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Bayberry Skilled Nursing & Healthcare Center

1800 Adobe Street, Concord, CA 94520 · For profit - Limited Liability company · 99 certified beds · (925) 825-1300 Medicare & Medicaid certified

Call the home — (925) 825-1300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 20251 actual-harm citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • about 18% of its spending goes to commonly-owned related companies

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1800 Sutter St Ste 100 · (925) 939-8585 · Call to confirm hours
Pharmacy
1800 Concord Ave · (925) 674-9477 · Call to confirm hours
Grocery
1859 Adobe St · (925) 825-9043 · Call to confirm hours
Park
Todos Santos Plaza, 2100 Pacheco St · (510) 602-0655 · Typically dawn to dusk
Place of worship
Av. San Francisco y Gral. José E. Díaz · +59552020020

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.7%10.2%15.4%better
Long-stay residents who lose too much weight2.4%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms1.8%7.3%6.5%better
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.4%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened3.2%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication7.9%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers1.9%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control4.1%10.2%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table12.4%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%93.2%79.4%better
Short-stay residents rehospitalized after admission15.4%23.0%22.6%better
Short-stay residents with an outpatient ER visit9.8%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days1.202.251.67better
Long-stay outpatient ER visits per 1,000 resident days1.661.571.80typical

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.

61.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 58 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.1%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.40U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 28 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 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF61.1%CMS range 47.8–74.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 5.4–14.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge50.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge42.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge42.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 discharge85.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 3.9–13.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.251.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.46
RN hours/ resident / day
1.32
LPN hours/ resident / day
2.01
Aide hours/ resident / day
3.79
Total nurse hours/ resident / day
0.22
RN hoursweekends
35.1%
Total nursing turnover
27.3%
RN turnover

How full it usually is: this home is certified for 99 beds and averages 83.0 residents a day — about 84% occupied, or roughly 16 beds typically open. It usually has some room. 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 3.79 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.27 hrs/resident/day on weekends vs 4.00 on weekdays — 18% thinner on weekends. RN hours go from 0.56 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

