Pacific Coast Manor
1935 Wharf Road, Capitola, CA 95010 · For profit - Limited Liability company · 99 certified beds · (831) 476-0770 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2024
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 4 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 improved from 3 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 8.1% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.9% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.4% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.1% | 7.3% | 6.5% | better |
| 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 | 4.0% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 5.7% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.6% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.5% | 10.2% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.7% | 12.0% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.2% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.7% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.91 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.75 | 1.57 | 1.80 | typical |
‡ 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.
69.7% 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 751 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 74.0% 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 385 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 0.83 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 69.7%CMS range 66.7–72.7 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 8.3–12.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 74.0% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 68.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 70.9% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 99.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 99.8% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 77.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.9%CMS range 6.0–9.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 99 beds and averages 96.1 residents a day — about 97% occupied, or roughly 3 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 4.39 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.17 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.88 hrs/resident/day on weekends vs 4.60 on weekdays — 16% thinner on weekends. RN hours go from 1.24 to 1.01 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% 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
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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · D2025-04-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
During a review of Resident 1's MD (medical doctor) Progress note dated 1/23/25, note indicated, Pt [patient] admitted for fall at home.Assessment/Plan.10. OSA (obstructive sleep apnea) G47.33 [diagnosis code] Continue home CPAP. During a review of Resident 1's Order Summary Report dated 3/25/25 at 10:40 am, current orders indicated, no active orders for the use of a CPAP machine. During a review of Resident 1's Medication Administration Record (MAR) dated 1/21/25-2/28/25, MAR indicated no administrations charted for the use of a CPAP machine for any day. During an observation on 3/25/25, at 10:40 a.m., in Resident 1's room, no CPAP machine was observed in the room. During a review of Resident 1's Facesheet, dated 3/25/25, facesheet indicated Resident 1 had a diagnosis listed for Obstructive Sleep Apnea (Adult).onset date 12/20/24. During an interview on 3/25/25 at 11:59 a.m., with Licensed Vocational Nurse (LVN) A. LVN A stated, she was assigned nurse to Resident 1 and took care of Patient 1 multiple times. LVN A stated, Resident 1 had a complaint that he did not have a CPAP…
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 before2025-02-20 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record reviews, and facility policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I Screening was updated to reflect the presence of newly diagnosed serious mental disorders for 1 (Resident #67) of 3 residents reviewed for PASARR requirements. Findings included: A facility policy titled, Resident Assessment - Coordination with PASARR Program, reviewed/revised 05/2024, revealed, This facility coordinates assessments with the preadmission screening and Resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy specified, 9. Any Resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level Il Resident review. Resident #67's admission Record indicated the facility admitted…
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 before2025-02-20 · 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, record review, and facility policy review, the facility failed to ensure medications were securely stored for a resident deemed safe to self-administer medications for 1 (Resident #247) of 1 resident reviewed for secure storage of self-administered medications. Findings included: A facility policy titled, Resident Self-Administration of Medication, reviewed/revised 06/26/2024, specified, 7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into other resident's [sic] rooms or to confused roommates of the resident who self-administers medications. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers and cabinets are required only if locked storage is ineffective. b. The medications provided to the resident for bedside storage are kept in containers dispensed by the provider pharmacy. An admission Record indicated the facility admitted Resident #247 on 01/31/2025. An admission Minimum Data Set (MDS), with…
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 · D2024-08-02 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 interview and record review, the facility failed to follow their policy and procedure (P&P) to notify the Office of State Long-Term Care Ombudsman (organization that advocates for the residents) when one of two sample resident (Resident 1) was transferred to the acute care hospital (ACH: provides treatment for brief but severe episode of illness and conditions) from the facility. This failure had the potential to compromise Resident 1's admission, transfer, and discharge rights. Findings: Review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's discharge summary from ACH dated 4/11/2024 indicated, diagnoses included dementia (loss of ability to think, remember, and reason to levels that affect daily life and activities) with behavior changes. Review of Resident 1's clinical record indicated Resident 1 was transferred to ACH same day on 4/11/2024 following episode 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.
