Glenbrook
1950 Calle Barcelona, Carlsbad, CA 92009 · For profit - Limited Liability company · 94 certified beds · (760) 704-6800 Medicare only — no Medicaid
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $9,311 in federal fines (most recent 2023-08-23)
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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 7.3% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.0% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.9% | 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 | 5.3% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 16.0% | 9.8% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 13.5% | 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 | 3.0% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 8.8% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.8% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.6% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.5% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.5% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.18 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.46 | 1.57 | 1.80 | better |
‡ 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.
68.8% 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 532 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 90.0% 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 191 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 0.56 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% 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 | 68.8%CMS range 65.3–72.5 | 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 8.2–12.7 | 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 | 90.0% | 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 | 83.2% | 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 | 78.5% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 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 | 100.0% | 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 | 0.6% | 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 | 2.6% | 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 | 7.2%CMS range 5.1–9.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.83 | 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 94 beds and averages 54.9 residents a day — about 58% occupied, or roughly 39 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.23 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.05 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.10 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 4.78 hrs/resident/day on weekends vs 5.41 on weekdays — 12% thinner on weekends. RN hours go from 1.17 to 0.76 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · G2023-08-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure the nutritional status was monitored and acceptable parameters were maintained for one of one resident, (Resident 23), with unintended, unplanned severe weight loss of 16.43% in six months (9/4/22-2/4/23) when: 1) The resident's nutritional status was not reassessed, the laboratory values were not drawn, or the interventions were modified after five, ten, or fifteen percent of weight loss occurred, according to facility policy and standards of practice. 2) The resident was not placed on weekly weights from 9/1/2022-3/31/2023 to monitor weight status after a loss of five or ten percent of body weight, according to policy. 3) The resident's meals and snack/nourishment consumption were not monitored to determine the resident's actual food intake in order to evaluate nutrition status, according to facility policy. These failures had the potential to result in Resident 23 experiencing further functional decline, loss of lean body mass…
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 · E2025-09-19 · tag F0605 — failed to not use drugs as a restraint — patternPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to initiate nonpharmacological or behavioral intervention before initiating antipsychotic medications (medication to treat psychosis [mental disorder characterized by disconnection from reality]) for two of five sample residents (Residents 31 and 49).This deficient practice had the potential for Resident 31 and 49 to receive unnecessary antipsychotic medication or inappropriate dose for behavioral treatment.Findings:1. A review of Resident 31's admission Record indicated the resident was readmitted on [DATE] with diagnoses which included Alzheimer's disease (a progressive brain disorder that causes memory and other cognitive decline), dementia (loss of mental function such as thinking, memory and reasoning skills), delusional disorders (false belief of reality), depression, mild cognitive impairment and disorientation.A review of Resident 31's History and Physical (H&P), dated 2/12/25, indicated Resident 31 was alert to person and not to place and time.