California Park Post Acute
2850 Sierra Sunrise Terrace, Chico, CA 95928 · For profit - Corporation · 90 certified beds · (530) 894-1010 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- 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.
| 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 2 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.4% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.0% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.7% | 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 | 1.8% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 10.7% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 27.8% | 13.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.7% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.6% | 10.2% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.4% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.1% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.7% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.73 | 2.25 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.04 | 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.
64.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 565 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.4% 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 241 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 0.62 therapist hours per resident per day in 2026Q1 — more than 89% 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
| 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 | 64.5%CMS range 60.7–68.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 19.2%CMS range 16.6–22.3 | 10.7% | Oct 2022–Sep 2024 | worse than 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 | 56.4% | 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 | 59.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.0% | 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 | 7.4%CMS range 5.2–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.15 | 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 90 beds and averages 83.3 residents a day — about 93% occupied, or roughly 7 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 4.31 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.83 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 3.85 hrs/resident/day on weekends vs 4.50 on weekdays — 15% thinner on weekends. RN hours go from 0.47 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2024-01-17 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, this requirement was not met when the facility failed to provide pain medication as ordered to one of five sampled residents (Resident 1). This caused Resident 1 to have significant back pain, interrupted his sleeping patterns, and had the potential to negatively affect his health. Findings A review of Resident 1's admission Record, dated 1/12/24, indicated he was admitted to the facility after being hospitalized for pneumonia (an infection of the lungs), and he had a history of back pain. A review of Resident 1's discharge medication list from an acute care hospital on 1/12/24 indicated that Resident 1 should continue to receive pain medication Norco (a narcotic pain medication) Oral Tablet 5-325 MG (milligrams, a unit of measure), give 1 tablet by mouth every 6 hours as needed for pain 4-10 (a scale from zero to ten, used to measure pain) for 14 days. Begin 1/13/24 11:15 AM. A review of the facility's policy titled Pain Management, Dated 11/24/17, indicated, Pain medication is to be given before pain becomes severe. Response to pain is to 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 before2025-12-22 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure 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
Based on interview and record review, the facility failed to ensure one Certified Nursing Assistant (CNA A) had appropriate competency and skill sets to care for residents based on their identified needs. This failure had the potential to place residents' safety at risk.Findings:On 12/10/25 the facility reported to the California Department of Public Health that a resident-to-resident altercation had occurred on12/8/25 where Resident 1 walked into the dining room and grabbed Resident 2's arm. During a concurrent interview and record review on 12/16/25 at 1:32 pm with the Administrator (Admin) and the Director of Nursing (DON), the Admin stated that residents are not to be left unsupervised while in the dining room. CNA A was in the dining room during the resident-to-resident altercation. During the facility investigation, the Admin confirmed from video footage that CNA A failed to perform their job duties by keeping residents safe when Resident 1 was able to grab Resident 2 by the arm. During a facility job description titled Certified Nursing Assistant dated 3/1/14, indicated that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-13 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure a certified nursing assistant (CNA) immediately reported an allegation of rough care to facility management so they could carry out the facility's abuse protocol for 1 (Resident #32) of 1 resident reviewed for an allegation of staff-to-resident abuse. Findings included: A facility policy titled, Abuse, Prevention of, revised 05/10/2018, indicated, PURPOSE: To ensure that residents' rights, safety and well-being are protected by providing a method for the prevention of any type of resident abuse. POLICY: It is the policy of this facility that each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, exploitation, mistreatment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultant or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The section of the policy titled, G. Reporting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-13 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the classes of medications received during the assessment look-back periods for 2 (Resident #74 and Resident #70) of 2 residents reviewed as part of the Resident Assessment task and failed to ensure MDS assessments accurately reflected weight-loss statuses for 2 (Resident #8 and Resident #25) of 2 sampled residents reviewed for nutrition. Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, indicated, 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The information captured on the assessment reflects the status 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.
