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Stonebrook Post Acute

4367 Concord Boulevard, Concord, CA 94521 · For profit - Limited Liability company · 120 certified beds · (925) 689-7457 Medicare & Medicaid certified

Call the home — (925) 689-7457 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Dec 20251 actual-harm citation$12,735 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $12,735 in federal fines (most recent 2026-03-23)

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 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4118 Phoenix St
Pharmacy
4424 Treat Blvd · (925) 676-4040 · Call to confirm hours
Grocery
Safeway0.9 mi
4309 Clayton Rd · (925) 356-2710 · Call to confirm hours
Park
4321 Concord Blvd · Typically dawn to dusk
Place of worship
4380 Concord Blvd · (925) 446-9501

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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 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 increased11.9%10.2%15.4%better
Long-stay residents who lose too much weight4.1%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 infection2.0%1.2%2.0%typical
Long-stay residents with depressive symptoms10.5%7.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury8.2%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened21.2%9.8%16.1%worse
Long-stay residents on antianxiety or hypnotic medication6.0%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 control23.7%10.2%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table7.6%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%93.2%79.4%better
Short-stay residents rehospitalized after admission26.4%23.0%22.6%worse
Short-stay residents with an outpatient ER visit15.2%11.2%12.0%worse

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.

57.2% 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 230 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.2%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
24.5%U.S. median 56.6%
Met the expected recovery
0.59U.S. median 0.31
Therapy hours / resident / day
0.27hours / resident / day
Physical therapy
0.28hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 24.5% 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 106 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 0.59 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 37% 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 SNF57.2%CMS range 51.4–62.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.2–14.310.7%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 discharge24.5%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 discharge27.4%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 discharge40.6%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 setting99.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.5%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 hospitalization6.4%CMS range 4.1–11.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.711.02Oct 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

0.66
RN hours/ resident / day
1.48
LPN hours/ resident / day
2.57
Aide hours/ resident / day
4.71
Total nurse hours/ resident / day
0.48
RN hoursweekends
32.2%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 109.7 residents a day — about 91% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 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 4.22 hrs/resident/day on weekends vs 4.90 on weekdays — 14% thinner on weekends. RN hours go from 0.73 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% 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

4
deficiencies at the latest standard inspection (2026-06-25)
5
at the previous standard inspection (2025-03-06)

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

Inspection deficiencies

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

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · Gcited beforedisputed · IIDR2026-03-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled Residents' (Resident 1) was free from accidents during incontinence care (the management and support for individuals with involuntary urine or stool leakage, aiming to maintain hygiene, skin health, dignity, and quality of life).This failure resulted in Resident 1 falling out of bed and sustaining a bruise (discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) to the forehead, perinasal hematoma (accumulation of blood within the nasal septum, which is the wall of cartilage and bone that divides the two nostrils), right elbow abrasion (a superficial, minor injury where the top layer of skin is scraped or rubbed away), and right femoral fracture (a serious, high-impact break in the longest, strongest bone in the leg, usually caused by severe trauma like car accidents or falls). During a review of Resident 1's admission Record, printed on 2/5/26, the admission Record indicated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-06-25 · 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 record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when:The dishwashing machine failed to reach the required sanitization temperature.Two dietary staff did not wear required beard restraints while in food preparation areas.This failure had the potential to result in food contamination and foodborne illnesses for a medically vulnerable population with a census of 114 residents.Findings:During a concurrent observation and interview on 6/22/26 at 1:53 p.m. in the Main Kitchen with Dietary Aide (DA) 1, DA 1 was operating the facility's dishwashing machine with a stationary rack and dual operating temperatures. The temperature gauges on the machine, labeled Rinse 180oF (Fahrenheit, unit of measurement for temperature) (MIN [minimum]), indicated a temperature of 170oF during the rinse cycle. DA 1 confirmed the temperatures were not rising to the minimum required temperature of 180oF for the rinse cycles.During an interview on 6/22/26 at 2:21 p.m. with the Dietary Supervisor…