11
deficiencies at the latest standard inspection (2026-01-08)
6
at the previous standard inspection (2024-06-28)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2026-01-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for one of two sampled residents (Resident 6) who were reviewed for accidents, the facility failed to ensure two staff were present and bed rails were provided during incontinent care (providing support for individuals who cannot control their bladder or bowels) when Certified Nursing Assistant (CNA) 2 let go of Resident 6, with no bed rail to hold onto. Resident 6 fell out of bed and sustained fracture of the surgical neck of the left humerus with fracture line extension to the greater tuberosity (left shoulder fracture).During a review of Resident 6's admission Record (AR) dated 1/5/26, the AR indicated Resident 6 was admitted to the facility in November 2025 with multiple diagnoses that included hemiplegia (paralysis that affects only one side of the body) affecting right dominant side, and morbid obesity (severe obesity, excessive fat stores and a body mass index of 40 or higher (BMI, a measure of body fat based on height and weight, normal BMI…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-08 · tag F0641 — pattern
    Ensure 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 observation, interview, and record review, the facility failed to ensure accurate coding of the Minimum Data Set (MDS, a resident assessment tool to drive resident care plan) for four of seven sampled residents (Resident 42, 49, 52, and 64) when residents' tobacco use was incorrectly coded as No on the MDS despite evidence of tobacco use. This failure resulted in an inaccurate reflection of the residents' smoking status and had the potential to affect the development and implantation of resident-centered care plans.During a review of the admission Records (ARs) for Resident 42, 49, 52, and 64, printed on 1/7/25, the records indicated that these residents were admitted to the facility on [DATE], 12/3/25, 5/16/24, and 11/7/24, respectively.During observations on 1/6/26 and 1/7/26 at 11:35 a.m., Residents 42, 49, 52 and 64 were observed smoking on the recreation patio in Special Treatment Program (STP) unit.During an interview on 1/6/25 at 11:45 a.m., unit supervisor, Licensed Vocational Nurse (LVN) 2…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-08 · tag F0800 — pattern
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility document review, the facility failed to provide an accurate and complete diet manual reference for all diets provided in the facility.This failure had the potential to result in residents receiving diets that do not match physicians' orders. Findings:During a concurrent observation and interview on 1/06/2026 at 11:28 a.m. with Restorative Nursing Assistant/ Certified Nursing Assistant 1 (RNA/CNA 1) at the nursing station, RNA/CNA 1 could not locate the diet manual. Once RNA/CNA 1 received assistance, she was able to locate the manual. RNA/CNA 1 stated that she could not locate the information for the soft and bite size (SB6) diet in the diet manual. RNA/CNA 1 stated that she would not know where to find the information if she had questions about the diet.During a review of the facility's Generations Diet Manual for Bayberry Community, dated 10/20/25, the diet manual did not include information on the puree, soft and bite size (SB6) and minced and moist diets.During a review of the facility's Diet Spreadsheet (a sheet containing the kind…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-08 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure 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 facility document review, the facility failed to provide mechanically altered foods according to the menu for SB6 diets (a therapeutic, texture-modified eating plan for individuals with swallowing difficulties, weak chewing muscles, or high choking risks).This failure had the potential to result in decreased satisfaction with food and/or decreased nutrient intake for one out of six (Resident 26) residents receiving SB6 diets.Findings:During a review of Diet Spreadsheet, dated Tuesday Week 2 Day 11, the diet spreadsheet indicated the SB6 diet served for lunch was beef stroganoff (minced), egg noodles (chopped), spinach (chopped), white bread (slurry), cookie (chopped).During a concurrent observation and interview on 1/06/2026 at 12 p.m. with DC in the kitchen during trayline, Resident 26's tray contained chopped pieces 1/2 inch in length of beef stroganoff, chopped macaroni noodles, chopped spinach, slurry bread and a regular cookie. DC stated that the items on the tray do not match the diet spreadsheet for SB6 diet.During a review 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-08 · tag F0808 — failed to follow doctor-ordered diets — pattern
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility document review, the facility failed to prepare foods in a form designed to meet individual needs, as hard candy was found on resident's meal tray with a physician's order for SB6 diet (a therapeutic, texture-modified eating plan for individuals with swallowing difficulties, weak chewing muscles, or high choking risks). These failures had the potential to result in difficulty swallowing, chewing, and a decrease in food and nutrient intake in one out of six (Resident 26) residents receiving SB6 diets.Findings:During a concurrent observation and interview on 1/5/2026 at 12:24 p.m. with Resident 26 in her room, the lunch meal tray was on the bedside table in front of the resident. The meal tray contained all appropriate items in addition to two pieces of wrapped hard candy. Resident 26 stated The people who brought me the tray brought me the candy.During an observation on 1/5/2026 at 12:26 p.m. in Resident 26's room, Licensed Vocational Nurse 8 (LVN 8) walked in the room, delivered a container of Ensure (oral nutritional drink to help…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-08 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in a safe and sanitary environment when:1. Gloves were not used appropriately;2. Food preparation equipment and utensils were not clean or in good working condition;3. Ice machine bin was dirty and not cleaned per manufacturer instructions;These failures had the potential to result in contamination of food, food preparation equipment, and utensils used for food and/or leading to food borne illness for 78 residents who received food from the kitchen with a total census of 78.1.During an observation on 1/06/2026 at 12 p.m. in the kitchen during meal tray line, Dietary Aide (DA) used his gloved hands to touch a container of oil, handles on refrigerator, dial on stove and then touched ready to eat hamburger buns and cheese.During a review of the facility's P&P titled, Food Preparation, dated 2023, the P&P indicated, plastic gloves should be worn to avoid direct contact with food.Hands must be washed prior to putting on gloves and any glove changes.During 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-08 · tag F0813 — pattern