- Potential for harm · D2024-11-06 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 2 sampled residents (Resident 2) was treated with dignity and respect during direct patient care when privacy was not provided, and Resident 2 was rushed. This failure resulted in Resident 2 feeling embarrassed, with increased anxiety, and difficulty sleeping. Findings: A review of the facility ' s policy revised 10/20/2017, titled, Resident Rights, indicated the purpose of this policy is to assure protection of rights for residents in the facility. This facility ' s policy also indicted all residents have the right to personal privacy. Staff will protect privacy by announcing themselves or knocking on the door before entering room or privacy curtain and closing the door and pulling the privacy curtain when providing or assisting with personal care. A review of the facility ' s policy revised 9/15/2017, titled, Activities of Daily Living, indicated the purpose of this policy is to preserve the resident ' s ability to carry…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-17 · tag 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 interview and record review, the facility failed to ensure the licensed nurses reported changes of condition to the physician for 1 of 3 residents (Resident 1) when: 1. Resident 1 had edema (swelling) that went from mild lower leg edema to deep pitting (leaves an indent in skin for a period of time) to the hips. This resulted in a transfer to hospital for fluid overload, ascites (fluid in abdomen), anasarca (fluid throughout all of body, puffy body), bilateral pleural effusions (fluid in the lungs), and exacerbated (make worse) his congestive heart failure. 2. Resident 1 had sudden new onset of 7/10 pain (severe pain) with as needed (PRN) pain medication given for first time on 8/18/24 and 8/19/24. This resulted in increased pain and discomfort. Findings: A review of facility's policy titled, Change in Condition Policy Assessment, revised on 9/17/17, indicated residents who experience a change of condition will be assessed promptly and follow up action will be taken as indicated in a timely manner. This includes any sudden and/or marked adverse change in signs, symptoms, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-17 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure 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
Based on interview and record review the facility failed to ensure licensed nursing staff had the skills and competencies to ensure the medical needs for one of three sampled residents (Resident 1) were met when significant changes of condition were not identified and reported to the physician. This resulted Resident 1 to be transferred to the hospital for fluid overload, ascites (fluid in abdomen), anasarca (fluid throughout all of body, puffy body), bilateral pleural effusions (fluid in the lungs), and exacerbated (make worse) congestive heart failure. Findings: A review of Resident 1's record indicated he was admitted into this facility on 7/4/24 to rehabilitate from a hip replacement. Resident had Parkinson's Disease (movement disorder of the nervous system), high blood pressure, and heart failure Resident 1 was his own health care decision maker. During a record review of acute care hospital discharge notes for 7/4/2024, Resident 1 had +1 (mild) pitting (when one presses on the site, there is a pit or indentation) edema to right lower extremity and +2 (moderate) pitting to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-17 · 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, this requirement was not met when the facility failed to be free of significant medication errors when a necessary heart medication was not provided to one of five sampled residents (Resident 1) after it was ordered by a physician. This had the potential to put Resident 1 at risk of heart failure, further hospitalization, or death. Findings Resident 1 was admitted to the facility after being hospitalized for pneumonia, and severe peripheral artery disease following a history of heart surgery. During his hospitalization, he was diagnosed with atrial fibrillation (Afib, a heart condition that causes the heart chambers to be chaotically and out of rhythm, dysrhythmia) and he was prescribed digoxin, an important medicine to correct this dysrhythmia, to be continued by the long-term care facility. Review of the facility's policy titled, Medication Administration, dated 11/24/17, indicated that licensed nurses must administer medications in accordance with physician orders. 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.
- Potential for harm · F2023-10-20 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours per day/ 7 days a week. This failure had the potential to adversely affect oversight and direction regarding resident's quality of care and quality of life directly impacting overall health and well-being. Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information), for Fiscal Year Quarter 3: (April - June 2023), indicated the facility had no RN on duty for: 4/29/23 Saturday (Sa), 5/20/23 (Sa), 5/27/23 (Sa), 6/3/23 (Sa), 6/4/23 Sunday (Su), 6/10/23 (Sa), 6/11/23 (Su), 6/12/23 Monday (M), 6/13/23 Tuesday (T), 6/14/23 Wednesday (W), 6/15/23 Thursday (Th), 6/17/23 (Sa), 6/18/23 (Su), 6/24/23 (Sa), 6/25/23 (Su) During a review of the RN monthly schedule, dated April, May, and June 2023, indicated there was no RN coverage for Saturdays or Sundays during the month of June. During an interview on 10/18/23 at 2:30 pm, the Assistant Director of Nursing (ADON) confirmed, We have had just a few shifts…