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 · D2025-09-19 · 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 interview and record review the facility failed to ensure three of four sampled residents (Residents 2, 44 and 11) knew the location of the survey results binder.This failure had the potential to keep residents, family members, and visitors from easily reviewing the most recent survey results and the facility's plan of corrections, which were essential for making informed decisions about living at the facility.During an interview on 9/17/25 at 2:30 PM, three of four residents polled at the resident council meeting did not know the location of the survey results binder.During a concurrent observation of the facility and interview with the Administrator (ADM) on 9/17/25 at 4:37 PM. The ADM verified the three locations of the survey results binders and confirmed there was no sign at one of the sites in the facility indicating where to find it. ADM stated that the facility did not have a policy and procedure regarding posting and accessibility of survey results. A review of the State of California-Health and Human Services Agency, Attachment F Resident [NAME] of Rights, Section…
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 · D2025-09-19 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Office of the Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes) before discharge for two of four sampled residents (Resident 5 and 7). This deficient practice had the potential to leave residents unprotected from improper discharge and deny them access to an advocate for their options and rights.1.During a review of Resident 7's History and Physical (H&P), dated 9/2/25, the H&P indicated Resident 7 was sent to the hospital on 8/24/25, and came back to the facility on 8/30/25. During an interview with the SSD on 9/18/25, at 10:11 AM. She stated the facility must send written notification to the ombudsman when resident was discharged or transferred. Medical records staff must send the notification. During a concurrent interview and record review with the (MRD) on 9/18/25, at 10:21 AM, MRD confirmed there was no written notification of transfer sent to the ombudsman. A review of the facility's policy and procedure…
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 · D2025-09-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly identify and provide necessary assistive devices for repositioning for one of the sampled residents (Resident 27).This failure had the potential to cause accident and injury to Resident 27.During a concurrent observation and interview with Resident 27 on 9/16/25 at 9:28 AM, Resident 27 was observed holding on to the bedside drawer while turning to their side. Resident 27 expressed difficulty repositioning in bed. Resident 27 had been using the bedside table drawer to assist in turning to their side.A review of Resident 27's admission Records dated 9/18/25, indicated Resident 27 was admitted on [DATE].A review of Resident 27's History and Physical (H&P), dated 9/5/25, indicated a chief complaint of fall which resulted in right femur fracture (a complete or partial break in a bone, often caused by excessive force, an accident, or repetitive stress). The H&P also indicated Resident 27 had the capacity to make own healthcare…
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 before2024-10-17 · 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 ensure one resident ' s (Resident 1) written care plan for transfers was consistently implemented. Resident 1 had an unwitnessed fall while transferring into a chair. Findings: A review of the admission Record for Resident 1 reflected Resident 1 was admitted to the facility on [DATE] with diagnoses that included: unspecified dementia (a condition of decline in thinking ability and memory); diabetic neuropathy (a severe condition caused by high blood sugar, and symptoms can include sensations of pain, numbness or burning, loss of balance or weakness). On 9/20/24 an unscheduled visit was made to the facility in response to a report of Resident 1 falling and fracturing her left wrist. On 9/20/24 at 12:10 P.M. Resident 1 was interviewed in her room. Resident 1 is sitting up in bed, with a clean cast on her left wrist. Resident 1 stated her arm and cast is very awkward, and needs extra care. Resident 1 stated she was still working with therapy as much 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 · Fcited before2023-08-24 · tag F0800 — widespreadProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview and record review, the facility failed to ensure overall systems were met for the Food and Nutrition Services in the kitchen when: a resident experienced an unplanned insidious severe weight loss of 16% in a six months; residents' food temperatures were not monitored for safety and palatability; kitchen staff did not perform tasks competently for food safety in food preparation, food storage, and sanitation for dishwashing and dish storage; kitchen staff did not monitor the temperatures in the dry storage room and emergency food supply room closet to ensure safe quality of the food supply; recipes were not followed for time and temperature control for food safety foods (TCS); and fruit fly pests were found in the kitchen. These failures placed all residents at risk for harm and exposure to contamination that had the potential to impair their nutrition and health status. The facility census was 57. Cross reference F692, F802, F803, F804, F812, F925 Findings: During the initial kitchen tour on 8/21/23 at 8:14 A.M., multiple observations 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 · Fcited before2023-08-24 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview and record review, the facility failed to ensure kitchen staff competently carried out the functions of the food and nutrition services department when: 1. A Kitchen staff did not correctly label and date TCS (Time/Temperature Controlled for food safety) foods in a walk-in refrigerator and did not monitor the dry storage room by correctly labeling, dating, and checking the quality of the food supply. 