Trellis Chino
5454 Walnut Ave, Chino, CA 91710 · For profit - Limited Liability company · 59 certified beds · (909) 465-0246 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (25% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (15) — 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 | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.1% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.0% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 4.8% | 11.2% | 12.0% | better |
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.
60.9% 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 578 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 81.7% 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 224 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 1.25 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% 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 | 60.9%CMS range 57.2–63.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 8.8–13.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 81.7% | 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 | 88.0% | 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 | 73.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 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 | 8.4%CMS range 6.8–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.66 | 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 59 beds and averages 57.4 residents a day — about 97% 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 4.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.57 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.18 hrs/resident/day on weekends vs 4.67 on weekdays — 11% thinner on weekends. RN hours go from 0.61 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 25% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · D2026-02-12 · tag F0839 — isolatedEmploy staff that are licensed, certified, or registered in accordance with state laws.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of the three licensed vocational nurses (LVN 1) held a valid and current license to practice when LVN 1 worked with an expired license from [DATE], through [DATE].This failure had the potential to place 59 highly vulnerable residents at risk due to LVN 1's non-compliance with the legal requirement to practice nursing.Findings: During a telephone interview with LVN 1, on February 12, 2026, at 12:08 PM, LVN 1 stated I had been under the impression that I was working with an active license but was unaware that it had expired. LVN 1 stated her license expired on [DATE], and was only renewed on [DATE]. (22 days have passed since its expiration.)During a review of a letter from the Board of Vocational Nursing and Psychiatric Technicians regarding LVN 1, dated [DATE], it indicated LVN 1 was issued her license as a vocational nurse on [DATE]. Further review indicated .On [DATE], the license went delinquent (inactive) due to failure to renew. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-14 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the proper and safe infection control practices were followed when:1. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene in between Residents 33 and 80's rooms. CNA 1 did not disinfect vital signs machine in between Resident 33 and 80. 2. CNA 2 did not perform hand hygiene before and after perineal care (cleaning the genital and anal areas) and did not utilize personal protective equipment (PPE - clothing and gear designed to protect you from hazards at work or during certain activities) in isolation room (room used to keep germs from spreading) for Resident 11. 3. Licensed Vocational Nurse (LVN) 1 did not perform hand hygiene nor don gloves after medication preparation and before medication administration in an isolation room for Resident 7. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 54 vulnerable residents whose health…
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 before2025-08-14 · 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 and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately for one of two residents reviewed for resident assessment (Resident 43). This failure resulted in an inaccurate assessment, potentially leading to a misidentification of Resident 43's care and support needs.Findings:During a review of Resident 43's admission Record (a document that contains demographic and clinical data), it indicated Resident 43 was admitted to the facility on [DATE], with diagnoses which included fibromyalgia (a long-term condition that involves widespread body pain) and rhabdomyolysis (condition in which damaged skeletal muscle [the main tissue responsible for body posture and movement] breaks down rapidly).A review of Resident 43's physician order, dated July 30, 2025, indicated Percocet [an opioid that binds to specific receptor in the body to give pain relief] . give 1 tablet by mouth every 4 hours as needed for 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 · D2025-08-14 · 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, and record review, the facility failed to ensure resident food preferences were provided for one of seven residents reviewed for nutrition (Resident 37) when Resident 37 did not receive a fresh fruit cup for breakfast as indicated on meal ticket on August 11, 2025.This failure had the potential to cause nutritional decline and unmet care needs for Resident 37.Findings:During a review of Resident 37's admission Record (contains demographic and medical information), it indicated Resident 37 was admitted to the facility on [DATE], with the diagnoses of osteoarthritis (degeneration of the cartilage in single joint, leading to pain, stiffness and reduced range of motion), metabolic encephalopathy (condition where brain dysfunctions from metabolic imbalances such as nutrient intake or toxin buildup) and dysphagia (difficulty swallowing).During a review of Resident 37's Diet Order dated July 9, 2025, it indicated regular diet (healthy meal plan for individuals without specific medical…