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility document review, the facility failed to ensure:Residents had a location to safely store perishable foods.Residents' food was separated from facility food.This failure had the potential to cause foodborne illnesses from unsafe food storage, decreased food intake and did not provide a homelike environment for 78 residents who consumed food out of a total census of 78.Findings:During a concurrent observation and interview on 1/05/2026 at 10:00 a.m. with DC in the kitchen, it was observed that a resident's popsicles were stored in the reach in freezer in the kitchen with facility food. DC stated that Nancy's popsicles are stored in the freezer for her to eat any time.During an interview on 1/05/2026 at 1:45 p.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated, the facility does not have a refrigerator, so perishable food must be consumed immediately. During an interview on 1/05/2026 at 1:55 p.m. with Registered Nurse Supervisor 2 (RNS 2), RNS 2 stated, there isn't a way to store perishable food. RNS 2 stated residents must consume…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-08 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview , and record review the facility failed to ensure safe infection prevention practices with census of 82 when: 1. Shared glucometer (device measuring blood sugar) was not cleaned and sanitized in-between resident care. 2. Licensed Nurse did not put on gloves before assessing Resident 14's swelling and redness to the Right eye. These unsafe practices could result in spread of infection among vulnerable elderly residents in the facility. Findings: 1. During a medication administration observation with Licensed Nurse (LVN 6), on 1/5/26, at 4:06 PM, at the Station 1 hallway, LVN 6 was observed placing a glucometer and supplies in a small tray and was taken into Resident 6's room to measure blood sugar (or BG). LVN 6 placed the tray on top of bedside table, then with gloved hand poked Resident 6's right index finger with lancet (a pricking device) to get drops of blood and then soaked the test strip (a small strip transmits blood content to glucometer machine) attached to the glucometer…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-08 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure safe pharmaceutical services with census of 82 residents when:Non-narcotic prescription drugs destruction was not witnessed by two licensed staff from April 2025 to August 2025.Hazardous drugs (or HD, medication that can cause harm posing risks to healthcare workers and patients through exposure during handling) were not stored and handled safely in the medication carts and during medication administration.These failed practices had the potential to result in drug diversion (unauthorized drug use) and unsafe drug handling for both staff and residents.Findings1. During an interview and record review, with Licensed Nurse (LVN 9), on 1/5/26 at 10:29 a.m., in Med Room on Station 2, LVN 9 stated non-narcotic prescription medications were disposed every 2 weeks and logged in the non-narcotic drug logbook. LVN 9 stated the disposal of non-narcotic drug form required only a one-person signature. LVN 9 confirmed there was only one signature on the non-narcotic drug disposal for April 2025 through August…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-08 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility failed to ensure medication use parameters ordered by the doctor were followed in 3 out of 30 sampled residents (Resident 4, Resident 6, and Resident 9) when:Resident 4's blood sugar parameters for insulin (drug in shot form to treat blood sugar disease) were not followed as ordered by medical doctor.Resident 6's opioid medication use did not follow the pain level ordered by the medical doctor.Resident 9's blood pressure drug parameter was not followed.These failed practices could contribute to unsafe medication use and residents not benefiting from prescribed medication and/or experience side effects.1. During a record review of the Resident 4's Order Summary Report, dated 1/8/26, the record indicated the following orders: NovoLOG Flex Pen Subcutaneous (or SC, inject under the skin) solution Pen-Injector (or Flex Pen, a pen shaped insulin container) . (insulin Aspart, a short acting insulin): Inject 3 units subcutaneously with meals . hold if patient doesn't eat meal; Start date: 10/21/25 (Novolog is a type on insulin, unit is 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-08 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure safe storage of medications and supplies with expired, unlabeled and comingled drugs in the medication's rooms and medication carts with resident census of 82.These unsafe practices had the potential for residents to receive medications with reduced potency and may contribute to medication errors.During an observation and concurrent interview, on 1/5/26 at 10:35 a.m., with License Vocational Nurse (LVN 9), in medication room on Station 2 , the following were observed:i. Comingled medications with different routes of administration were stored on the same shelf with no dividers. Medication included liquid prescription drugs, non-prescription pills were stored side by side with topical product such as topical head lice drug along with enema and rectal suppositories.ii. Expired medications and supplements were stored in the cabinets included: packages of Beneprotein (instant protein powder) with expiration date of 5/2025, Ingress (drug for movement disorder) with expiration date of 12/06/25, Nicotine gum…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2025-06-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 of three sampled residents (Resident 1) reviewed for allegations of abuse was free from physical abuse when Certified Nursing Assistant (CNA) 1 forcefully turned Resident 1 while on the shower chair, forcefully removed Resident 1's clothing, hitting Resident 1's hand, and pulling Resident 1's hair. This failure resulted in Resident 1 to experience physical abuse and pain. Findings: During a review of Resident 1's undated admission Record , the admission Record printed on 5/5/25 indicated, Resident 1 was admitted in the facility on 5/15/23 with a diagnosis of Alzheimer's disease (progressive brain disorder that gradually destroys memory and thinking skills, ultimately impacting the ability to carry out even simple tasks). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) , dated 1/20/25, the MDS indicated, Resident 1 had a Brief Interview for Mental Status (BIMS, is a scoring system used…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-06-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in a safe and sanitary environment when: 1. Kitchen Floors were not clean and maintained in good condition; 2. Chicken was not thawed safely; 3. The ice machine was not clean and was not cleaned according to manufacturer's instructions; 4. A can opener was not clean; and 5. Cutting boards were not clean and were in poor condition These failures had the potential to result in contamination of food, food preparation equipment, and utensils used for food, leading to food borne illness and/or food related illness for 80 residents who received food from the kitchen out of a census of 80. 1. An observation in the kitchen on 6/24/24 at 10:09 a.m., showed the floor between the reach in refrigerator and the warewashing sink with broken and missing tiles. The floor had an uneven surface. During an interview with the Maintenance Supervisor (MS) and a concurrent observation in the kitchen on 6/25/24 at 12:39 p.m., MS stated he was aware of the broken tiles throughout the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-06-28 · tag F0813 — widespread
