Canyon Creek Post-Acute
22103 Redwood Road, Castro Valley, CA 94546 · For profit - Limited Liability company · 70 certified beds · (510) 537-8848 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0604), cited Feb 2020
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 fell from 5 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.4% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.8% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.6% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.2% | 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 | 2.2% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 7.5% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.1% | 13.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 91.8% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.8% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 3.1% | 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 | 9.5% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.4% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.8% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 11.8% | 11.2% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.52 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.53 | 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.
47.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 48 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 48.9% 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 45 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 0.44 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% 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 | 47.6%CMS range 35.3–58.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 5.8–14.1 | 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 | 48.9% | 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 | 48.9% | 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 | 46.7% | 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 | 93.6% | 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 | 4.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 3.4–11.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.10 | 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 70 beds and averages 65.2 residents a day — about 93% occupied, or roughly 5 beds typically open. It runs fairly full. 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 4.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.97 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.66 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.97 hrs/resident/day on weekends vs 4.77 on weekdays — 17% thinner on weekends. RN hours go from 1.12 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · G2020-02-27 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record reviews, the facility used bed rails and a position change alarm (bed alarm) for the convenience of staff, to prevent one of 13 residents (Resident 48) from voluntarily leaving his bed, and failed to re-evaluate the ongoing need for use of the restraining devices. This failure resulted in psychological and emotional distress for Resident 48, who was afraid to move around in bed, and had the potential to result in injury if he became entangled in the bed rails, or attempted to climb over the bed rails. Findings: During a review of Resident 48's admission Record, printed 2/25/2020, the admission Record indicated an admission date in January 2019, with included diagnoses of hemiplegia (paralysis of the right side of his body), and generalized muscle weakness. The admission Record indicated Resident 48 had a responsible party (RP) for healthcare decisions. During a review of the Annual Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 1/18/2020, the MDS indicated Resident 48 could understand others, and was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-12 · 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 safely transfer one of three sampled residents (Resident 1) from wheelchair to bed using a Hoyer lift (a mechanical device used to lift and transfer residents with limited mobility), when one of loops/straps of the sling (a supportive fabric, shaped like a hammock which holds the residents. Loops of the sling are attached to the bars of the Hoyer lift) broke, causing Resident 1 to land directly onto the floor. This failure resulted in Resident 1 hitting his left leg onto the bottom bar (base) of Hoyer lift, sustaining a laceration (deep cut in the skin) on left shin, requiring transfer to an acute care hospital for staples (metal or plastic clips applied to close a tear in the skin) and Resident 1 feeling lack of confidence in facility's capabilities. During a review of Resident 1's admission record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of bilateral Osteoarthritis of knee (natural wear and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-12 · tag F0836 — isolatedEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted 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, interview and record review, facility failed to report a fall incident for one of three sampled residents (Resident 1) to the State Agency when Resident 1 was being transferred from wheelchair to bed using a Hoyer lift (a mechanical device used to lift and transfer residents with limited mobility from one surface to the other). One of loops/straps of the sling (a supportive fabric, shaped like a hammock which holds the residents. Loops of the sling are attached to the bars of the Hoyer lift) broke, causing Resident 1 to land directly onto the floor. Resident 1 hit his left leg onto the bottom bar (base) of the Hoyer lift, sustained a laceration (deep cut in the skin) on left shin, requiring transfer to the emergency room of an acute care hospital for staples (metal or plastic clips applied to close a tear in the skin).This failure resulted in facility being non-compliant with unusual occurrence reporting to the State Agency. (Cross Reference F689)During a review of Resident 1's admission…