2. A Lead [NAME] (LCK) did not prepare the tuna salad correctly using the cool down process for ambient temperature foods. 3. A Dishwasher did not enter the dish machine wash and rinse temperatures on a log in a timely manner. These failures placed all residents at risk of cross contamination and the potential to acquire food-borne illnesses. The census was 57. Cross reference F800, F804, F812 Findings: 1. During the initial kitchen tour on 8/21/23 at 8:25 A.M., an observation of the walk-in refrigerator and interview with the Executive Chef (EXC) was conducted. There was a metal tray of soup ingredients on the first two shelves that included sliced…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-08-24 · 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 food safety and sanitation practices were met in the kitchen according to standards of practice when: 1. An ice scooper was left inside the ice machine. 2. The kitchen's clean dish storage area had dirty serving utensils and debris in tray with clean dishes. 3. A Lead cook (LCK) did not prepare the tuna salad correctly using the cool down process for ambient temperature foods. 4. The floor in the walk-refrigerator and freezer had dirty label, brown stains, trash and other debris on the floor. 5. Fruit flies were in the flying around uncovered food in the kitchen and dry storage area. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing foodborne illness. The facility census was 57. Cross- reference F800, F802, F925 Findings: 1. During an initial kitchen tour on 8/21/23 at 8:25 A.M., an ice machine scooper was found inside the ice machine. During an interview on 8/21/23 at 8:30 A.M., with the Director of Food 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 · D2023-08-24 · 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 interview and record review, the facility failed to ensure care/treatment was provided according to professional standards of practice for two of 15 sampled residents (Resident 3 and 45) when: 1. Licensed nurses (LN) did not respond to Resident 3's low blood glucose reading (a value less than 70 mg/dl [milligrams/deciliter]) by assessing the resident for signs and symptoms of hypoglycemia (low blood glucose/sugar) and notifying the resident's physician. In addition, LN did not clarify Resident 3's physician order related to a low blood glucose parameter. 2. A response to a change of condition related to nutritional assessment was not conducted in a timely manner. As a result, there was the potential risk to the residents' health and well-being. Findings: 1. A review of Resident 3's admission Record indicated the resident was readmitted on [DATE] with diagnoses to include diabetes mellitus (the body's inability to regulate blood sugar) and dementia (a condition characterized by impairment of at least 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 · D2023-08-24 · 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 observation, interview and record review, the facility failed to ensure that one of eight sampled residents (Resident 361) reviewed for medication administration, received the medication in accordance with the physician's orders. This failure had the potential for the for Resident 361 to experience unexpected medication side effects or decreased drug action. Findings: During an observation on 8/23/23 at 9:38 A.M., licensed nurse (LN) 2 gave Resident 361 Aspirin 81 (milligram) mg chewable using a plastic spoon. Resident 361 swallowed the medication and did not chew the chewable Aspirin. LN 2 did not provide instructions to Resident 361 and the resident did not chew the Aspirin before swallowing. An interview on 8/23/23 at 9:42 A.M., with LN 2 was conducted. LN 2 stated that Resident 361 should have been instructed that the Aspirin was chewable and needed to be chewed first before swallowing to help with absorption. A review of Resident 361's physician's order on 8/23/2023 indicated an order for Aspirin chewable 81 milligram 1 tablet daily. During an interview on 8/25/2023 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2023-08-24 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure 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