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure: 1. Family members could bring in food for residents. 2. Residents had a location to safely store perishable food. 3. A policy described the safe storage of food brought in by family members. This failure had the potential to result in foodborne illness from unsafe food storage, decreased food intake, and did not create a homelike environment for 80 residents who took food by mouth out of a census of 80. Findings: During an interview on 6/24/24 at 11:21 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated that the facility did not have any refrigerators to store resident food in, and perishable foods were thrown away. During an interview on 6/24/24 at 11:25 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 confirmed that there was no refrigerator on the unit to store food in, and that perishable resident food was thrown away if the resident did not want to consume the food at the time it was provided. During an interview on 6/24/24 at 11:27 a.m., the Assistant Director of Nursing (ADON) stated…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-28 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure 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 facility document review, the facility failed to provide pureed vegetables according to the menu for residents receiving pureed diets. This failure had the potential to result in decreased satisfaction with food and/or decreased nutrient intake for four out of five (Residents 29, 54, 3, 30) residents who received pureed diets. Findings: An observation in the kitchen and interview with the Dietary Supervisor (DS) and [NAME] (C) 1 on 6/24/24 at 10:25 a.m., showed metal pans in the oven. C1 stated the food in the metal pans included pureed carrots. C1 stated he placed the pureed food in the oven about 9:50. DS stated tray line normally started about 11:45 a.m. Review of the Diet Spreadsheet dated Monday Week 2 Cycle 17, showed the vegetables served for lunch on 6/24/24 were sliced carrots, and the pureed textured diets received pureed sliced carrots. During an observation and interview with DS on 6/24/24 at 12:45 p.m., test trays were conducted, and the regular textured and pureed textured food served to residents for lunch were sampled. The pureed…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-28 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure proper labeling of biologicals (made from a variety of natural sources human, animal, or microorganisms and are used to treat, prevent, or diagnose diseases and medical conditions) when one opened multi-dose vial of Tuberculin Purified Protein Derivative (PPD- indicated to aid diagnosis of tuberculosis infection (TB) in persons at increased risk of developing active disease.) was unlabeled and undated with an open date. This failure had the potential for residents to receive a false test result due to Tuberculin PPD with reduced potency from being used past their discard date. Findings: During a concurrent observation and interview on 06/26/24 at 9:12 a.m. with RN (Registered Nurse) 1 in the medication room, one 1 milliliter (mL) multi-dose vial of PPD was in the refrigerator without a vial cap and a label of the open date. RN 1 stated, the vial could have been opened months ago and should have an open date label. During a concurrent interview and record review on 06/26/24 at 1:15 p.m. with IP…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-28 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure 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 facility document review, the facility failed to provide the texture of food prescribed for one resident (Resident 62). This failure had the potential to cause one Resident 62 to choke on the food provided out of 80 residents who received food from the kitchen. Findings: During a record review, Resident 62's admission Record showed Resident 62 was diagnosed with oropharyngeal phase dysphagia (swallowing problems occurring in the mouth and/or throat. During a record review for Resident 62, the Speech Therapy Treatment Encounter Note(s) dated 6/19/24 and 6/24/24 showed Resident 62 was assessed by SLP and current foods in both reports were Soft + Bite-Sized Foods SB6. A concurrent observation and document review during tray-line food service on 6/24/24 at 12:25 p.m., showed staff placed food on resident trays according to the physician prescribed diet printed on a tray ticket and the Diet Spreadsheet dated Monday Week 2 Cycle 17. The tray ticket for Resident 62 showed he was prescribed a Soft & Bite-Sized SB6, Mildly Thick Liquids, Renal diet. The…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-28 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure all equipment was maintained in good working order when one of three freezers did not maintain food frozen solid. This failure to improperly store food had the potential to result in decreased quality of food as well as foodborne illness to residents receiving food from the kitchen. Findings: During an observation on 6/24/24 at 9:29 a.m., the temperature of freezer 1 was 19 degrees Fahrenheit (F). Items inside the freezer, including individual cartons of supplement shakes and pie crusts were soft to the touch and not frozen solid. During a concurrent observation and interview on 6/24/24 at 10:05 a.m. with the Dietary Supervisor (DS), freezer 1 and its contents were observed again. Seven uncooked pie dough crusts labeled with a received date of 4/22/24 were all noted as being soft to the touch, along with 2 angel food cakes labeled with a received date of 5/24/24. The DS then opened two health shakes stored in the freezer, which were not frozen solid and had a gooey, pudding-like consistency and ice…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-11-19 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, the facility failed to ensure the medication rate was less than 5% for two of 19 sampled residents (Resident 23 and Resident 317). 