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Valley Pointe Nursing & Rehabilitation Center

20090 Stanton Avenue, Castro Valley, CA 94546 · For profit - Limited Liability company · 50 certified beds · (510) 538-8464 Medicare & Medicaid certified

Call the home — (510) 538-8464 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation$10,033 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,033 in federal fines (most recent 2024-01-26)
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
20126 Stanton Ave, #201 · (510) 581-2559 · Call to confirm hours
Pharmacy
20353 Lake Chabot Rd · (510) 537-9402 · Call to confirm hours
Grocery
3550 Somerset Ave · (510) 582-6625 · Call to confirm hours
Park
Ebmud Lands · Typically dawn to dusk

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 4 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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.4%10.2%15.4%better
Long-stay residents who lose too much weight4.6%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection1.0%1.2%2.0%better
Long-stay residents with depressive symptoms14.5%7.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%1.6%3.3%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication3.3%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers0.7%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control8.8%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 table0.0%12.0%17.1%check this — see note marked star below the table
Short-stay residents who newly got an antipsychotic medication1.2%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%93.2%79.4%better
Short-stay residents rehospitalized after admission16.3%23.0%22.6%better
Short-stay residents with an outpatient ER visit17.8%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.232.251.67better
Long-stay outpatient ER visits per 1,000 resident days3.271.571.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

56.7% 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 274 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.7%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
41.2%U.S. median 56.6%
Met the expected recovery
0.69U.S. median 0.31
Therapy hours / resident / day
0.47hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 41.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 97 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 0.69 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.7%CMS range 49.0–62.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 7.2–13.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge41.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge33.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge38.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge99.0%98.7%Oct 2024–Sep 2025CMS 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 stay1.2%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 4.7–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.341.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.56
RN hours/ resident / day
1.27
LPN hours/ resident / day
2.34
Aide hours/ resident / day
4.17
Total nurse hours/ resident / day
0.60
RN hoursweekends
35.2%
Total nursing turnover
64.3%
RN turnover

How full it usually is: this home is certified for 50 beds and averages 47.5 residents a day — about 95% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.17 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.34 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.78 hrs/resident/day on weekends vs 4.33 on weekdays — 13% thinner on weekends. RN hours go from 0.54 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