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 · E2024-11-01 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to complete annual Minimum Data Set (MDS) assessments within 14 calendar days following the Assessment Reference Date (ARD), which affected 3 (Residents #14, #27, and #29) of 3 residents reviewed for annual MDS requirements. Findings included: A facility policy titled, MDS Completion and Submission Timeframes, revised July 2017, revealed, Our facility will conduct and submit resident assessments in accordance with current federal timeframes. The policy revealed, 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The Center for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1 dated October 2024, revealed, The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual…
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 · E2024-11-01 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed within 14 calendar days following the Assessment Reference day (ARD), which affected 3 (Residents #13, #16, and #22) of 3 residents reviewed for quarterly MDS requirements. Findings included: A facility policy titled, MDS Completion and Submission Timeframes, revised July 2017, revealed, Our facility will conduct and submit resident assessments in accordance with current federal timeframes. The policy revealed, 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The Center for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1 dated October 2024, revealed, The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act]…
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 · D2024-11-01 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and a review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) for 1 (Resident #26) of 1 resident reviewed for hospice services. Findings included: On 10/31/2024 at 1:19 PM, the MDS Coordinator stated the facility followed the MDS 3.0 Resident Assessment Instrument manual. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.19.1 dated October 2024 revealed, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD [assessment reference date] must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be…
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 before2024-11-01 · 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
Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement a person-centered comprehensive care plan for 1 (Resident #167) of 21 sampled residents. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022, specified, 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The policy indicated, 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set] assessment. An admission Record indicated the facility admitted Resident #167 on 07/14/2023. According to the admission Record, the resident had a medical history that included diagnoses of vascular…
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 before2024-11-01 · 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, record review, interview, and facility policy review, the facility failed to transcribe and carry out treatment orders for 1 (Resident #42) of 21 sampled residents. Findings included: A facility policy titled, Medication and Treatment Orders, revised 07/2016, revealed no information on transcribing and carrying out written physician orders. An admission Record indicated the facility admitted Resident #42 on 05/14/2024. According to the admission Record, the resident had a medical history that included diagnoses of encephalopathy (disorder of the brain) and non-traumatic intracerebral hemorrhage (brain bleed). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/14/2024, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident required substantial to maximal assistance with lower body dressing and putting on/taking off footwear. Resident #42's care plan, included a focus area revised 06/02/2024, that indicated the resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received showers per shower schedule. Resident 1 received only one shower in more than two weeks long stay at the facility. This failure placed Resident 1 at risk for lack of cleanliness and comfort. Findings: During a review of Resident 1 ' s admission Record, printed on 3/27/24, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and discharged from the facility on 2/09/24. During a record review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 2/13/24, the MDS assessment Section GG - Functional Abilities and Goals showed Resident 1 needed a setup or clean-up assistance (the helper assists prior to or following the activity) for shower. During a review of Resident 1 ' s Activities of Daily Living (ADL) Care plan dated 3/27/24, the care plan showed Resident 1 had an ADL self-care performance deficit and was at high risk 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 · D2023-09-20 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer Heparin Sodium Injection Solution 5000 Unit/ml (a medication used to prevent and treat blood clots and other clotting-related conditions) for one (Resident 1) of four sampled residents. This failure resulted in Resident 1 not receiving medications as per physician's orders and placing Resident 1 at high risk for developing a blood clot. Findings: During a review of Resident 1's admission record, printed on 9/20/23, the admission record indicated Resident 1 was originally admitted to the facility on [DATE]. During a review of Resident 1's Physician orders dated 8/23/23, the Physician orders indicated to administer Heparin Sodium (Porcine) Injection Solution 5000 Unit/ml subcutaneously (injected into the tissue between the skin and muscle) every 12 hours (9:00 a.m. and 9:00 p.m.) for DVT (Deep vein thrombosis -a condition in which the blood clots form in veins located deep inside the body, usually in the thigh or lower legs) Prophylaxis.…
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 · D2021-07-23 · 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