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 · F2023-10-20 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility did not report a failed water heater to state and local agencies for 12 days. This failure had the potential to place all residents at risk for exposure to germs and illness related to a lack of hot water. Findings: A facility policy, titled, Unusual Occurrences, reviewed 4/30/22, was reviewed. The policy indicated a list of unusual occurrences that should have been reported to the California Department of Public Health (CDPH) within 24 hours by telephone and confirmed in writing. Among the reportable occurrences was any that, constituted an interference with facility operations, or which threatened the welfare, safety or health of residents, personnel, or visitors. During a concurrent interview and record review, on 10/17/23, at 11:30 AM, in the facility laundry room, Housekeeper (HSK) A stated the hot water had been off for one and a half weeks. HSK A confirmed a temperature log for the month of October 2023 contained a last recorded water temperature of 151 degrees Fahrenheit on 10/5/23 at 4:30 AM. No further temperatures had…
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 · F2023-10-20 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, observations and record review the facility failed to ensure essential equipment was maintained in safe working order when: 1. The temperature of the nourishment refrigerator located in nursing station one was above 41 degrees Fahrenheit (° F, a unit of measuring temperature). 2. The manufacturer guidelines were not followed for cleaning and sanitizing the ice machine. 3. A walk-in freezer located in the large storeroom in the basement had ice build-up on the inside of the door, around the fans and around a pipe. These failures had the potential for the equipment to not be maintained to ensure proper functioning. Findings: During a review of facility's policy and procedure titled Maintenance Shop dated 2023, it indicated it was the policy to maintain a Maintenance Log of service visits, repairs and inspections of the facility's fixtures, equipment, systems and buildings. 1. According to the US Food and Drug Administration titled Keep your appliances at the proper temperatures dated 1/18/23. Keep the refrigerator temperature at or below 40° F or 4° Celcius (C,…
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 19 citations
- Potential for harm · E2023-10-20 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 that care plans for three of 17 sampled residents (Resident 25, 62, and Resident 275) were revised and updated to identify resident specific needs. This failure had the potential for residents individual care needs to go unrecognized, and a risk for a decline in residents physical, mental, and psychological status related to weight loss, communication needs, and proper transfers required to for pain management. Findings: 1. During a review of the facility's policy and procedure (P&P) titled, Care Plans, revised 1/31/22, the P&P indicated that it is the policy of this facility that the care plan is to be reviewed and revised after the resident's initial assessment, quarterly, and more often as warranted by the changes in a resident's condition. During a review of the facility's policy and procedure (P&P) titled, Change of Condition, revised 9/15/17, the P&P indicated that the licensed nurse is to update the care plan to reflect any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-20 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure safe handling of prescription medications with census of 66, based on standards of practice and regulatory requirements when: 1. The Emergency Kit (or EKit, an emergency supply of drugs that used based on a doctor order for urgent needs of a resident) for injectable (or a shot) drugs was not safely secured after use and was not replaced on timely manner in the main medication room. 2. The disposition of discontinued or unusable prescription medications were not cosigned by two licensed staff in both medication rooms. These unsafe medication handling practices could contribute to risk of diversion (abuse of prescription drugs) and drug loss. Findings: 1. During an inspection of the facility's medication room, at Station 1, on 10/18/23, at 12:45 PM, accompanied by Licensed Nurse D (LN D), the Ekit for injectable medication was observed to be open and unsealed. The EKit container had a yellow carbon copy of a slip indicating it was used on 10/10/23 for a new medication order by the doctor. LN D…
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 · Ecited before2023-10-20 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with the census of 66 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of five errors out of 38 opportunities which resulted in a facility wide medication error rate of 13.16 % in two out of nine residents (Resident 8 and Resident 15) during medication administration observation. These failures may result in unsafe medications use, medication error, and not following the doctor's orders. Findings: 1. During a medication pass observation of Resident 15, with Licensed Nurse A (LN A), on 10/17/23, at 9:13 AM, LN A administered a total of 10 medications and called the doctor's office on not having two medications not available to administer. LN A stated a blood thinner called Eliquis and a pain medication called Meloxicam was out 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 · E2023-10-20 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 practices in three out of five medication and treatment Carts (cart or container on a wheel that stored immediate use medications) with census of 66 residents when medications were not marked with beyond use date (the date a product should no longer be used) based on manufacturer recommendations. These failed practices may result in unsafe and spoiled medication use in the facility. Findings: 1. During a concurrent inspection of facility medication Cart #2, at facility's Station 1, accompanied by Licensed Nurse D (LN D), on 10/17/23, at 10:17 AM, the medication cart stored medications with no markings for when it was first opened or with a beyond use date per manufacturer recommendations as follow: a. Basaglar Insulin pen (also known as Glargine; a shot