11
deficiencies at the latest standard inspection (2026-05-01)
7
at the previous standard inspection (2025-06-20)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · Gcited before2024-01-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 ensure adequate supervision was provided to two of 20 sampled residents (Residents 148 and 23) as follows. 1 a). Resident 148, identified as a high risk for falls, was not provided with a sitter after the resident was deemed needing one-one supervision to prevent further falls. This resulted in Resident 148 sustaining another serious fall injuries (a comminuted fracture that is broken in at least two pieces caused by trauma to the right clavicle (collarbone), and a subdural hematoma (condition when a pool of blood develops between the brain and its covering, usually from head trauma). b). Resident 148 eloped on 12/7/23 and was later found in a hospital emergency department (ED). This episode of elopement was not reported by the facility to the department. 2. The facility did not apply the ordered bed pad alarm (alerts staff of position movement out of bed) for Resident 23. For Resident 23, this had the potential for fall injuries.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-01 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure water temperatures were maintained within a safe range for five of eight sampled residents (Residents 1, 40, 45, 59, and 60) when two Jack-and-[NAME] bathrooms (shared bathrooms with two separate entrances from two different rooms) had faucet sink water temperatures exceeding 120 (degrees) Fahrenheit (a temperature scale used to measure how cold or hot something is).This failure placed Residents 1, 40, 45, 59, and 60 at risk for scald (type of burn caused by contact with hot liquids or steam) injuries.During a record review of Resident 1's admission Record (AR), printed on 4/28/26, the AR indicated Resident 1 was admitted to the facility in March 2026 with diagnosis of Alzheimer's disease (a progressive, irreversible brain disorder that destroys memory and cognitive functions)During a record review of Resident 40's AR, printed on 4/30/26, the AR indicated Resident 40 was admitted to the facility in May 2024 with diagnosis of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-01 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 did not demonstrate competency in dialysis care to provide services for four (Resident 22, Resident 32, Resident 66, and Resident 3) of four dialysis-dependent (dialysis, a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys fail) residents in accordance with the facility assessment.This failure did not ensure the licensed nurses' competency and skills were met to provide safe care which could potentially result in dialysis-dependent residents receiving inappropriate care and services.A review of Resident 22's admission Record printed 5/1/26 indicated resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (renal failure), diabetes mellitus (high blood sugar), and dependence on renal dialysis, with a port catheter (Port-a-Cath, a dialysis access site surgically placed fully under the skin that cannot be assessed for bruit [swishing sound] and thrill [a buzzing…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-01 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility did not ensure medications were administered in accordance with physician orders for two of two sampled residents (Resident 1 and Resident 5) when licensed nursing staff administered medications, including anticoagulant (commonly known as blood thinners, are substances or medications that prevent or reduce the body's ability to form blood clots) and antiplatelet (medications that prevent blood cells called platelets from sticking together and clumping) medications, approximately 90 minutes earlier than physician-ordered administration times and subsequently documented inaccurate administration times that did not reflect the actual time of medication administration.This failure placed Resident 1 and Resident 5 at risk for clinically significant medication errors, reduced therapeutic effectiveness and adverse drug reactions including bleeding complications.During a record review of Resident 1's admission Record (AR), printed on 4/28/26, the AR indicated Resident 1 was admitted to the facility in March 2026 with…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-01 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices with census of 47 when:1. Multiple medications with different routes of administration (a way by which a drug is taken into the body) were stored together in medication refrigerator and Medication Cart #1.2. Four pre-refilled COVID-19 (contagious respiratory illness) vaccine (medication that helps body build immunity against a disease) syringes were stored in the medication refrigerator without the original container and without labeling.These failed practices had the potential for medication identification errors, contamination, improper medication use, and administration errors. During a record review of Resident 1's admission Record (AR) printed on 4/28/26, the AR indicated Resident 1 was admitted to the facility in March 2026 with diagnoses including metabolic encephalopathy (acute brain dysfunction caused by chemical imbalances) and glaucoma (an eye condition that damages the optic nerve).During a record review of Resident 2's AR printed on 4/29/26,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed when:The cool down process for time, temperature control for safety (TCS) food, food that needs to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored. 2. Facial hair was not covered. 3. Meal preparation equipment was not air dried. 4. The food preparation sink did not have backflow prevention. 5. Opened food in resident refrigerator was not labeled and dated. 6. The kitchen environment was not clean or in good working order. 7. The test strips used to monitor cleaning solution levels were expired. These failures posed the risk for foodborne illnesses in a highly susceptible resident population of 45 facility residents who received food prepared in the kitchen. 