1. For Resident 317, Licensed Vocational Nurse 5 (LVN 5) administered inhaler medications, Incruse Ellipta and Symbicort, for chronic obstructive pulmonary (lung) disease (COPD) and DuoNeb (treats COPD or wheezing and shortness of breath caused by asthma (airways become inflamed and narrow). Resident 317 was not instructed to rinse and spit after receiving Incruse Ellipta and Symbicort which were not administered in the correct sequence. 2. LVN 4 administered Tetrahydrozoline HCI (hydrochloride) (decongestant eye drop for eye irritation and redness). However, the physician ordered Pataday Solution eye drops (antihistamine for itchy, red eyes due to allergies) for Resident 23. Instructions for closing the eyes, and rotating the eyeball were not provided. These failures had the potential for Resident 317 to develop oral thrush (fungus) from not rinsing and spitting. Resident 23 received the wrong eye drops…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-19 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately code the discharge disposition of one of 19 sampled residents (Resident 68) on the discharge MDS (Minimum Data Set- an assessment used to guide care) assessment. This failure resulted in an inaccurate reflection of Resident 68's discharge disposition on the MDS assessment. Findings During an interview and record review on 11/19/21, at 9:34 a.m., with MDS Coordinator (MDSC), MDSC stated Resident 68's Discharge summary dated [DATE] was reviewed. MDSC stated Resident 68 was discharged home on 8/18/21. During an interview following the record review of the Discharge Summary on 11/19/21, 9:35 a.m., MDSC stated Resident 68's MDS discharge assessment wasin error and indicated Resident 68 was discharged to the Acute Care Hospital (possible return to the facility after a therapeutic leave to the hospital). MDSC stated Resident 68's inaccurate MDS coding resulted in an incorrect discharge disposition.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the hospice interdisciplinary team participated in the initial care plan for one (Resident 14) of nineteen sampled residents to address Resident 14's hospice care needs. This deficient practice had the potential to result in not receiving a person-centered hospice plan of care. Findings: Review of the admission Minimum Data Set - (MDS - an assessment screening tool used to guide care) dated 5/28/21, indicated Resident 14's diagnoses included respiratory failure (serious lung and breathing disorder). Resident 14 was on hospice care. Review of the Resident Care Conference dated 5/24/19, indicated Resident 14 was readmitted from home on 5/21/21 to the facility for hospice care. Further review of Resident 14's Resident Care Conference dated 5/24/21, indicated the interdisciplinary team members who participated in the care plan development did not include hospice representatives. During an interview on 11/18/21 at 12:31 p.m., Social Services Director (SSD) stated she coordinated Resident 14's 5/24/21 care plan…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-19 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow-up for one (Resident 62) of 19 sampled residents prescribed eyeglasses order for three months. This deficient practice resulted in Resident 62 having difficulty reading, prevented her from fully enjoying her pastime activities and seeing her surroundings clearly. Findings: During a concurrent observation and interview on 11/16/21, at 8:22 a.m., Resident 62 stated she was concerned about her eyeglasses that have not arrived yet and has been months. Resident 62 had two pairs of over-the-counter (OTC) eyeglasses from the Dollar store on the overbed table. Resident 62 stated the OTC eyeglasses do not help her vision. During an interview on 11/17/21, at 9:50 a.m., with the Social Services Director (SSD), SSD stated Resident 62 was seen by the optometrist (eye doctor) and started the order for Resident 62's eyeglasses back in August 2021. SSD stated she usually calls to follow-up with an order but could not provide documentation reflecting having checked the status of Resident 62's prescription eyeglasses.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-19 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 and record review, for one of five sampled residents (Resident 24) reviewed for unnecessary medications use, the facility failed to act upon the Consultant Pharmacist's (CP) report of a medication irregularity when an approved change in medication directions was not implemented. This failure did not ensure safe medication administration and had the potential for adverse side-effects. Findings: Review of Resident 24's admission Record indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included chronic pain. Review of CP's titled, Note To Attending Physician/Prescriber dated 9/10/21 indicated; This resident has an order for Lidocaine Patch 4% (treats pain) order needs to be clarified. Current directions of 2 patches is indicated for Lidocaine 5% (max of 3 patches) not indicated for Lidocaine 4%. Lidocaine 4% direction typically is 'apply 1 patch topically to affected area for up to 12 hours; max 1 patch on body at a time; usually limit use to 1 week'. CP's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to GENERATIONS HEALTHCARE — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 54.1≈ chain avg
Health inspection 3 of 53.6-0.6 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 5 of 54.6+0.4 vs chain
The other 26 homes this chain runs (chain average 4.1★, per CMS)
2 of 5Horizon Health & Subacute CenterFresno, CA 2 of 5Temecula Healthcare CenterTemecula, CA 2 of 5Walnut Creek Skilled Nursing & Rehabilitation CentWalnut Creek, CA 3 of 5Canyon Oaks Nursing And Rehabilitation CenterCanoga Park, CA 3 of 5English Oaks Convalescent & Rehabilitation HospitaModesto, CA 3 of 5Newport Nursing And Rehabilitation CenterNewport Beach, CA 3 of 5Smith Ranch Skilled Nursing & Rehabilitation CenteSan Rafael, CA 3 of 5The Bradley GardensSan Jacinto, CA 4 of 5Castle Manor Nursing & Rehabilitation CenterNational City, CA 4 of 5Cedar Crest Nursing And Rehabilitation CenterSunnyvale, CA 4 of 5Coronado Ridge Skilled Nursing & Rehabilitation CeHenderson, NV 4 of 5Gramercy CourtSacramento, CA 4 of 5Lompoc Skilled Nursing & Rehabilitation CenterLompoc, CA 5 of 5Anberry Nursing And Rehabilitation CenterAtwater, CA 5 of 5Arbor Hills Nursing CenterLa Mesa, CA 5 of 5Bradley CourtEl Cajon, CA 5 of 5Friendship Manor Nursing & Rehab CenterNational City, CA 5 of 5Heritage Park Nursing CenterUpland, CA 5 of 5Kearny Mesa Convalescent And Nursing HomeSan Diego, CA 5 of 5Lakeside Special Care CenterLakeside, CA 5 of 5Lawton Skilled Nursing & Rehabilitation CenterSan Francisco, CA 5 of 5Pleasanton Nursing And Rehabilitation CenterPleasanton, CA 5 of 5Plum Tree Care CenterSan Jose, CA 5 of 5Siena Skilled Nursing & Rehabilitation CenterAuburn, CA 5 of 5Stanford Court Skilled Nursing & Rehab CenterSantee, CA 5 of 5Vista Manor Nursing CenterSan Jose, CA