Based on observation, interview and record review, the facility failed to ensure residents received foods that retained nutritive value and were served at an appetizing temperature when holding temperatures on the steam table and resident trays were below acceptable range. These failures had the potential to result in decreased food intake and further compromise the nutritional status of medically vulnerable residents in the facility. The facility census was 57. Cross reference F692, F800, F802, F803 Findings: During a kitchen observation and interview on 8/21/23 at 11:48 A.M., with [NAME] 1 (CK1) and the EXC of the steam table, the temperature of lunch meal main entrée Harissa Marinated Chicken was at 153 degrees F. CK1 stated the temperature of the chicken entrée was 165 degrees F right after cooking, but she never re-checks it or logs the final cooking temperature. CK 1 stated she takes the temperature again when the food is on the steam table. The EXC stated CK 1 should have checked to ensure the holding temperature was safe to make sure it was at the steam table. 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 · Dcited before2023-08-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a visitor wore the proper personal protective equipment (PPE) while in contact with one of one sampled resident (Resident 8) on isolation precaution. As a result, there was a potential for spread of infection. Findings: Resident 8 was re-admitted to the facility on [DATE] with diagnoses which included sepsis (blood infection) per the facility's admission Record. On 8/21/23 at 3:12 P.M., a joint observation with Certified Nurse Assistant (CNA) 4 was conducted. Resident 8's room had a sign indicating Resident 8 was on Enhanced Barrier Precautions (everyone must perform hand hygiene and wear gown and gloves for certain activities with the resident). Resident 8's family member was observed going inside the room and sat on the resident's bed without the proper PPE. CNA 4 stated she did not know if Resident 8's family member should be wearing PPE while sitting on the resident's bed. On 8/22/23 at 9:29 A.M., an interview with Resident 8…
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 · D2023-08-24 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview and record review, the facility failed to ensure the kitchen and dry storage room was free of pests. This failure had the potential to contaminate food stored in the kitchen which could lead to widespread foodborne illness. The facility census was 57. Cross- reference F800, F802, F812 Findings: During the initial kitchen tour on 8/21/23 at 8:25 A.M., there were three flies observed flying around the tray line counter area. During a concurrent observation and interview on 8/21/23 at 8:45 A.M., with the Director of Food and Nutrition Service (DFS), in the kitchen, three flies were observed flying around throughout the kitchen. The DFS acknowledged the fruit flies and stated there should be no fruit flies in the kitchen, to prevent cross contamination. The DFS stated he will call the pest control company to come out and look at it. During a concurrent observation and interview on 8/21/23 at 9:40 A.M., with the Executive Chef (EXC), in the kitchen dry storage room, there were four fruit flies observed flying around and an uncovered open 5-quart plastic…
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 before2023-08-23 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a care plan for bladder scanning for one of three residents (Resident 1) when: 1. Resident 1's bladder scanning, and straight catheterization were not done as ordered by the physician. 2. The Licensed Nurses (LN) did not follow their straight catheterization procedure. 3. The facility did not educate their nurses on bladder scanning and straight catheterization. As a result, Resident 1 had a change of condition and was transported to the hospital where he was treated with intravenous (IV) antibiotics for a urinary tract infection, sepsis (blood infection), and urinary retention. Findings: A review of Resident 1's undated facility face sheet was conducted. Resident 1 sustained a fall at home, which resulted in a collar bone fracture. After stay in the hospital the resident was admitted to the facility on [DATE], with diagnoses which also included a history of type 2 diabetes mellitus (condition of having elevated blood sugar), 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 · Fcited before2020-01-16 · tag F0800 — widespreadProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on food and nutrition services observations, staff interviews, and record reviews, the facility failed to ensure effective overall operational systems were established for oversight of the Food and Nutrition Services department. This failure to ensure an effective system for day to day oversight of dietary operations may have placed 84 facility residents at health and nutritional risk of unsafe, unsanitary, and ineffective food practices that could further compromise their health status. (Cross reference F801, F802, F805, F812, F813, and F814) Findings: During the initial kitchen tour and review of operations in the food and nutrition services department from 1/13/20-1/16/20, multiple observations and concurrent interviews were conducted with kitchen staff of the overall food and nutrition services department regarding storage of unlabeled and undated foods, serving unpasteurized eggs unsafely for over a month, and kitchen sanitation. In addition, other