1.During a concurrent observation and interview on 04/27/2026 at 9:42 AM with Registered Dietitian (RD) in the kitchen, tuna salad and egg salad labeled with a preparation date of 04/26/2026 was found in the reach in refrigerator. RD…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-01 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure proper disposal and containment of refuse. The outdoor dumpster located near the facility was observed with its lid propped open due to an overflow of trash inside the container. Additional refuse, including dirty gloves and food waste, were scattered on the ground beneath and around the bin. The recycling area also contained overflowed cardboard boxes and other recyclables placed on the ground next to the recycling container.These deficient practices had the potential to attract rodents and insects and cross-contamination of food.During a concurrent interview and observation on 4/27/26 at 2:33 p.m., of the outdoor dumpster area with the Registered Dietitian (RD), the dumpster lid was observed propped open due to an overflow of trash inside the container, and a strong foul odor was present. Additional refuse, including dirty gloves and food waste were scattered on the ground beneath and around the bin. The recycling dumpster was also observed with an overflow of cardboard boxes and other recyclables placed on the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-01 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 implement their infection prevention and control policies and procedures when:1. For one (Residents 45) of three sampled residents, resident's unbagged continuous positive airway pressure (CPAP, a machine that uses a mask to supply air pressure in keeping the airway open) mask and nebulizer (used to deliver medication in a fine mist over the nose and mouth) mask were left exposed to air.2. For one (Residents 59) of three sampled residents, Resident 59's unbagged nasal cannula was found on the floor.3. For one (Residents 3) of three sampled residents, Licensed Nurse performed direct patient care without wearing the proper personal protective equipment (PPEs, wearable gear to protect workers from illness or infection) upon entrance to a room on Enhanced Barrier Precaution (EBP, an infection control strategy to reduce risk of multidrug-resistant organisms).For Residents 45, 59, and 3, these deficient practices had the potential to result in the spread of infection.4. Housekeeping (Hskg)/Laundry Staff belongings…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-01 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services consistent with professional standards for one of five sampled residents (Resident 72) on oxygen (O2, a prescription drug used to treat low blood oxygen level) therapy when the facility did not follow physician orders for oxygen administration. This failure resulted in Resident 72 receiving more oxygen than ordered, which placed the resident at risk for serious harm.A review of Resident 72's admission Records, printed on 4/28/26, indicated resident was admitted to the facility on [DATE] with diagnoses that included multiple rib fractures and history of fall.A review of Resident 72's Care Plan, indicated a focus titled, Oxygen: Resident requires the use of oxygen (continuous) related to shortness of breath due to (d/t) .rib fractures. Interventions included, Administer oxygen at two liters (2L) via nasal cannula.Monitor and report signs of hypoxia (when the body is not getting enough…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-01 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review, the facility failed to provide pharmaceutical services and procedures to one sampled resident (Resident 49) to ensure the timely acquisition, dispensing, and administration of routine medications when Resident 49's inhalation medication was not available during medication administration.This failure had the potential to result in delayed or missed medication administration and had the risks for increased exacerbation of respiratory conditions.During a record review of Resident 49's admission Record (AR) printed on 4/30/26, the AR indicated Resident 49 was admitted to the facility in February 2026 with diagnoses including nontraumatic intracerebral hemorrhage (bleeding into brain tissue) and cognitive communication deficit (difficulty communicating because of thinking skills).During a record review of Resident 49's Medication Administration Record (MAR) dated 4/1/26 to 4/30/26, the MAR indicated Resident 49 had a physician order dated 2/14/26 for Breo Ellipta (reduces inflammation in the lungs and relaxes and opens the airways to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-01 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 49) received medications as ordered without an error. The facility's medication pass observation during the survey resulted in two errors out of 31 opportunities and indicated a medication error rate of 6.45 percent (%).This failure placed Resident 49 at risk for not getting the full therapeutic effect of their prescribed medications and had the potential to result in adverse health outcomes including, worsening of respiratory symptoms, increased risk for blood clot (thick, viscous, or semi-solid lump formed when blood thickens) formation and stroke (a medical emergency caused by a sudden interruption of blood flow to the brain or a ruptured blood vessel, leading to rapid brain cell death).During a record review of Resident 49's admission Record (AR) printed on 4/30/26, the AR indicated Resident 49 was admitted to the facility in February 2026 with diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) following nontraumatic intracerebral…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Dcited before2026-05-01 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in safe operating conditions when:The ice machine was not sanitized as per the manufacturer's instructions.The facility failed to follow the manufacturer's required maintenance and operational guidelines for the equipment. This failure had the potential to prevent the equipment from functioning as intended, which could have resulted in the gradual degradation of its internal components and