- Potential for harm · D2024-08-01 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 to follow their policy and procedure (P&P) to assess for history of psychosocial, trauma and stressors trigger an event, for two of two sample residents (Resident 1 and 2). This failure had the potential to effect health, psychosocial well-being, and person-centered trauma informed care for Resident 1 and 2. Findings: Review of Resident 1's FS (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE] and readmitted to facility on 6/14/2024. Review of Resident 1's FS indicated Resident 1's admission diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in daily living activities), anxiety (a mental health condition involves persistent and excessive worry that interferes with daily living activities), and insomnia (a sleep disorder that make it hard to fall asleep or stay asleep). Review of Resident 1's physician…
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 before2024-05-09 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect resident's right to be free from physical abuse for two of two sampled residents (Resident 1 & Resident 2) when: 1. Resident 1 was hit in the face by Resident 3 2. Resident 2 was kicked in the leg by Resident 3. These failures resulted in Resident 1 sustaining a minor laceration to the face and Resident 2 sustaining a minor laceration to the leg, both requiring minor medical care. Findings: 1. During an interview on 5/7/24, at 10:20 a.m., with Administrator (ADM), ADM stated, we got a report from Resident 4, he saw Resident 2 grab Resident 3's arm, then Resident 3 punched Resident 1 in the head. ADM stated both Resident 1 and Resident 3 have been involved in resident-to-resident altercations before. During a review of SBAR-Alleged Abuse Report of Incident dated 5/6/24, indicated, Resident 3 was involved in an incident of alleged: Physical abuse with redness [to] right hand 2nd and 3rd knuckle.Behavior status 1.Agitated.Staff responded to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-13 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to protect a resident's right to be free from sexual abuse for one of two sampled residents (Resident 1) when Certified Nursing Assistant (CNA A) observed kissing Resident 1 on the face. This failure had the potential to endure emotional and psychological harm for Resident 1. Findings: During a review of Resident 1's admission Record, dated 10/31/23, admission Record indicated, diagnosis information of metabolic encephalopathy (a disorder causing brain dysfunction), muscle weakness, unspecified dementia (a condition where the person loses ability to think, remember, learn or makes decisions), and major depressive disorder. During a review of Verification of Incident/ Administrative Summary, dated 10/20/23, indicated an incident with Resident 1 and CNA A occurred on 10/24/23. Summary indicated, Type of incident: Allegation of Sexual Abuse. The brief description of the incident/event when C.N.A. witnessed a kiss between CNA A and Resident 1. Futhermore, the immediate actions taken: Resident 1 had a BIMS [brief interview for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-11 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 social services advocating and assisting residents to promote resident's rights for one of three residents (Resident 1) and significant family members (SFM). This failure had the potential to result in the Resident 1 for not receiving necessary mental, psychosocial, emotional support, care, and services to attain Resident 1's highest practicable well-being. Findings: During the review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated, Resident 1 admitted to facility on 5/10/2023 with diagnoses including alcoholic cirrhosis of liver with ascites (a disease caused by heavy use of alcohol with buildup of fluids in the abdomen), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), adjustment disorder (an emotional or behavioral reaction to a stressful event or change in person's life), chronic pain (pain that lasts for over three months despite medication or treatment) hypertension (a condition in which the force…
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 · E2023-06-16 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis based on Staffing Data Report submitted to Centers for Medicare & Medicaid Services (CMS). This failure had the potential to affect resident's care, health, and psychosocial wellbeing. Findings: During an interview with the staffing coordinator (SC) on 6/16/2023 at 4:10 p.m., SC confirmed staffing was a struggle. SC agreed the Direct Care Service Hours Per Patient Day (DHPPD) should have been 3.5. During an interview with the Excutive Director (ED) on 6/16/2023 at 4:23 p.m., ED stated the low staffing back on January - March 2023 was due to the storm, and Coronavirus disease (COVID-19, a disease caused by a contagious virus) outbreak. During a document review titled, Census and Direct Care Service Hours Per Patient Day, from January through March 2023, indicated the following dates with actual DHPPD were below 3.5: 1/1- 2.73; 1/2-3.08; 1/3-3.17; 1/4-3.21; 1/7-2.8; 1/8-2.85; 1/9-3.19; 1/10-3.18; 1/14 -2.36; 1/15-2.64; 1/17-3.29; 1/18-3.3; 1/19-3.06; 1/20-2.88;…
