (resident 20) when Resident 20's PRN (as needed) oxygen physician order did not include indication. This failure had the potential to cause Resident 20 to receive inadequate oxygen and place Resident 20 at higher risk of insufficient oxygenation. Findings: During a record review of the facility's face sheet (a document containing resident's demographic and medical information) of resident 20,the face sheet indicated Resident 20 was admitted with a diagnosis which included Congestive Heart failure (a chronic condition which causes low oxygen level because the heart cannot pump enough oxygen the way it should). During an observation on March 12, 2024, at 9:00 AM, in Resident 20's room, Resident 20 was observed lying in bed with a nasal cannula (NC-a medical device that provides supplemental oxygen therapy to Resident 20) set at 2 liters (unit of measurement) per minute. During a review of Resident 20's Physician Orders, dated March 13, 2024, it…
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 · D2024-03-19 · 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 interview, and record review, the facility failed to ensure an order for Clonazepam ( a psychotropic medication that affects how the brain works and causes changes in mood, awareness, feelings and behavior) PRN (give only as needed) was renewed by the physician within 14 days for one of three sampled residents (Resident 17). This failure had the potential for Resident 17 to continue to receive PRN doses of Clonazepam, that may no longer be necessary and could cause changes in Resident 17's fatigue, mood and memory problems. Findings: During a review of Resident 17's History and Physical (H&P- a document that includes a Resident 17's medical assessment performed by a medical provider), the H&P indicated, Resident 17 was admitted to the facility on [DATE] with diagnoses including severe deconditioning (mental and physical decline that results from physical inactivity), anxiety (feeling of fear, dread and uneasiness that can cause physical stress), and hypertension (HTN- high blood pressure). During a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-19 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 observation, interview, and record review, the facility failed to ensure the medication rate was less than 5 percent when three medications out of 28 opportunities were crushed and given together through Percutaneous endoscopic gastrostomy (PEG- a tube feeding inserted through the stomach which medications, food, and water is given) for Resident 4. This failure had the potential to affect the health and well being and cause drug interactions for Resident 4. Findings: During a review of Resident 4's History and Physical (a document that contains basic information) indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included PEG tube and Lennox-Gastaut syndrome (a type of seizure). During a concurrent medication observation and interview on March 13, 2024, at 8:01 AM, with Licensed Vocational Nurse (LVN 1), LVN 1 administered the following medications at the same time through the PEG tube: 1. Clobazam (a medication used for seizures) 10 mg (milligram a unit of measurement)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-19 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 follow proper maintenance and sanitation practices when several dish drying racks were found to have black stains on both the inner and outer part of the racks and some dish drying racks had cracks with jagged edges. This failure had the potential to result in food borne illness in a medically vulnerable population of 18 residents. Findings: During a concurrent observation and interview with the Director of Nutrition Services (DNS) and Food and Nutrition Services (FNS) in the kitchen, on March 11, 2024, at 10:08 AM, several dish drying racks were observed with black stain in the inner part and outer part of the rack. Some had a crack with a jagged edge on it. The FNS washed one dish drying rack with soap and water and the black stain came off. She stated the black stain is not dirt it is residue from heat and hot water. She confirmed one dish drying rack had black stain. When asked how often they clean the racks the DNS stated, We will replace the old dish racks. There are seven old racks. She confirmed 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 · Dcited before2024-03-19 · 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, and record review, the facility failed to maintain infection control practices when Licensed Vocational Nurse (LVN 1) did not perform hand hygiene when preparing medications for two out of five sampled residents (Resident 20 and 5). This failure had the potential to put the health of sampled Residents 20 and 5 at risk of contracting infectious diseases caused by bacteria, viruses, fungi, or parasites. Findings: 1. During a review of facility's (undated) admission record for Resident 20, the admission record indicated Resident 20 was admitted on January 30, 2024, with a diagnosis of Congestive Heart Failure (a chronic condition that affects the heart to pump blood). During an observation for Resident 20's medication administration, on March 14, 2024, at 8:49 AM, in front of Resident 20's room, LVN 1 did not perform hand sanitization process after touching her personal cell phone while preparing Resident 20's medication. During an interview on March 14, 2024, at 8:52 AM, in the nurse's station with LVN 1, the LVN 1 acknowledged touching her personal…
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 · D2024-03-19 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 for one of five sampled residents (Resident 18) was offered a pneumococcal vaccine (a vaccine which helps to prevent a lung infection) upon admission to the facility on August 1, 2023. This failure had the potential to affect the health and well- being for Resident 18 by not being offer the pneumococcal vaccine to help prevent a lung infection. Findings: During a review of Resident 18's clinical record, Resident 18's History and Physical, indicated Resident 18 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar) and seizure disorder. During a concurrent interview, and record review, with the Infection Preventionist (IP), on March 14, 2024, at 10:46 AM, a review of Resident 18's immunization records was conducted. There was no documented evidence a pneumococcal vaccine was offered . The IP stated, [I] don't know if pneumococcal and COVID was offered during admission. A review of the document provided…
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 · D2024-03-19 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 for one of five sampled residents (Resident 18) was offered a COVID vaccine (a vaccine which helps to prevent a lung infection) upon admission to the facility on August 1, 2023. This failure had the potential to affect the health and well being for Resident 18 by not being offer the COVID vaccine to help prevent a lung infection. Findings: During a review of Resident 18's clinical record, Resident 18's History and Physical, indicated Resident 18 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar) and seizure disorder. During a concurrent interview, and record review, with the Infection Preventionist (IP), on March 14, 2024, at 10:46 AM, a review of Resident 18's immunization records was conducted. There was no documented evidence a COVID vaccine was offered . The IP stated, [I] don't know if pneumococcal and COVID was offered during admission. A review of the document provided by the IP only…
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.
- No harm found · Ccited before2024-03-19 · tag F0732 — widespreadPost nurse staffing information every day.
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 a completed nurse staffing information with actual hours worked by the licensed staff responsible for direct resident care was prominently displayed in the nursing station . This failure resulted in nurse staffing information with actual hours worked not being prominently displayed to the public in the nursing station. Finding: During an observation on March 14, 2024, at 10:00 AM, in the facility's nursing station, it was noted that the nurse staffing information was not displayed in a readily accessible area. During a review of the facility provided document titled, Nurse Staffing Information, dated March 12, 2024, through March 14, 2024, Nurse Staffing Information indicated that the actual work hours worked by the licensed staff responsible for direct resident care were not specified. During an interview on March 19, 2024, at 4:00 PM, in the Director of Nursing's office with the Director of Nursing (DON), DON acknowledged that nurse staffing information was not posted daily on a prominent place and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| HAMBLIN, GARTH | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 07/01/2015 |
| BAKER, STEVEN | Individual | CORPORATE DIRECTOR | since 12/01/2020 |
| BOSS, PETER | Individual | CORPORATE DIRECTOR | since 12/01/2018 |
| BRINER, JOHN | Individual | CORPORATE DIRECTOR | since 03/01/2021 |
| CLARKE, ELLEN | Individual | CORPORATE DIRECTOR | since 09/01/2021 |
| KALIHER, MARK | Individual | CORPORATE DIRECTOR | since 12/01/2020 |
| NORMAN, MARY | Individual | CORPORATE OFFICER | since 03/23/2004 |
| RAYNER, EVAN | Individual | CORPORATE OFFICER | since 11/15/2021 |
| BEAR VALLEY COMMUNITY HEALTH CARE DISTRICT | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 01/19/1988 |
CMS files one row per role, so the 10 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
What families pay in CA
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 555468. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-04, 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.