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 / managerTypeRoleSince
LIFE GENERATIONS HEALTHCARE, LLCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/21/2017
MASTROCOLA, LOISIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/21/2017
OLDS, THOMASIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 07/21/2017
SMITH, FREDIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 07/21/2017
BMO BANK NATIONAL ASSOCIATIONOrganization5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/22/2025
THERAGEN, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/15/2025
BARRERRO, AUGUSTOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/06/2016
BHAMBRA, PREETIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2025
DHADDEY, PRABJOTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/27/2022
ENDRIGA, CHONAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/30/2020
FETALINO, LEIGH ANNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/28/2019
HARRISON, DENNISIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/13/2018
JONES, BRANDINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/05/2023
MENDOZA, CHRISTINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/10/2021
SOLORIO, CYNTHIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/12/2022
CONTRA COSTA RE, LLCOrganizationADP OF THE SNFsince 09/01/2017

CMS files one row per role, so the 36 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

4 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.

$10.5M
Net patient revenuemost recent cost report
-18.9%
Operating marginrevenue minus expenses
$2.2M
Related-party expense18% of expenses
Who pays — share of resident-days
Medicaid 10%Medicare 8%Other / private 82%

This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$532per resident / day
operating cost
$16,168per month
≈ monthly operating cost
$447per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 056260. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

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

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