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 · E2023-06-16 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
2. During an observation on 6/13/2023 at 9:38 AM, in Resident 37's room, CNA H applied Resident 37's Foley catheter's dignity bag with both gloved hands. However, after leaving the resident's room, the CNA H disposed of her gloves in the trash bin located in the hallway without performing hand hygiene immediately. The CNA H proceeded to open the storage closet in the hallway, removed linens, and then returned to Resident 37's room. CNA H did not perform hand hygiene promptly after disposing of her gloves and handling the linens in the hallway. During an interview on 6/13/2023 at 1:44 p.m., with CNA H, she acknowledged the observation and stated she should have performed hand hygiene after disposing of her gloves. During an interview on 6/16/2023 at 4:00 p.m., with the Infection Preventionist (IP), IP stated hand hygiene should have been performed between tasks and after removing gloves. During a review of the facility's policy and procedure titled, Hand Hygiene, dated October 2022, indicated, .2.Hand hygiene is indicated and will be performed under the conditions listed in, but not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · D2023-06-16 · 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
Based on interview and record review, the facility failed to ensure one of eight residents (59) had informed consent (written permission before implementing a healthcare intervention) prior to initiating a change in dosage of psychotropic medication (medication capable of affecting the mind, emotions, and behavior). This failure resulted in the resident receiving psychotropic medication without being informed about the change in dosage, the risks and side effects. Findings: Review of Resident 59's admission Record indicated Resident 59 was admitted to the facility with diagnoses including pneumonia (a lung infection), malignant neoplasm (cancer) of prostate (a gland in the male reproductive system), insomnia (a disorder in trouble falling asleep or staying asleep), and depression (an illness characterized by persistent sadness and a loss of interest in activities). Further review of Resident 59's admission Record indicated Resident 59 was the responsible party (health care decision maker). Review of Resident 59's Order Summary Report indicated, Trazodone HCl (antidepressant - 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 · D2023-06-16 · 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 complete and transmit the Minimum Data Set (MDS, a comprehensive assessment tool) discharge assessment in a timely manner for two of five residents (Residents 69 and 23). This failure resulted in the resident's discharge assessment not being transmitted and received by the Center for Medicare and Medicaid System (CMS) within the time requirement. Findings: 1. During a concurrent interview and record review on 6/16/2023 at 1:44 p.m., the MDS Director (MDS D) reviewed Resident 69's clinical records. Resident 69 was admitted to the facility on [DATE] and Resident 69 was discharged to home on 1/30/2023. The MDS discharge assessment was completed on 6/14/2023. MDS D confirmed the discharge assessment was completed late. MDS D stated she missed completing the MDS discharge assessment on time. 2. During a concurrent interview and record review on 6/16/2023 at 1:50 p.m., the MDS D reviewed Resident 23's clinical records. Resident 23 was admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-16 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to accurately complete the PASRR (pre-admission screening and resident review, a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) for one of two residents (Resident 3). This failure had the potential to put the resident at risk for not receiving appropriate care and services. Findings: Review of Resident 3's clinical record indicated he had the diagnoses of depression (a group of conditions associated with the elevation or lowering of a person's mood), dementia (disorder of the mental process caused by brain disease or injury), schizoaffective disorder (a combination of schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly] and mood disorder), and unspecified psychosis (a mental disorder characterized by a disconnection from reality). Resident 3's preadmission PASRR Level 1 screening, dated 12/03/22, was reviewed. Question number 10, section 3 asked, Does the individual have a serious diagnosed mental disorder such as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-16 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow professional standards for one of 22 sampled selected residents (Resident 6) when Licensed Vocational Nurse G (LVN G) did not wait for the recommended time between each puff of the inhaler medications. This deficient practice had the potential for Resident 6 to not receive the full amount of each medication and the adverse effects on resident's health. Findings: During a record review of Resident 6's clinical record indicated he was admitted to the facility with diagnosis including Chronic Obstructive Pulmonary Disease (COPD, a common lung disease causing restricted airflow and breathing problems). During a record review of Resident 6's physician orders included the following: - Tiotropium Bromide Monohydrate (Spiriva, oral inhaler to treats asthma) 18 micrograms (mcg, unit of mass), 1 capsule inhale orally in the morning for 2 inhalations. - Symbicort 80-4.5 mcg (oral inhaler, used long-term to improve symptoms of chronic obstructive pulmonary disease), 1 puff inhale orally and two times a day. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free of accidents and hazards for two of 22 sampled residents (39 and 145) when: 1. Resident 39's smoking safety was not reviewed quarterly and the smoking care plan was not followed; and 2. Resident 145 was not properly assessed for Smoking Safety Screen. These failures had the potential to result in serious injury to the residents in the facility. Findings: 1. Review of Resident 39's admission Record indicated, Resident 39 was admitted to the facility with diagnoses including unspecified dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning), ataxia (impaired balance or coordination), polyneuropathy (nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body), history of falling, nicotine dependence and unspecified visual loss. Review of Resident 39's Annual Minimum Data Set (MDS-an assessment tool), dated 2/25/2023, indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-16 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 review the risks and benefits of bed rails (adjustable metal or rigid plastic bars that attach to the bed) for three of 22 sampled residents (Residents 81, 72 and 53). This failure had the potential to put the residents at risk for entrapment and serious injury due to not being aware of the risks and benefits of bed rails. Finding: 1. During a concurrent observation and interview on 6/12/23 at 9:49 a.m., in Resident 81's room, Resident 81 was lying in bed with half side rails up bilaterally (on both sides of the bed). Resident 81 stated her bed rails were very wobbly and seemed like they were going to break off. Review of Resident 81's clinical record indicated she was admitted on [DATE] and had the diagnoses of dementia (disorder of the mental process caused by brain disease or injury), muscle weakness, low back pain, altered mental status, history of falling, anxiety disorder (characterized by feelings of worry, anxiety, or fear that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-16 · 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 ensure controlled medications (those with high potential for abuse and addiction) reconciled with the corresponding Medication Administration Records (MAR) for two of 3 randomly selected residents (Residents 53 and 13). This deficient practice had the potential to result in medication error and/or drug diversion. Findings: 1. During a review of Resident 53's physician order for Percocet (Oxycodone with Acetaminophen, a controlled medication for pain) 5-325 milligrams (mg, unit of measurement), 1 tablet by mouth every 4 hours as needed for moderate pain, dated 4/18/2023. During a review of Resident 53's Controlled Drug Record (CDR) for Percocet 5-325 mg and MAR for May and June 2023 reflected the nursing staff removed and documented on the Controlled Drug Record: 1 tablet on 5/9/23 at 4:40 a.m.; 5/30/23 at 5:55 p.m.; and 6/8/23 at 9:00 p.m., but did not document in the MAR. During a concurrent interview and record review on 6/13/2023 at 5:20 p.m., with the Director of Nursing (DON) and Health Information Manager (HIM),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of 8 sampled residents (Residents 57, 63, and 59) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 57 received Seroquel (used to treat certain mental or mood conditions) without an appropriate diagnosis and monitoring behavior, as recommended by the Pharmacy Consultant (PC); 2. Resident 57 received PRN (as needed) Lorazepam (medication used to treat anxiety) beyond 14 days and without supportive rationale for its continued use; 3. Resident 63 received prn (as needed) Temazepam (used to treat insomnia (difficulty falling asleep or staying asleep) without monitoring hours of sleep; and 4. Resident 59 received Lorazepam without documentation of its specific duration in the resident's clinical record. These failures had the potential for increased risks associated with the use of psychotropic medications that could negatively affect 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 before2023-06-16 · 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 — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to appropriately label a Tuberculin (TB, aid in the detection of infection with Mycobacterium tuberculosis) vial for 1 of 2 medication rooms observed. This deficient practice had the potential to affect residents' health and well-being in the facility. Findings: During a concurrent observation and interview on 6/12/2023 at 02:04 p.m., with Registered Nurse F (RN F) in the Station 1 medication room, there was an opened TB vial inside the refrigerator without an open date. RN F acknowledged the TB vial should have been dated upon opening. During a review of the facility's policy and procedure, titled, Medication Administration Operating Standard Guideline, dated 12/2012, the P&P indicated, Date tuberculin . when opened. Discard TB vial after 30 days.