Based on interviews and record review, the facility failed to ensure one (Resident 20) of 12 sampled residents were free from unnecessary drugs when the interdisciplinary team did not evaluate Resident 20's use of Quetiapine {(seroquel) an antipsychotic drug} for appropriateness, adequate clinical rational and indication for continued usage. This failure had the potential for Resident 20 to receive unnecessary drugs and suffer adverse medication side effects. Findings: During a review of Resident 20's Physician Orders (PO) dated 7/9/20, the PO indicated Quetiapine (Seroquel) 50 mg(milligrams) tablet by mouth in the evening for Bipolar (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). During a review of the Annual Minimum Data Set - (MDS - an assessment screening tool used to guide care), dated 5/9/21, indicated Resident 20's Basic Interview of mental status (BIMS) score was 01 meaning poor cognitive impairment. Resident 20 had no delusions or hallucinations and had not exhibited wandering. Resident 20's diagnoses included Alzheimer's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · D2021-07-23 · tag F0801 — isolatedEmploy 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 interviews and record review the facility failed to ensure the person designated to serve as Dietary Supervisor (DS) of food and nutrition services had the federal and/or state educational qualifications for the position. This deficient practice had the potential for lack of competency and skill set necessary to carry out all the functions of the food and nutrition services. Findings: During an interview with DS on 7/20/21, at 9:06 a.m., (DS) stated she did not have a dietary supervisor certificate. DS stated she was enrolled in a dietary program. DS stated the Registered Dietitian (RD) visits the facility twice a month to complete residents' nutrition assessments, review weekly weights and inspects kitchen sanitation. During an interview with Registered Dietician (RD) on 7/20/21, at 11:27 a.m., RD stated she was not full time staff at the facility. RD stated she visits the facility twice a month as a contracted Dietician Consultant. RD stated her responsibilities included review of admissions, significant weight changes, and inspect kitchen sanitation During an interview…
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 · D2021-07-23 · 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, interviews and record review the facility failed to ensure food was served at a safe temperature when during lunch tray line curry lemon chicken was not served at appropriate temperature. This deficient practice placed residents at risk of non appetizing food temperature and a potential for food borne illness. Findings: During tray line observation on 7/20/21, at 11:08 a.m., the [NAME] (CK) in the presence of the Dietary Supervisor (DS) and Registered Dietician (RD) prepared and served for lunch mashed potato with gravy, curry chicken and puree chicken . The curry chicken's temperature was 146 -151 degrees Fahrenheit (F). During an interview on 7/20/21, at 11:27 a.m., the RD stated the chicken temperature of 145-151 degree (F) could be served but stated the chicken may be cold by the time it got to the resident. During an interview on 7/20/21, at 11:39 a.m., CK stated he had adjusted the oven to 180 to 200 degrees when cooking the chicken and he was sorry. During an interview on 7/21/21, at 12:08 p.m., DS stated the CK adjusted the oven down to 180 degrees, DS…
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 before2021-07-23 · 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 — the official record, unedited, may be distressing
Based on observation, interviews and record review, the facility failed to store and prepare food under sanitary conditions when the hand washing sink had a pinkish brownish substance around the faucets and the trash cart had a brownish substance around the open area. These failures had the potential to result in food borne illnesses. Findings: During the initial tour of the kitchen on 7/19/21, at 9:33 a.m., accompanied by the Dietary Supervisor (DS), the hand washing sink was observed with pinkish brownish substance around the faucet and one trash can with brownish substance around the open area. During an interview on 7/19/21, at 9:33 a.m., DS stated the pinkish material accumulated around the faucet may be dirt or mold. During an interview on 7/21/21, at 12:08 p.m., DS stated dietary staff are expected to keep the hand washing sink and other items in the kitchen clean, but staff are not particularly assigned to clean the hand washing sink.
- Potential for harm · Ecited before2020-02-27 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 safe food practices when: 1. Unpasteurized eggs were used to make soft-yolk, fried eggs for residents. 2. Freezer 2 had a temperature above zero degrees Fahrenheit (F): bread, waffles, and bread rolls inside the freezer were not solidly frozen; ice cream cups were liquified. 3. The facility ice machine had a white residue on the air intake filter. 4. The following items were stored unlabeled and undated, as follows: Refrigerator 2 had one 12-ounce jar of pickles with an unsealed lid; Freezer 1 had one unsealed box of 48 rainbow sherbet cups, and two individual 4-ounce cups of vanilla ice cream; Freezer 2 had one plastic bag of frozen enchiladas, sealed by knotting the plastic bag; four frozen bags of peas; one 32-ounce bag of frozen cauliflower; and five 40-ounce bags of frozen brussel sprouts; Refrigerator 1 had one tray of four-ounce plastic glasses of both water and juice, and four trays of four-ounce plastic glasses containing milk. These failures placed all residents who ate/drank these products,…
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 · E2020-02-27 · 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
Based on observation, interview, and record review, the facility failed to ensure staff followed policy and procedures for hand hygiene for seven of 14 sampled residents (Residents 26, 35, 18, 30, 101, 2, and 49). The failure of Certified Nursing Assistant 1 (CNA) to perform required hand hygiene during the passing and setting up of the residents' lunch trays had the potential to result in illness, and the spread of illness for Residents 26, 35, 18, 30, 101, 2, and 49. Findings: During a continuous observation on 2/24/2020, at 12:10 p.m., in the dining area, CNA 1 pushed the lunch tray cart into the dining area, and without performing hand hygiene (HH), picked up a lunch tray, delivered it to Resident 26, and removed the plate cover. CNA 1 returned to the meal cart, and without performing HH, picked up a lunch tray, delivered it to Resident 35, and removed the plate cover. CNA 1 returned to the tray cart, and without performing HH, picked up a lunch tray, and delivered it to Resident 18. CNA 1 removed Resident 18's plate cover, and the covers for the milk and water