compromised its reliability and safety.During interview and observation on 04/27/2026 at 3:05 PM, the Maintenance Supervisor (MS) was observed utilizing Clorox bleach-type solution for cleaning the ice machine. This method does not align with the manufacturer's recommendations, which specify the use of a Montauk-type descaler solution. While the ice machine appeared to be clean and in good condition following a professional cleaning the day before, the use of an improper cleaning chemical raises concerns about the potential degradation of the machine'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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-20 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a safe, comfortable and homelike environment when one of four sampled resident room (Resident 102) had dust covering the ceiling air vent, scattered areas of peeling paint on the wall, and task lighting cord was not long enough for resident to reach. This failure had the potential to compromise Resident 102's health by exacerbating (making something that is already bad even worse) the respiratory symptoms and decreasing the resident's autonomy (the capacity to decide for oneself and pursue that course of action) . Findings: A review of Resident 102's face sheet dated 6/17/25, indicated Resident 102 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure (a severe condition where the respiratory system cannot adequately oxygenate the blood, leading to low blood oxygen levels and potentially affecting tissue oxygenation), chronic obstructive pulmonary disease with acute exacerbation (COPD, a type of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-20 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling when: 1. Resident 5's Latanoprost was stored beyond the use by date in the medication cart (Latanoprost is an eyedrop used to treat a condition in which increased pressure in the eye can lead to gradual loss of vision). 2. Six Retacrit medication vials which belonged to discharged resident 261 were found in medication room refrigerator (Retacrit is a medication used to treat a blood disorder caused by a kidney disease). 3. One opened unlabeled Lispro insulin vial was found in medication room refrigerator (Lispro insulin is a fast-acting injection medication that helps treat high blood sugar in the body). 4. Resident 11 did not have an accurate medication card label for Metoclopramide that matched the physician's order. (Metoclopramide is a medication that helps in nausea and vomiting). 5. Eighteen whole loose pills were found scattered underneath the medication cards in the medication cart. 6.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-20 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served in a safe and sanitary manner, when food preparation utensils and equipment were not cleaned and/or maintained in good condition. These failures placed 44 residents who received food from the kitchen at risk for food borne illnesses or illnesses related to use of contaminated utensils. Findings: During an observation and concurrent interview with the Registered Dietitian (RD) on 6/17/25 at 3:21 p.m., the following were observed: 1. A two-slot toaster situated on an open shelf across the stove, had hardened, black, burned particles which resembled bread crumbs on its surface, and had a significant amount of the same substance between its slots and its bottom. 2. A knife stored in a knife rack attached to the wall adjacent to the stove had a silicone coating on its handle which was warped, jagged and dented. 3. An industrial can opener mounted on a kitchen preparation table had black/dark brown sticky substance on its blade and on the crevices of the feed wheel.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-20 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 follow infection control procedures when the specimen refrigerator (a specimen refrigerator is a specialized cooling unit used to store various biological samples collected from patients, such as urine, stool, blood, or tissue) was observed to be stored in the medication storage room. These failures had the potential to contaminate the residents' medications and for the spread of infectious disease. Findings: During a concurrent observation and interview on 6/16/25, at 11:28 a.m., with Licensed Vocational Nurse (LVN) 1 , in the facility medication storage room, the specimen refrigerator was observed to be stored below the medication refrigerator (a medication refrigerator is a specialized appliance specifically designed and used for storing temperature-sensitive medications). Observed inside the specimen refrigerator were a stool specimen in a container and urine specimen samples. LVN 1 stated the specimen refrigerator have been in the medication storage room for a long time, but she could not remember the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-20 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility failed to provide meal assistance in a dignified manner to Resident 254. This failure resulted in an undignified and disrespectful treatment of Resident 254 which could potentially result in more serious negative outcomes. Findings: During a meal observation on 6/16/25 at 12:29 p.m., in the dining room, Resident 254 was sitting in a wheelchair and Occupational Therapist (OT) 1 was standing beside the resident. OT 1 began to assist and spoon feed Resident 254 her lunch meal. On interview, OT 1 stated, when she fed the residents, she would stand sometimes and would sometimes be seated which depended on the cues that she had to give to the residents while assisting the residents with their meals. A review of Resident 254's admission record, dated 6/18/25, indicated that the resident was admitted on [DATE] with diagnoses which included dysphagia (difficulty swallowing), hemiplegia (paralysis that affects only one side of the body), and dementia (loss of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 provide a safe environment for one of 13 sampled residents (Resident 3) who was not assessed for smoking. This deficient practice created a potential risk for burn injury to Resident 3 while smoking and placed other residents' lives