- Potential for harm · D2023-06-16 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
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 food storage when food brought by visitors to one of 22 residents (Resident 46) was not properly stored. This failure had the potential to result in food-borne illness and food contamination. Findings: During an observation and concurrent interview on 6/15/23 at 10:20 a.m., with the director of nursing (DON), the DON confirmed there was an employee refrigerator in the parlor that had a sign that indicated, No residents food. There was an undated container of yogurt in the employee refrigerator labeled with Resident 46's name and room number. During an interview on 6/15/23 at 10:22 a.m. with registered nurse A (RN A), RN A stated Resident 46's visitors brought food for Resident 46 all the time, but was unsure where the food was stored. During an observation and concurrent interview on 6/15/23 at 10:25 a.m., with certified nursing assistant B (CNA B), CNA B confirmed Resident 46's container of yogurt was stored inside the employee refrigerator in the parlor. During an observation and concurrent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-16 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to conduct regular inspections of resident bed frames for one of 22 beds. The facility failed to ensure the footboard was securely, properly installed, and maintained according to the manufacturer's requirements. This failure had the potential to place the residents at risk for accidents and unsafe environment. Findings: During an observation on 6/12/23, at 9:16 a.m., in Resident 3' room, Resident 3 was lying in bed asleep. The wooden lining of the bed's footboard was in disrepair and coming off. There was a piece of surgical tape attached to the end of the wooden lining. During a concurrent observation and interview on 6/12/23, at 11:22 a.m., with Certified Nurse Assistant C (CNA C), in Resident 3's room, he verified the above observation and stated he would call someone to check on it. During a concurrent observation and interview on 6/12/23, at 11:26 a.m., with Maintenance Director (MD), in Resident 3's room, MD verified the above observation and stated that the footboard should have been securely 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 · D2019-12-05 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure call lights (a device to call help when needed) were within residents' reach and answered in timely manner for seven of 18 residents (Residents 2, 8, 9, 27, 32, 46, and 231). This failure placed residents at risk for unmet needs and a diminished quality of life. Findings: 1. During observation on 12/5/19 at 9:12 a.m., Resident 9 was sitting in bed and her call light was on the floor not within reach for the resident. Resident 9 was asking for bread and juice. During interview with CNA B (certified nursing assistant B) on 12/5/19 9:15 a.m., CNA B picked up the call light and clipped it on the pillowcase for Resident 9 within reach. CNA B stated there would be no way for the resident to ask for assistance if her call light was not within reach. During a review of the facility's policy and procedure, dated copyright 2006, Call light, Use of, indicated 11. Be sure all call lights are placed on the bed at all times, never on the floor 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 · Dcited before2019-12-05 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services provided meet professional standards for two of five residents reviewed, when Resident 286's multivitamins with minerals was not given and Resident 23's vital signs (VS, clinical measurements, specifically pulse rate, temperature, respiration and blood pressure) were not monitored as ordered, which had the potential to result in compromising residents' health conditions. Findings: 1. During a random medication pass observation on 12/4/19 at 9:48 a.m., registered nurse F (RN F) prepared and administered Resident 286's morning medications. RN F did not administer a tablet of multivitamins and minerals. Review of Resident's 286's physician order, dated 11/24/19, indicated to administer multiminerals one tablet by mouth in the morning. During an interview on 12/4/19 at 12:39 p.m. with RN F, he confirmed the above observation and stated the medication was not available. During an interview with the director of nursing (DON) 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 · D2019-12-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 monitor wound progress for one of four residents when there was lack of wound assessments that included Braden scale (for predicting pressure ulcer risk) and description of skin condition or wound measurement for the period of 10/20/19 to 11/15/19, which had resulted in Resident 52's Stage 2 pressure ulcer (partial thickness skin loss involving the epidermis) on the coccyx (tailbone). Findings: During review of Resident 52's clinical record, Resident 52 was admitted on [DATE] with diagnoses including encephalopathy (brain disease), heart failure, and age-related physical debility (weakness) During review of Resident 52's minimum data set (MDS, resident tool assessment) dated 11/2/19, indicated Resident 52 was cognitively intact. Section M (Skin condition) indicated no pressure ulcer. During review of Resident 52's admission wound assessment dated [DATE], indicated wound location: coccyx, type: moisture related rash, treatment: nystatin and barrier…