glasses. Without…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-02-27 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility staff failed to close the privacy curtains around one (Resident 14) of 14 sampled residents' beds during care provision. This failure resulted in the exposure of Resident 14's genitals to her roommate, and passers-by in the hallway. This failure had the potential to result in emotional distress for Resident 14. Findings: During a review of Resident 14's, admission Record, on 2/25/2020, the Record indicated the facility admitted Resident 14 in 2018, with included diagnoses of generalized muscle weakness, with paralysis of the right side. The Record also indicated Resident 14 had a responsible party for healthcare decisions. During a review of Resident 14's, Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/28/18, the MDS indicated Resident 14 was totally dependent on assistance from one person for bed mobility, eating, toileting and personal hygiene. The MDS indicated Resident 14 was non-English speaking, and was severely impaired in the ability of daily decision-making. During an observation 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 · D2020-02-27 · 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 observation, interview, and record review, facility staff failed to fully inform the responsible party (RP) of the current dental health status of one of 13 sampled residents (Resident 25). This failure had the potential to result in Resident 25 developing an oral infection or gum disease, which could negatively impact her general health. Findings: During a record review on 2/25/20 of Resident 25's admission Record, printed 2/25/2020, the admission Record indicated Resident had an original admission date in 2008. The Record indicated Resident 25 had diagnoses which included generalized muscle weakness, and brain damage. The Record also indicated Resident 25 had a responsible party for healthcare decisions. During a review of Resident 25's Minimum Data Set (MDS, an assessment tool used to guide care), dated 10/26/19, the MDS indicated Resident 25 had severe impairment of her ability for daily decision making, and was totally dependent on assistance from one person for eating, toileting, and hygiene. During a review of Resident 25's care plan for oral/dental health concerns,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-02-27 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the correct documentation for refusal of treatment was present in the medical record of one of eight sampled residents (Resident 46). The facility failure to change the medical record, to reflect a change in the status of Resident 46's wishes for treatment in the event of a medical emergency, had the potential to result in the undesired life sustaining treatment of cardiopulmonary resuscitation. (CPR, an emergency procedure that combines chest compressions with artificial ventilation (mouth to mouth breathing, or assisted breathing through a tube inserted into the throat.) Findings: During a review of Resident 46's Social Work Progress Notes, dated [DATE], the Notes indicated Resident 46 had been re-admitted from an acute care hospital with included diagnoses of dementia (a progressive deterioration of the brain functions affecting the abilities to remember, think clearly, communicate, and perform daily activities), and kidney failure. 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 · D2020-02-27 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 provide notification of the need to alter the dietary treatment for one of 14 residents (Resident 100). The failure to inform the physician of Resident 100's refusal, for four days, to complete the infusion of the ordered liquid tube feeding (provision of nutrition and hydration through a tube inserted into the stomach, for residents unable to orally ingest sufficient quantities to support daily needs), had the potential to result in weight loss, body chemistry imbalance, and negatively impact general health status. Findings: During a review of Resident 100's admission Record, printed 2/24/2020, the admission Record indicated Resident 100 was admitted to the facility the previous week, with an included diagnosis of difficulty swallowing. The admission Record indicated Resident 100 was her own responsible party. During a review of Resident 100's Medication Review Report (MRR), dated 2/20/2020, the MRR indicated Resident 100 had a physician order dated 2/19/2020 for Resident 100 to receive a daily volume 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 · Dcited before2020-02-27 · 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, for two of 14 sampled residents (Resident 7 and Resident 32), the facility failed to develop and implement a comprehensive care plan to address: 1. Resident 7's need for assistance with activities of daily living (ADL, the activities of dressing, eating, hygiene, toileting, mobility, ambulation, and bathing), and use of psychotropic medications (medication used to modify mental and/or emotional states). 2. Resident 32's need for assistance with ADLs, and use of psychotropic medications. These deficient practices had the potential to result in Resident 7 and Resident 32 not receiving the appropriate medical interventions necessary to meet the residents' nursing care needs. Findings: 1. During a review of Resident 7's admission Record, printed February 26, 2020, the admission Record indicated Resident 7 was admitted to the facility in July 2019 with diagnoses that included Alzheimer's Disease (a brain disorder that affects the ability to remember, think clearly, communicate,…