in danger. Findings: During a review of Resident 3's admission record, it indicated that resident was admitted on [DATE] with diagnoses that included weakness and need for assistance with personal care. During an interview on 6/17/25 at 3:40 p.m., Resident 3 stated he stepped out of the facility to smoke a cigarette accompanied by staff two times a day every day. During a joint interview on 6/17/25 at 3:28 p.m. with Registered Nurse (RN) 1 and RN 2 , RN 1 and RN 2 both stated that Resident 3 was a cigarette smoker, and the facility did not have a smoking schedule for Resident 3 . RN 1 stated during day shift (7:00 a.m. to 3:30 p.m.) which she worked, Resident 3 went out to smoke in the mornings once a day 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-01-26 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    During an observation on 1/24/24 at 7:20 a.m., the entry door was open to the shared room (Room B) of Resident 28 and Resident 149. On the wall adjacent to Room B was a posted sign which indicated, Stop Red Room. During an observation on 1/24/24 at 7:50 a.m., Certified Nursing Assistant 5 (CNA 5), Registered Nurse 2 (RN 2) and Certified Nursing Assistant 3 (CNA 3) were passing the breakfast meal trays from the meal tray delivery cart to resident rooms. RN 2, CNA 3, and CNA 5 entered the Room B without donning PPE. RN 2, CNA 3, and CNA 5 exited Room B and did not perform hand hygiene. During an interview on 1/24/24 at 7:53 a.m., with Infection Preventionist/Director of Staff Development (IP/DSD), IP/DSD stated the residents in Room B (Resident 28 and Resident 149) both had COVID. IP/DSD stated the door to their shared room should be kept closed at all times. IP/DSD stated when the door was not closed there was a risk for the spread of infection to other residents. The facility policy and procedure titled, Coronavirus Disease (COVID-19), revised 3/1/2023, indicated, For a resident…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-01-26 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews, the facility failed to maintain the facility's ventilation system in a safe operating condition when the heating, vacuum, air conditioning (HVAC) in the broiler room did not have the required MERV 13 filtration recommended for healthcare settings during a COVID-19 outbreak. (MERV filters reduces up to 75% of large airborne particles including: dust and lint, dust mite debris, pollen, per dander, mold spores, bacteria and virus carriers). This failure had the potential to spread airborne infections during COVID-19 outbreak. Findings: During an observation and concurrent interview on 1/25/24 at 8:09 a.m., accompanied by Maintenance Supervisor (MS), the filter from the HVAC system in the broiler had black dust in the filter spaces dated 9/6/23. MS stated he was aware the facility had a COVID outbreak. but had not checked the HVAC system. MS stated he had not checked the HVAC system or changed the filters. MS stated the filter in the HVAC is not the required filter for virus, bacteria filtration. MS further stated the MERV 8 filter was the…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor 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 facilitate Advance Directives (a legal document that provide instructions for medical care that go into effect if you cannot communicate your own wishes) status, including the right to accept or refuse medical/surgical treatment for five out of five residents upon admission. These failures resulted in Residents 26, 32, 94, 192, and 193 or their responsible party (RP) not being aware of their right to participate in their medical and surgical care. Findings: During a review of Resident 26's admission Record, Resident 26 was admitted to the facility on [DATE]. During a review of Resident 32's admission Record, Resident 32 was admitted to the facility on [DATE]. During a review of Resident 192's admission Record printed on 01/23/24, the record indicated Resident 192 was admitted to the facility on [DATE]. During a review of Resident 193's admission Record, Resident 193 was admitted to the facility on [DATE]. During a concurrent interview and record review…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a baseline care plan within 48 hours, and provide three (Residents 18, 93, and 94) of 20 sampled residents and their representatives with a summary of the baseline care plan. This failure did not ensure the minimum healthcare information to plan care for each resident upon admission and provide the baseline care plan summary indicating residents and representatives were informed. Findings: Review of the admission Record, indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses that included sepsis (a life-threatening complication of an infection). Review of the Resident 18's baseline care plan, dated 12/11/19, the care plan indicated, facility did not complete Resident 18's baseline care plan within 48 hours and provide Resident 18 and their representatives with a summary of the baseline care plan. Review of the admission Record indicated Resident 93 was admitted to the facility on [DATE] with diagnoses that included…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months when; - Five of five Certified Nursing Assistants' (CNAs) annual performance evaluations were not completed. - Three of five licensed nursing staff did not receive ongoing in-service training for the use of personal protective equipment (PPE) and isolation precautions during a COVID-19 outbreak. This failure had the potential for the spread of infection due to unknowledgeable staff about managing and caring for residents during a COVID 19 outbreak. Findings: During a review of the employee files on 1/24/24 at 12:29 p.m., in the presence of the Infection Preventionist/Director of Staff Development (IP/DSD), the Certified Nursing Assistants'(CNAs) annual performance evaluations were not completed for CNA 6 hired 4/2/95, CNA 7 hired 2/7/11, CNA 8 hired 2/11/22, CNA 9 hired 11/6/22, and CNA 10 hired 12/1/21. During a review of the in-service training records titled, COVID Outbreak, dated 12/5/23, on 1/24/23 at 12:29 p.m., in the presence of the…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-26 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to label medications and properly dispose of expired medications for two of 20 sampled residents (Resident 17 and Resident 12), for medication cart one: 1. Resident 17's three open inhalers (devise used for inhaling medicine into the lungs) were found with no open date labels. 