medicine used to treat blood sugar disease; the medicine in pen shape for ease of administration) was stored in the medication cart for daily use and the label on the medications was missing the Date Opened. The insulin pen had 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 · E2023-10-20 · tag F0801 — patternEmploy 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 observation, and interview, the facility failed to ensure federal regulations related to the education qualification requirements of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with meal distribution accuracy, safe food handling and sanitation guidelines. Findings: According to the HSC 1265.4, (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. On 10/18/23 at 9:25 AM an interview was conducted with the CDM. The CDM was asked for documentation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-20 · 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, facility document and Policy and Procedure review, the facility failed to ensure Food and Nutrition Services followed food safety and sanitation guidelines when: 1. Two of two hand washing sinks didn't not reach 85 degrees Farenheight (° F, a unit of measuring temperature). 2. The temperature in the nourishment refrigerator located on Nursing Station 1 was 4° F above the recommended temperature range. 3. The ice machine located in kitchen was not clean. 4. The sanitizer solution in the third compartment of the manual dishwashing sink was less than 200 parts per million. 5. Time temperature control for safety foods (TCS) prepared at ambient temperature (room temperature) were not monitored on the cool down log. 6. Food preparation equipment was not air dried. 7. Food service utensils were not in sanitary condition. 8. Food service utensils were not of approved material. 9. Food was not stored properly in 1 of 2 walk in freezers. 10. The floor drain next to the ice machine was not clean. These failures had the potential to cause food borne illnesses in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-20 · tag F0813 — patternHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, observations and record review the facility failed to ensure the policy for resident food brought from the outside allowed food to be reheated. In addition, family members, and visitors who brought food from the outside were not informed of safe food handling practices, and employees were not educated on safe food handling practices. This failure had the potential for food brought in from the outside to not be handled in a safe manner. Findings: During review of facility's policy and procedure titled Food from Outside Source reviewed on 1/31/22, indicated facility staff are not allowed to reheat foods brought in from outside the facility. Nursing and/or dietary staff are to discuss proper food storage and handling with the family to promote food safety. On 10/18/23 at 9:11 AM during interview with Assistant Director of Nursing (ADON) when asked how families get educated on safe food handling, she stated she refers to Certified Dietary Manager (CDM). On 10/18/23 at 12:57 PM during interview with Registered Dietician (RD) she stated she is not involved with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-20 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, Policy and Procedure review, the facility failed to ensure refuse was stored in a sanitary manner when: One of three outdoor refuse dumpsters was not closed, and the surrounding area was not maintained in a sanitary manner. This failure had the potential to attract vermin. Findings: During review of facility's policy titled Sanitation, dated 2023, it indicated kitchen wastes .should be kept in leak proof, non-absorbent and tightly closed containers and shall be disposed of as necessary to prevent a nuisance or unsightliness. According to USDA Food Code, Section 5-501.113 Covering Receptacles: Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered .with tight-fitting lids or doors if kept outside the food establishment. According to USDA Food Code, Section 5-501.115 Maintaining Refuse Areas and Enclosures: A storage area and enclosure for REFUSE .shall be maintained free of unnecessary items . and clean. On 10/18/23 at 9:40 AM an observation of the outdoor refuse storage area and concurrent interview 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 · Dcited before2023-10-20 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of seventeen residents, (Resident 43 and Resident 276) were monitored and the physician updated for a change in condition. 1. Resident 43's physician was not updated with a new onset of cough, and inablity to sleep due to new cough for at least 4 days. 2. Resident 276's physician was not updated with Urinalysis (U/A, a test to diagnose a urinary tract infection (UTI) results from 10/16/23, and Culture and Sensitivity (a test to identify specific antibiotics for treatment of a UTI) results for three days. Resident 276 was not monitored for signs and symptoms of an infection during pending U/A results which indicated Resident 276 did have a UTI. This failure resulted in Resident 43 and Resident 276 to not receive daily assessments including vital signs, obtaining labs requested, and the potential for a hospitalization. Findings: 1. During a review of the facility's policy titled, Change in Condition, revised 9/15/17, the policy…