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 · D2025-08-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the observation, interview, and record review, the facility failed to maintain an appropriate environment for storing all drugs and biologicals in accordance with accepted professional principles and the facility's policies and procedures for one of two medication rooms (South Station medication room) and one of two treatment cart (Treatment Cart 2) reviewed for medication storage, when: 1. The medication refrigerator inside the South Station medication room was found to be unsanitary on August 12, 2025. 2. Three opened and used ointments tubes were found without documented opened dates inside Treatment Cart 2 on August 13, 2025. These failures had the potential to cause contamination (when something harmful, like dirt, germs, or chemicals, mixes with something clean or safe, making it unsafe to use) and reduce confidence in medication efficacy and safety for 59 highly vulnerable residents. Findings:1. During a concurrent observation and interview, on August 12, 2025, at 3:16 PM, in the South Station medication room, with the Infection Prevention Nurse (IPN), the medication…
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 · D2025-08-14 · 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
Based on observation, interview, and record review, the facility failed to ensure the menu was followed for three residents reviewed for puree diets (Resident 4, 46, and 79) when the incorrect portion size of pureed meatball was served for lunch on August 11, 2025. This failure has the potential to cause unintended weight loss (a noticeable decrease in body weight that occurs without conscious effort, such as dieting or exercising more), and inadequate nutritional needs (a state where the body doesn't receive enough of the essential nutrients it needs to function properly) for medically compromised Residents 4, 46 and 79 on puree diet (a modified diet where regular foods are transformed into a smooth, lump-free consistency, resembling pudding). Findings: During a review of the facility's Meal Distribution Report, it indicated Residents 4, 46, and 79 were on puree diet.During a review of the facility recipe for Meatballs / Marinara menu, it indicated Serve meat with a #8 scoop, topped with 4 oz (1/2 cup) of tomato sauce (1 cup total). An observation of the lunch tray line's puree…
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 · D2025-08-14 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the recipes were followed for puree (a modified diet where regular foods are transformed into a smooth, lump-free consistency, resembling pudding) diets for three residents reviewed for puree diet (Residents 4, 46, and 79) when the pureed lemon herb chicken, served for lunch on August 12, 2025, was crumbly and not smooth.This failure had the potential to cause choking and dissatisfaction for Residents 4, 46, and 79 who are medically compromised. Findings: During a review of the facility's Meal Distribution Report, it indicated Residents 4, 46, and 79 were on puree diet. During a review of the facility recipe for Lemon Herb Chicken, it indicated, Puree Diets: Place portions of meat needed into a food processor. Process to a fine texture. For every 5 portions. Prepare a slurry with 4 tbsp thickener and 1 cup hot liquid. Mix well with a wire whip. Add 1/2 of the slurry to the chicken. Process for 1 minute; if too dry, and more slurry until meat is pudding consistency.During a concurrent observation 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 · D2024-06-06 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, document review, and facility policy review, the facility failed to transmit discharge Minimum Data Set (MDS) assessments for 2 (Resident #16 and Resident #40) of 3 sampled residents reviewed for resident assessment. Findings included: A facility policy titled MDS Completion and Submission Timeframes, dated July 2017, indicated, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy indicated, 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, dated 10/2023, indicated, Discharge assessment refers to an assessment required on resident discharge from the facility. 1. An admission Record revealed the facility admitted Resident #16 on 12/12/2023. According to the admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to provide conduct an assessment and monitor the provision of a nebulizer treatment for 1 (Resident #165) of 1 sampled resident reviewed for respiratory care. Findings included: A facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised in 10/2010, indicated, The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. The policy specified, Documentation The following information should be recorded in the resident's medical record. 1. The name, title and initials of the person administering the treatment. 2. The date, time and length of treatment (treatment administration record). 3. The type and amount of medication administered (medication administration record). 4. The type and source of gas. 5. Pulse, respiratory rate and lung sounds before and after treatment. 6. Pulse during treatment. 7. Amount and characteristics of sputum production. 8. The resident's tolerance…
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 · D2024-06-06 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to monitor the dialysis fistula for 1 (Resident #165) of 1 sampled resident reviewed for dialysis. Findings included: A facility policy titled, Hemodialysis Catheters - Access and Care of, revised in 02/2023, specified under the section titled, Care of AVFs [arteriovenous fistula] and AVGs [arteriovenous graft], 3. Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots). 4. To prevent infection and/or clotting: a. Keep access site clean at all times. b. Do not use the access site arm to take blood samples, administer IV [intravenous] fluids or give injections. c. Needle access for hemodialysis should be rotated. d. Check for signs of infection (warmth, redness, tenderness, or edema) at the access site when performing routine care and at regular intervals. e. Do not use the access arm to take blood pressure. f. Advise the resident not to sleep on, wear tight jewelry or lift heavy objects with the access arm. g. Check the color 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.