2. Resident 12's one bottle of acetaminophen (pain and fever medication) caplets was expired. This failure could potentially expose residents to the expired medications loss of potency and efficacy. Findings: 1. Resident 17 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing related problems). During a concurrent observation and interview on 1/23/24, at 2:00 p.m., with Registered Nurse (RN) 1, while inspecting medication cart one, Resident 17 had two opened medication boxes which contained Breyna or Budesonide-Formoterol-Fumarate inhalers with no open date…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-26 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were served palatable food when food was served at a low temperature. This failure had the potential for 48 of 48 residents to consume a decreased amount of nutrients leading to weight loss and/or nutrient related medical complications. Temperature of the food was not palatable. Findings: During an interview on 01/22/24 at 10:09 a.m., with Resident 11, Resident 11 stated meals served at the facility were often cold and not palatable. During a telephone interview on 01/22/24 at 01:55 p.m., with Responsible Party (RP) for Resident 26, RP stated the food served to Resident 26 is often cold and not palatable. During an observation on 01/23/24 at 12:00 p.m., a meal delivery cart holding resident lunch trays, including one test lunch tray was transported from the kitchen. During a concurrent observation and interview on 01/23/24 at 12:30 p.m., with Registered Dietician (RD), in the activities/dining room, a regular diet lunch…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. Food was opened, unlabeled and undated. 2. The blender container was cloudy and dirty. 3. The bottom shelf of two-door freezer had crusted food and ice buildup. 4. Two dry food storage bins containing food were dirty, unlabeled, undated. 5. Cutting boards were dirty and ready for use. These failures put the facility at increased risk for food contamination and food borne illness for 48 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview during the initial kitchen tour on 01/22/24 at 09:45 a.m., with Dietary [NAME] (Cook), two opened loaves of bread and one opened bag of bagel were on the kitchen counter, without a label and a date. [NAME] stated she had used the bread and bagel for residents' breakfast and had forgotten to label and date the items. [NAME] stated, the risk for not labeling and dating food is not knowing if the food is expired and cross contamination.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-26 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 one visually impaired resident (Resident 30) of two sampled residents assistance with eating when the Certified Nursing Assistant (CNA 4) did not assist Resident 30 with meal tray set-up and food positioning on the plate. This failure caused Resident 3 confusion and challenges with eating. Findings: Review of the Significant change-Minimum Data Set (MDS -an assessment screening tool used to guide care), dated 1/12/24, indicated Resident 30's Basic Interview of Mental status (BIMS) score was 15 (meaning cognitively intact). Resident 30 had clear speech, able to make self-understood and able to understand others. Resident 30 had limited vision, and not able to see but could identify objects. Resident 30 needed touch assistance with eating, and a helper to provide verbal cues and contact guard assistance as resident completes activity. Resident 30's diagnoses included cataracts (clouding of normally clear lens of the eye, glaucoma (a group of eye conditions that can cause blindness), macular degeneration…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-26 · tag F0912 — isolated
    Provide 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, interview, and record review, the facility had three resident rooms (Room numbers 19, 20, 21), and total of 12 licensed beds that were occupied by 12 residents, that provided less than 80 square feet (sq. ft.) per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for storage of resident belongings. Findings: During an observation on 1/22/24 at 11:00 am, rooms [ROOM NUMBER] were observed to have four beds in each room. Each room measured less than 80 sq. ft. per resident. room [ROOM NUMBER] had 280 sq. ft. and 70 sq. ft. of space per resident. room [ROOM NUMBER] had 280 sq. ft. and 70 sq. ft. of space per resident. room [ROOM NUMBER] had 280 sq. ft. and 70 sq. ft. of space per resident. During random observations of care and services from 1/22/24 to 1/26/24, residents and staff never complained about the room size and staff have enough room to do their job. There was sufficient…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-06-20 · tag F0912 — pattern
    Provide 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 failed to provide 10 of 45 residents in resident rooms [ROOM NUMBER] with at least 80 square feet per resident. This failure had the potential to result in lack of sufficient space for the provision of care by facility staff, and for the lack of sufficient space for residents to have personal belongings at the bedside. After observation and interview, there was adequate space for residents and staff to move about safely and without obstruction. The State Agency recommends renewal of waiver. Findings: During an interview with the Maintenance Director (MD) on 6/17/25 at 11:43 a.m., MD confirmed that resident rooms 19, 20 and 21 had four beds each. MD measured all three rooms: room [ROOM NUMBER] measured a total of 16'6 X 19'6 = 432 sq ft with 73.56 sq ft per bed. room [ROOM NUMBER] measured a total of 16'6 X 19'6 = 432 sq ft with 73.56 sq ft per bed. room [ROOM NUMBER] measured a total of 16'6 X 19'6 = 432 sq ft with 73.56 sq ft per bed. Random observations 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.