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 before2020-02-27 · 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, for one of 14 sampled residents (Resident 100), the facility failed to provide nursing services that met professional standards of quality when Resident 100 refused to receive the complete ordered dose of tube feedings (medical device used to provide nutrition when a person has trouble eating) for 3 days, and the medical doctor (MD) had not even been notified. This deficient practice resulted in Resident 100 not receiving adequate nutrition through enteral feeding. Findings: During a review of Resident 100's admission Record, dated February 24, 2020, the admission Record indicated, Resident 100 was admitted to the facility on [DATE] with diagnoses of Schizoaffective Disorder (a chronic mental health condition). The admission Record indicated, Resident 100 is self-responsible. During a review of Resident 100's Medication Review Report, dated 2/20/2020, the Medication Review Report indicated, Resident 32 had an order on 2/19/20 that read, Enteral Feed Order two times a day…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-02-27 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, facility staff did not develop and implement a communication plan for a non-English speaker, for one of 13 sampled residents (Resident 14). For Resident 14, this failure had the potential to result in emotional distress, and unmet care needs. Findings: During a review of Resident 14's admission Record, printed on 2/25/2020, the Record indicated the facility admitted Resident 14 in 2018, with included diagnoses of generalized muscle weakness, with paralysis of the right side. The Record also indicated her primary language was Chinese, and Resident 14 had a responsible party for healthcare decisions. During a review of Resident 14's, Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/28/18, the MDS indicated Resident 14 was totally dependent on assistance from one person for bed mobility, eating, toileting and personal hygiene. The MDS indicated Resident 14 was non-English speaking, had unclear speech, was rarely/never understood, but sometimes could understand others. During a review of Resident 14's care plan 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.
- No harm found · Bcited before2024-11-01 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
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, observation, facility document review, and facility policy review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) of 35 resident rooms. Findings included: A facility policy titled, Bedrooms, revised 05/2017, indicated, All residents are provided with clean, comfortable and safe bedrooms that meet federal and state requirements. The policy revealed, 2. Bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms. A Client Accommodations Analysis document dated 10/28/2024 revealed room [ROOM NUMBER] had a total floor area that measured 154 sq ft, and two beds occupied the room, which yielded 77 sq ft per resident. Further review revealed room [ROOM NUMBER] had a total floor area that measured 154 sq ft, and two beds occupied the room, which yielded 77 sq ft per resident. During an observation on 10/30/2024 at 9:11 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2021-07-23 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
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 and interviews, the facility had two resident (Rt) rooms (Rooms A and B) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents' belongings. Findings: During an observation on 7/22/21, at 8:38 a.m., the following rooms and corresponding square footage (sq. ft) per bed were identified: Room Activity Room Size Floor Area A Rt room [ROOM NUMBER].5 sq. ft 79.08 sq. ft/bed B Rt room [ROOM NUMBER].52 sq ft 79.56 sq. ft/bed During random observations of care and services from 7/19/21, to 7/22/21, there was sufficient space for the provision of care for the residents in all rooms. There were no heavy equipment kept in the rooms that might interfere with residents care. Each resident had personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings There were no negative…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2020-02-27 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
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 and interview, the facility had two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) with two beds each that provided less than 80 square (sq.) feet (ft.) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the resident belongings. Findings: During an observation on 2/25/20 at 10:30 a.m., the following rooms and corresponding square footage per bed were identified: Resident room [ROOM NUMBER] (two-bed room) was 11 ft. by 14.5 ft. Each resident's personal space was 70.08 sq. ft. Resident room [ROOM NUMBER] (two-bed room) was 10.8 ft. by 14.4 ft. Each resident's personal space was 70.56 sq. ft. During random observations of care and services from 2/24/20-2/27/20, there was sufficient space for the provision of care for the residents in room [ROOM NUMBER] and room [ROOM NUMBER]. There was no heavy equipment kept in the rooms that might interfere…
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 LINKS HEALTHCARE GROUP — 32 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 | 4 of 5 | 2.9 | +1.1 vs chain |
| Health inspection | 4 of 5 | 2.7 | +1.3 vs chain |
| Staffing | 4 of 5 | 2.7 | +1.3 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 31 homes this chain runs (chain average 2.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| FORBRIGHT BANK | Organization | 5% OR GREATER SECURITY INTEREST | since 05/01/2023 |
| RODRIGUEZ, CURTIS | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| TILFORD, TOBY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| LINKS HEALTHCARE GROUP LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| LINKS SUPPORT SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| BEARDSLEY, MARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| BERNHOLZ, VICTORIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| CARTER, MELISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| CORPUZ, ERIC | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| DHUGGA, GURPREET | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| FROJELIN, ANTONETTE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| SINGH, JERICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
CMS files one row per role, so the 25 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
3 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.
About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $248K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555341. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-01, 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 →
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