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 · D2019-12-05 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record, review the facility failed to ensure two of 18 residents (Residents 47 and 72) were free from unnecessary drugs when there was no evidence of documentation that the the side effects for the use of psychotropic medications (medications capable of affecting the mind, emotions, and behavior) was monitored. This failure had the potential for the residents to receive unnecessary medications. Findings: Resident 47's clinical record was reviewed. Her diagnosis included depression (a persistent feeling of sadness or a lack of interest) and dementia (a loss of mental ability severe enough to interfere with normal activities of daily living). Her physician order dated 10/29/19, indicated Risperdal (medication used to treat certain mental/mood disorders) 0.5 milligram (mg, unit of measurement) in the evening and dated 12/3/19 indicated Risperdal 0.25 mg by mouth in the morning every Tuesdays, Thursdays, and Saturdays for dementia. Review of Resident 72's clinical record indicated diagnoses that included depression. His physician order dated 11/8/19, indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-05 · 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 ensure that medications were dated, labeled properly, and not expired in two of five medication carts. This failure had the potential to result in an altered effectiveness of medications. Findings: During an observation on 12/2/19 at 2:44 p.m., with licensed vocational nurse G (LVN G), medications inside the cart for Resident 47 included the following: (1) Breo Ellipta (a medication used to help with breathing) with no open date and an expiration date of 11/2019 (2) Albuterol (medication used to help with breathing) with a discard date of 11/18/19 and (3) Symbicort 160/4.5 (medication used to help with breathing) with a discard date of 11/18/19. During a concurrent interview with LVN G, she stated the above expired and undated medications should be removed from the cart and discarded. During a concurrent observation and interview on 12/3/19 at 2:22 p.m. with LVN E, medications inside cart #4 for Resident 3 included Albuterol (medication used to help with breathing) which indicated an expiration date of 9/19.…
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 · D2019-12-05 · 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 the manufacturer's guidelines, and policy and procedures for checking the sanitizing solution concentration. This failure could result in the potential to spread food-borne illness. Findings: During a concurrent observation and record review on 12/2/19 at 8:34 a.m., with the dietary manager (DM), in the kitchen, the DM tested the sanitizing solution in the third compartment of the three-compartment sink (sink used in the kitchen to wash, rinse, and sanitize items such as pots and pans), and in two red sanitizer buckets (used for cleaning kitchen counters and food prep areas). For each test, the DM dipped the test paper in the sanitizing solution for less than ten seconds and her bare hands touched the sanitizing solution. During a concurrent observation and interview on 12/3/19 at 11:07 a.m., in the kitchen, with the cook, the DM, and registered dietician (RD), the cook tested the sanitizing solution in the three-compartment sink seven times. During the first and third through seventh tests, the cook…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to COVENANT CARE — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.8 | +2.2 vs chain |
| Health inspection | 5 of 5 | 2.5 | +2.5 vs chain |
| Staffing | 3 of 5 | 2.9 | +0.1 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 11 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| COVENANT CARE CALIFORNIA, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/01/2004 |
| CENTRE CAPITAL INVESTORS V, LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/17/2008 |
| CENTRE COVENANT PURCHASER (B), LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/17/2008 |
| CENTRE COVENANT PURCHASER (Q), LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/17/2008 |
| CENTRE COVENANT PURCHASER (S), LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/19/2008 |
| CENTRE V SECONDARY FUND, L.P. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/17/2008 |
| COVENANT CARE, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/17/2008 |
| COVENANT HOLDCO, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/17/2008 |
| COVENANT SUBCO, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/17/2008 |
| STATE TREASURER OF MICH CUSTODIAN OF PUBLIC SCHOOL EMPL RTMNT SYSTEMS | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/19/2008 |
| STOCKWELL FUND II LP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/19/2008 |
| EVANS, MARY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 04/17/2006 |
| LEVIN, ROBERT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 04/17/2006 |
| SIMS, CHRISTINE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 07/17/2008 |
| TOROK, ANDREW | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | NO PERCENTAGE PROVIDED | since 07/17/2008 |
| MIDCAP FUNDING IV TRUST | Organization | 5% OR GREATER SECURITY INTEREST | — | since 02/20/2014 |
| ASHLEY, DAVA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/26/2018 |
| CARNEY, KEVIN | Individual | CORPORATE OFFICER | — | since 11/01/2013 |
| SPARKS, CAROL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/01/2004 |
CMS files one row per role, so the 27 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.
12 organizational owners 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.
This home reported $2.6M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 056048. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-20, 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 →
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