Show the remaining 5 citations
- Potential for harm · D2024-06-06 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure ordered medication was available in the facility for 1 (Resident #32) of 6sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Orders and Receipt Record, revised in 04/2007, revealed no evidence related to receiving medications in a timely manner from the pharmacy. An admission Record indicated the facility admitted Resident #32 on 05/15/2024. According to the admission Record, the resident had a medical history that included a diagnosis of paraplegia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of05/18/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had moisture associated skin damage (MASD). Resident #32's care plan, initiated on 05/16/2024 indicated the resident had impaired skin integrity present upon admission as evidenced by skin discoloration. Interventions…
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 before2024-06-06 · 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, record review, and facility policy review, the facility failed to store nebulizer equipment for 1 (Resident #165) of 1 sampled resident reviewed for respiratory care. Findings included: A facility policy titled, Prevention of Infection Respiratory Equipment, revised in 11/2011, specified, Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 1. Obtain equipment 2. Wash Hands. 3. Take care not to contaminate internal nebulizer tubes. 4. Store the circuit in plastic bag, marked with date and resident's name and replace tubing and plastic bag once a week. An admission Record indicated the facility admitted Resident #165 on 05/23/2024. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory failure with hypoxia (insufficient oxygen level), chronic pulmonary edema (fluid accumulates in lung tissue), and acute on chronic congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/25/2024, revealed Resident #165 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 · E2023-01-06 · tag F0604 — failed to not use physical restraints improperly — patternEnsure 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, and record review, the facility failed to follow the policy and procedure for position change alarm (device place in the bed or wheelchair to alert staff when the person gets out from bed or wheelchair), for three of three residents (Residents 4, 5 and 7) reviewed for falls when position change alarms were used for Residents 4, 5, and 7 without a physician's order. This failure placed Residents 4, 5 and 7 at risk for decreased mobility, sleep disturbances, and agitation in response to the sound of the alarm. Findings: 1. During a review of Resident 4's admission Record (contains demographic and medical information), it indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included dementia (condition that affects the way the person's brain is working), seizures (convulsions), and anxiety (feeling of fear, dread and uneasiness). During a concurrent observation and interview, with the Infection Preventionist Nurse (IPN), on January 5, 2023, at 8:23 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-06 · 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 and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately to reflect the resident's status, care, and services in the skin conditions for one resident (Resident 52) reviewed for pressure ulcers (an open wound on the skin caused by a long period of constant pressure). This failure had the potential to cause inaccuracy in identifying Resident 52's care and support needs. Findings: During a review of Resident 52's admission Record (a document that contains demographic and clinical data), it indicated Resident 52 was admitted to the facility on [DATE], with diagnoses which included cellulitis (a deep infection of the skin caused by bacteria) of right lower limb and type 2 diabetes mellitus (a chronic, metabolic disease characterized by elevated blood sugar level) with foot ulcer (an open sore or wound). During a concurrent interview and record review, with the Treatment Nurse (TN), on January 6, 2023, at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-06 · 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 implement their infection control program to help prevent the spread of infections and other infectious diseases when four employees was not screened for Covid-19 (a highly infectious disease caused by the SARS-CoV-2 virus] symptoms and exposure upon entering the facility on January 4, 2023. This failure had the potential to cause harm to the 50 residents residing within the facility by causing cross contamination (the transfer of bacteria or viruses from one person to another) of the environment and increasing the risk of exposure and spread of the COVID-19 virus within the facility. Findings: During a concurrent interview and record review, with the Infection Preventionist Nurse (IPN), on January 5, 2023, at 9:11 AM, the IPN reviewed the facility provided list of employees and confirmed the following employees have worked on January 4, 2023: a. Certified Nursing Assistant (CNA 1) b. Certified Nursing Assistant (CNA 2) c. Physical Therapy Assistant (PTA) d. Housekeeper (HKP) During a further interview 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.
“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 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.9 | +2.1 vs chain |
| Health inspection | 5 of 5 | 2.5 | +2.5 vs chain |
| Staffing | 2 of 5 | 2.5 | -0.5 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CALIFORNIA OPCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/05/2021 |
| BAY BRIDGE CAPITAL PARTNERS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/05/2021 |
| OPCO HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/05/2021 |
| RUTHERFORD, KEINO | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 03/01/2017 |
| LORDS, TREVOR | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2023 |
| APT, FREDERICK | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| JERGENSEN, JOSHUA | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| MITCHELL, JOHN | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $868K 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 555910. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-14, 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.