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 · D2023-10-20 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to complete the Comprehensive Minimum Data Set (MDS, a standardized resident assessment) within 14 calendar days of admission for two of 17 sampled residents (Resident 275 and Resident 276.) This failure had the potential to delay the development of a comprehensive care plan necessary to provide appropriate individualized care and services for each resident related to the care areas that would have been identified on the Comprehensive MDS. Findings: During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set (MDS)/Resident Assessment Instrument (RAI), revised 1/3/2022, the P&P indicated, All comprehensive assessments should be completed and signed (Z0500) within seven days of the Assessment Reference Date (ARD), but no later than thirteen days after the ARD or by the fourteenth day of resident's admission. During a review of Resident 275's clinical record, Resident 275 was admitted to the facility on [DATE] with diagnoses that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-20 · 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 observation, interview, and record review, the facility failed to complete a comprehensive care plan for one of 17 residents (Resident 53). This resulted in Resident 53 did not have a care plan to address her fluid restriction. Findings: During a review of the facility's policy and procedure (P&P) titled, Care Plans, revised 1/31/22, the P&P indicated that it is the policy of this facility that a comprehensive care plan is to be developed for each resident within seven days of the resident's comprehensive Minimum Data Set (MDS) assessment. During a review of Resident 53's clinical record, Resident 53 was admitted to the facility on [DATE] for diagnoses that included dementia (general term for impaired thinking, remembering, reasoning, and functional ability), seizures (uncontrolled signals between brain cells), and urinary tract infections (bladder infections). During a review of Resident 53's Active Orders, dated 8/28/23, indicated fluid restriction of 1200 cubic centimeter (cc, a unit of measurement)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility Policy and Procedure review, the facility failed to ensure one of 17 final sampled residents (Resident 25) maintained acceptable parameters of nutritional status when: 1. The facility failed to provide documentation which showed the physician was notified of Resident 25's unplanned severe weight loss of 9.2 pounds, 7.2% from 9/11/23 to 9/30/23, and 13 pounds, 10% unplanned severe weight loss from 9/11/23 to 10/6/23, 2. The facility failed to reweigh Resident 25 per the facility policy when he experienced a severe weight loss of 9.2 pounds, 7.2% from 9/11/23 to 9/30/23, and 13 pounds, 10% severe weight loss from 9/11/23 to 10/6/23. 3. The facility failed to ensure the IDT (Interdisciplinary team) evaluated and monitored the effectiveness of the intervention implemented for Resident 25's unplanned severe weight loss on 10/12/23. 4. The facility failed to revise the resident centered plan of care for Resident 25 to reflect the unplanned severe…
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 · D2023-10-20 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and facility document review, the facility failed to ensure the menu was followed for 2 of 18 residents who received a controlled carbohydrate diet (CCHO, a diet that contains carbohydrate rich foods in fairly equal amounts) for Residents 52 and 272. This failure had the potential to result in the resident to not receive the CCHO diet as planned. Findings: A review of the facility document titled Cooks Spreadsheet week 3 Tuesday dated 10/17/23 showed, for the lunch meal the CCHO diets should be served one serving of peanut butter cake for dessert, no icing. A review of Resident 52's medical record showed Resident 52 was admitted on [DATE] with a diagnosis including type 1 diabetes mellitus (a chronic condition where the pancreas produces little to no insulin). A review of resident 52's physician orders showed a CCHO mechanical soft texture, thin liquid consistency diet was ordered on 1/23/23. During the lunch meal dining observation on 10/17/23 in Dining room [ROOM NUMBER] at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure and maintain infection control practices with census of 66 when: 1. The facility failed to ensure safe cleaning and sanitization of the shared glucometer (medical device used to measure blood sugar from a drop of blood) when the glucometer was not disinfected on three out of three residents (Residents 12, Resident 31, and Resident 273) tested for blood sugar level, based on standards of practice and manufacturer recommendations. 2. The facility failed to maintain infection control practices when one Housekeeping Staff (HSK A) failed to keep a clean sheet off the floor. These failures had the potential to cause the spread of germs which could have placed the vulnerable resident population at risk for infection and illness. Findings: 1. Review of facility's policy titled, Cleaning Point of Care Equipment (Blood Glucose Meter), in effect and last revised on 4/20/22, the policy indicated It is the policy of this facility to clean all point of care equipment, including blood glucose meters, according to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-24 · 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, policy, and clinical record review, the facility failed to revise 1 of 1 sampled resident's (Resident 32) Physician Orders for Life Sustaining Treatment (POLST, a directive that specifies what services and treatment an individual wishes in the event of an emergency or code blue such as resuscitation (CPR), hospitalization, artificial hydration and tube feedings). This had the potential for Resident 32 to receive end of life services and treatment that were against her wishes and negatively impact her quality of life. Findings: A review of the facility's policy titled, Advance Health Care Directive (AHCD), dated [DATE], was reviewed. The policy indicated, The IDT [Interdisciplinary Team, a team of health care professionals who work in a coordinated fashion toward a common goal for the patient] is to review the resident's AHCD at the quarterly care plan conference. If there is any change in the resident's status or desire, the physician is to be notified to reassess the resident. A review 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 · D2022-06-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record and policy review, the facility failed to ensure that their restraint policy was followed for 1 of 2 sampled residents (Resident 32), when a bed alarm and wheelchair alarm was initiated for Resident 32 without informed consent (information given to the resident or responsible party (RP) about the restraints and verification that they agreed to using them), a pre-restraint evaluation (a determination that the restraint is necessary before initiating), a specific diagnosis (medical reason), or reviewed by the Interdisciplinary Team (IDT, a team of health care professionals who work in a coordinated fashion toward a common goal for the patient) within 72 hours after initiation. This resulted in an unnecessary alarm restraint used on Resident 32, when there was no assessment or consent for the restraint alarm. Findings: Facility policies were provided by the facility's corporate consultant. The facility's policy titled, Alarms dated 1/31/22, was reviewed 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 · Dcited before2022-06-24 · 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 clinical record review, the facility failed to develop comprehensive care plans for 3 of 16 sampled residents. Two residents (Residents 32 and 213) were taking psychotherapeutic medications (a medication that affects the mind, emotions and behavior) and 1 resident (Resident 313) was on hospice care (supportive care to terminally ill residents that focuses on their comfort, quality of life, and being pain free). 1. Resident 32 did not have a care plan developed for the use of Ativan (an anti-anxiety psychotherapeutic medication that affects the mind, emotions and behavior). 2. Resident 213 did not have a care plan developed for the use of Seroquel (an antipsychotic psychotherapeutic medication). 3. Resident 313 did not have a care plan developed for Hospice (care that focuses on the end of life wishes of the terminally ill). This had the potential for the staff not to implement interventions that were consistent with managing the resident's behaviors, recognize the presence of adverse…
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 · D2022-06-24 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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, clinical record, and policy review, the facility failed to ensure that the consultant pharmacist (CP) A identified an irregularity in the Medication Regimen Review (MRR), for 1 of 1 sampled resident who was taking Ativan (an anti-anxiety psychotherapeutic medication- medication that affects the mind, emotions and behavior), and the facility had incorrectly monitored for the adverse side effects of an antidepressant medication. (Resident 32) This had the potential for unwanted adverse side effects to go unrecognized and impair the Resident 32's quality of life. Findings: The facility's policy titled, Medications, Psychotherapeutic Drugs dated 1/31/22, was reviewed. The Psychotherapeutic Reviews section directed, The consulting pharmacist is to review the psychotherapeutic medications monthly and make recommendations as appropriate. The pharmacist is to advise physicians regarding any recommendations regarding drug or dose adjustments. A review of LexiComp, an online drug reference site 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 · Dcited before2022-06-24 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that their medication error rate did not exceed 5 percent or greater for two of seven sampled residents (Resident 51 and 15) when three medication errors were observed within 32 opportunities when: 1. Resident 51 had two medications administered without following manufacturer's instructions. 2. Resident 15 was administered an inhaler without following manufacturer's instructions. This failure resulted in the facility's medication error rate to be 9.38 percent and had the potential medication to be ineffective for all residents. Findings: 1. During a record review of a document titled admission Record indicated Resident 51, was admitted to facility on 9/15/2021 for atrial fibrillation (A-fib an irregular heartbeat) and osteoarthritis (damage to joint and bone). A record review of the Resident 51's physicians orders dated 6/21/22, indicated, Allopurinol [treats arthritis] 100 milligrams (mgs), 1 tablet by mouth two times a day 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.
“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 KALESTA HEALTHCARE GROUP — 19 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.4 | +2.6 vs chain |
| Health inspection | 4 of 5 | 2.2 | +1.8 vs chain |
| Staffing | 2 of 5 | 2.6 | -0.6 vs chain |
| Quality measures | 5 of 5 | 4.0 | +1.0 vs chain |
The other 18 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KALESTA HEALTHCARE GROUP, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 06/01/2025 |
| CLAWSON, SCOTT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 44% | since 06/01/2025 |
| WILLIAMS, RYAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | 44% | since 06/01/2025 |
| PGIM REAL ESTATE AGENCY FINANCING, LLC | Organization | 5% OR GREATER SECURITY INTEREST | — | since 06/01/2025 |
| CHEN, KAI SHIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2025 |
| ELLIS, BRIDGET | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2025 |
| GARRETSON, CHARLES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2025 |
| JONES, STEVEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2025 |
| PORTER, MICAH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/01/2025 |
| RUHL, ERIK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2025 |
CMS files one row per role, so the 22 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $932K 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
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 555625. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-13, 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.