    Environmental Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$10,033 in federal fines across 1 penalty.

  • $10,033 — penalty dated 2024-01-26

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 PACS GROUP — 274 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 →

RatingThis homeChain avg
Overall 5 of 52.9+2.1 vs chain
Health inspection 4 of 52.5+1.5 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 273 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Anchor Post AcuteAiken, SC 1 of 5Arbor Post AcuteChico, CA 1 of 5Artesia Palms Care CenterArtesia, CA 1 of 5Arvin Post AcuteArvin, CA 1 of 5Ashland Post AcuteAshland, OR 1 of 5Bakersfield Post AcuteBakersfield, CA 1 of 5Beachwood Post-Acute & RehabSanta Monica, CA 1 of 5Brookshire Post AcuteDenver, CO 1 of 5Brushy Creek Post AcuteGreer, SC 1 of 5Buckeye Care And RehabilitationLancaster, OH 1 of 5Carnegie Park Post AcutePittsburgh, PA 1 of 5Cascade Terrace Post AcutePortland, OR 1 of 5Centennial Post AcuteAnchorage, AK 1 of 5Chandler Creek Post AcuteGreer, SC 1 of 5Chehalem Post AcuteNewberg, OR 1 of 5Country Hills Post AcuteEl Cajon, CA 1 of 5Delhi Post-AcuteCincinnati, OH 1 of 5Dublin Post AcuteDublin, OH 1 of 5Edisto Post AcuteOrangeburg, SC 1 of 5Evan Terrace Post AcuteMcMinnville, OR 1 of 5Forest Acres Post AcuteColumbia, SC 1 of 5Grandview Post AcuteCookeville, TN 1 of 5Great Plains Post AcuteWichita, KS 1 of 5Hemet Hills Post AcuteHemet, CA 1 of 5Highland Hills Post AcutePittsburgh, PA 1 of 5Highline Post AcuteDenver, CO 1 of 5Johns Island Post AcuteJohns Island, SC 1 of 5Karcher Post AcuteNampa, ID 1 of 5Kennedy Care CenterLos Angeles, CA 1 of 5Kern River Transitional CareBakersfield, CA 1 of 5Lakeview Post AcuteFlorissant, MO 1 of 5Marion Valley Post AcuteMarion, OH 1 of 5Mirage Post AcuteLancaster, CA 1 of 5Monroeville Post AcuteMonroeville, PA 1 of 5Napa Post AcuteNapa, CA 1 of 5North Royalton Post AcuteParma, OH 1 of 5Northstar Post AcuteCarson City, NV 1 of 5Overland Park Post AcuteOverland Park, KS 1 of 5Pikes Peak Post AcuteColorado Springs, CO 1 of 5Ridgeway Post AcutePetaluma, CA

Showing 40 of 273; lowest-rated first.

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 / managerTypeRoleShareSince
PROVIDENCE GROUP NORTH LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 06/20/2015
DHUGGA, GURPREETIndividualCONTRACTED MANAGING EMPLOYEEsince 12/01/2023
PIERCE, ROBERTIndividualW-2 MANAGING EMPLOYEEsince 09/01/2021
APT, FREDERICKIndividualCORPORATE OFFICERsince 01/01/2024
JERGENSEN, JOSHUAIndividualCORPORATE OFFICERsince 01/01/2024
MITCHELL, JOHNIndividualCORPORATE OFFICERsince 01/01/2024

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

Follow the money — this home’s finances

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

$12.4M
Net patient revenuemost recent cost report
+15.3%
Operating marginrevenue minus expenses
$649K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 9%Medicare 52%Other / private 40%

This home reported $649K paid to related parties (affiliated landlords or management companies) in its most recent 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

$689per resident / day
operating cost
$20,935per month
≈ monthly operating cost
$813per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555082. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-01, 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 →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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