deficient practices were identified during the survey in the areas of poor staff competence of food safety, equipment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2020-01-16 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on food and nutrition services observations, staff interviews, and record reviews, the facility failed to ensure effective oversight of dietetic services was provided to the food and nutrition services department, as evidenced by lapses in the delivery of food services associated with tags 800, 802, 803, 805, 812, 813 and 814. This failure to ensure effective oversight of day to day food and nutrition services operations placed 84 facility residents at nutritional risk, and in turn, may have further compromised their health and nutrition status. Findings: During the initial kitchen tour on 1/13/20 at 7:49 A.M., multiple observations and interviews were conducted about food and nutrition services operations with the kitchen staff. The CKS stated he was primarily in charge of ensuring kitchen staff performed their duties such as labeling and dating, dishwashing, and food preparation. On 1/13/20 at 4:20 PM, an interview was conducted with the FSDRD about the cool down process for ambient temperature foods. The FSDRD stated the tuna, chicken, and egg salads were made fresh daily.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2020-01-16 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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 dietary staff were competent to carry out the functions of the food and nutrition services in a safe and sanitary manner when: 1. Wet dish pans were stacked with clean dry pans in the storage area. 2. Dirty serving scoops with brown crusted food residue were stored with clean scoops. 3. Kitchen staff incorrectly demonstrated thermometer calibration. 4. Kitchen staff did not know the cool down process for ambient (room) temperature foods. These failures placed 84 residents at risk of widespread food borne illness. Cross reference 800, 812 Findings: 1. On 1/13/20 at 10:23 A.M., an observation was conducted of the pots and pans dry/clean storage area in the facility's kitchen. Fifteen wet stainless steel pans were stacked inside one another with clean dry pans. At 10:25 A.M., an interview was conducted with DA 1. DA 1 stated the pans should not have been stored wet. CK 16 stated the pans should have been air dried in the rack near the dishwasher before being stored on the dry/clean storage racks. According…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2020-01-16 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure dietary staff followed recipes and menus accurately as printed when: 1. The Daily Spreadsheet Menu for lunch was not followed when a CK served 1 ¾ oz. meat entrée portions instead of 3 oz. portions. 2. The recipe for Sausage Jambalaya was not followed 3. The lunch puree recipe for roast turkey was not followed. These failures resulted in a vulnerable resident population receiving inadequate and/or incorrect nutrition that could compromise their health status. The facility census at the time of survey was 84. Cross reference 800, 801, 805 Findings: 1. On 1/13/20 at 11:25 A.M., an observation and record review was conducted of the lunch service meal tray line. A review of the Daily Spreadsheet Week 5 - Day 2, 2019 December 15 to January 15 Monday 1/13/20 - Lunch Menu included: Regular Portion: Meat Loaf 3 oz., Gravy 1 oz., Yellow [NAME] #8 Scoop, Brussel Sprouts #8 Scoop. Small Portion: Meat Loaf 2 oz., Yellow [NAME] #16 Scoop, Brussel Sprouts #16 Scoop. Mechanical Soft (level 3): Meat Loaf bite sized…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2020-01-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and record review the facility did not ensure food was stored and prepared in safe and sanitary conditions according to professional standards of practice; and kitchen equipment was maintained according to manufacturer's guidelines in the Food and Nutrition Services department when: 1) Unpasteurized eggs were served to residents; 2) The hot water in the hand wash sink at the main kitchen entrance was 80.6 degrees; 3) Unlabeled, undated, and expired food items were stored in kitchen refrigerators and the dry storage area, and in the nursing unit; 4) Pots, pans and dishes were stacked and stored wet; 5) The ice machine had blackish-brownish smudge inside the condenser of the ice making section; 6) Lack of cool-down process for ambient temperature foods; 7) Use of a non-food grade approved chemical to clean food-contact surfaces; 8) [NAME] nets were not worn by five kitchen employees. These deficient practices had the potential to jeopardize the health and safety of 84…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2020-01-16 · tag F0813 — widespreadHave 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 departmental document review, the facility failed to follow the policy on Food from Outside Sources that included provisions on how they will provide safe food handling practices for resident food brought from the outside. This failure had the potential to lead to food borne illnesses in a medically compromised population of 83 out of 84 residents who could consume food. Cross reference 800, 801, 812 Findings: On 1/13/20 at 3:07 P.M., an observation of the refrigerator located in the Sun Room was conducted. The refrigerator had a poster on the outside door that read, Help ensure the safety of our residents, any food items placed in this refrigerator must have a resident name and date present . During an observation inside the refrigerator, there was a plastic lunch box with beets, and a resident's room number but no date. During an interview on 1/15/20 at 8:41 A.M., CNA 27 stated she would put the resident's food brought from outside in the refrigerator in the Sun Room which was designated for resident's food only. She stated she would put…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2020-01-16 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and departmental document review, the facility failed to ensure the appropriate food texture was served to 11 residents who were on mechanical soft diets (a diet with a soft and chopped texture for one who had difficulty chewing or swallowing) when they received a whole meatloaf slice instead of meatloaf chopped into bite size pieces. This deficient practice had the potential for residents to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway) on unchopped food, which could further compromise their medical and nutritional status. Findings: During a lunch meal tray line service observation in the kitchen on 1/13/20 at 11:25 A.M., residents with regular and mechanical soft diets received whole slices of meatloaf. During a concurrent review of facility document titled, Daily Spreadsheet: Monday-1/13/2020, it indicated .meatloaf with bite size pieces for the mechanical soft diet. During an interview and concurrent review of the daily spreadsheet with the FSDRD on 1/15/20 at 5:01 P.M., the FSDRD 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 · E2020-01-16 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and departmental document review, the facility failed to dispose of garbage and refuse properly when a dietary staff did not cover the garbage receptacles with lids when removing trash from the kitchen to the dumpster. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: On 1/13/20 at 3:55 P.M., an observation and interview of the garbage disposal process was conducted with DW 1. DW 1 was preparing to take the garbage bin full of trash bags with tied knots to the dumpster without a lid covering it. DW 1 stated yes when asked if he always transported the garbage bin to the dumpster without a lid. During an interview with DW 1 after the garbage was disposed of, on 1/13/20 at 4:05 P.M., he stated there was only one lid for four garbage bins in the kitchen, and that was why he did not use a lid to cover the garbage bin when taking it to the dumpster. DW 1 further stated the garbage bin with the lid had to stay in the kitchen. 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.
- Potential for harm · Dcited before2020-01-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement correct infection control practices when a licensed nurse did not consistently perform hand hygiene (hand washing or use of hand sanitizer) after glove removal during a gastrostomy tube (g-tube - a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) dressing change on Resident 50. This failure had the potential to transmit infectious agents to Resident 50. Findings: Resident 50 was readmitted to the facility on [DATE], with diagnoses which included malnutrition and diverticulum of the esophagus (a pouch that protrudes outward in a weak portion of the esophageal lining), per the facility's admission Record. Per Resident 50's H & P (History & Physical), dated 11/30/19, Resident 50 was oriented to person, place, and time. On 1/16/20 at 10:49 A.M., an observation of a g-tube dressing change by LN 11 on Resident 50 was conducted. LN 11 performed hand…
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
$9,311 in federal fines across 1 penalty.
- $9,311 — penalty dated 2023-08-23
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to CONTINUING LIFE — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.8 | +0.2 vs chain |
| Health inspection | 4 of 5 | 4.2 | -0.2 vs chain |
| Staffing | 5 of 5 | 4.8 | +0.2 vs chain |
| Quality measures | 5 of 5 | 4.8 | +0.2 vs chain |
The other 5 homes this chain runs (chain average 4.8★, 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 |
|---|---|---|---|---|
| ELWOOD JUSTIN WILSON, III AND JULIE FRANCES WILSON, TRUSTEE OF THE J. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 10% | since 09/29/1999 |
| SPIEKER LIVING TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 65% | since 09/29/1999 |
| ASCHENBRENNER, RICHARD | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 25% | since 09/29/1999 |
| HARNESS, SARAH | Individual | W-2 MANAGING EMPLOYEE | — | since 08/26/2020 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the California Medicaid page for homes that do.
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 555806. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-19, 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.