    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 before2026-06-25 · 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 ensure infection prevention and control practices was consistently implemented for three (Resident 88, 72 and 38) of 23 sampled residents when: Airborne Precautions (infection control measures used to prevent the spread of illnesses transmitted by tiny pathogens suspended in the air) for Resident 88 was not followed when the door to resident's room was open.Registered Nurse (RN) 1 did not wear a gown to administer antibiotics intravenously (IV, route directly into the bloodstream) to Resident 72 on Enhanced Barrier Precautions (EBP, infection control intervention used to reduce the transmission of multi-drug-resistant organisms (MDROs) by wearing gown and gloves during high contact resident care activities). The Oxygen (O2) concentrator (a medical device that draws in ambient air and delivers concentrated oxygen) for Resident 38 had a dusty filter.These failures had the potential to increase the risk of transmission of infectious organisms…

    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 · D2026-06-25 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure the rights of one of 23 sampled residents (Resident 3), when Resident 3 did not give informed consent for an antidepressant (medications used to treat major depressive disorder-severe mental health condition causing persistent sadness, hopelessness, and a loss of interest in activities) medication.This failure resulted in Resident 3 not being informed of potential side effects or complications and the ability to refuse treatment.During a review of Resident 3's Order Summary (OS), dated 4/28/26, the OS indicated Resident 3 had Venlafaxine (antidepressant) ordered for major depressive disorder.During a review of Resident 3's Psychotherapeutic Drug Informed Consent Forms (IC), there was no IC before 6/22/26 for Venlafaxine.During an interview on 6/25/26 8:37 a.m. with Supervisor Registered Nurse (SRN) 1, SRN 1 stated the purpose of informed consent for antidepressants was to ensure the resident and resident's representative understood the indications for use, symptoms, and side effects before making a decision about…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-25 · 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

    Based on observation, interview and record review, the facility failed to ensure safe smoking practices were implemented and monitored for one of 23 sampled residents (Resident 52) who used the designated smoking area. This failure placed Resident 52 and other residents who accessed the smoking area at risk for an uncontrolled fire and potential burns.Findings:During an observation on 6/24/26 at 7:45 a.m. the designated smoking area was observed to have no safety equipment, including the absence of a fire extinguisher or fire blanket. Multiple used cigarette butts were noted discarded in a flower planter rather than in proper receptacles. During an observation on 6/24/26 at 9 a.m. Resident 52 was noted to be smoking in the designated smoking area. During an interview on 6/24/26 at 2:35 p.m. with Administrator (ADM), ADM stated, there was no safety equipment placed in the smoking area. The ADM further stated he did not know who was responsible for monitoring the smoking area.During a review of the facility's policy and procedure (P&P) titled, Smoking Policy-Residents dated July 2017,…

    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 · D2025-12-29 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure for one of two sampled residents, (Resident 2) the Physician's Orders for Life Sustaining Treatment (POLST) was completed and the Do not Resuscitate physician order was followed during a medical emergency. This failure resulted in medical interventions for CPR (Cardiopulmonary Resuscitation - an emergency technique combining chest compressions and rescue breaths to maintain blood flow and oxygen to the brain and vital organs when someone's heart has stopped (cardiac arrest) and defibrillation (uses an electrical shock inside or outside the body to stop an abnormal heart rhythm in the heart's ventricles to allow the heart to start a normal rhythm again) on Resident 2 which were not requested. During a review of Resident 2's admission record (AR), the AR indicated Resident 2 was originally admitted [DATE], initially admitted on [DATE], and readmitted on [DATE] and discharged to the hospital on [DATE]. AR indicated Resident 2 was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-29 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the results of the investigations of an abuse allegation were reported timely to the State Agency (SA, which is the California Department of Public Health, CDPH), for one sampled resident (Resident 1) when Resident 1 alleged that staff was rough with him.This failure had the potential to compromise the safety of all residents in the facility from unreported investigations and results of the investigations. Review of Resident 1's admission record, undated, indicated that he was admitted on [DATE] with diagnoses that included diabetes, urine retention, and hyperlipidemia.Review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool used to guide care) dated 8/23/25 indicated Resident 1's Brief Interview for Mental Status (BIMS- a short scanner to help detect cognitive impairment) score was 14, indicating no cognitive impairment.During a review of the social services note (SSN) note dated 8/7/25, the SSN note indicated,…

    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 · E2025-12-22 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain a homelike environment when three out of four sampled rooms (Room A, B, and C) were observed to have privacy curtains that were worn and frayed along the bottom and side edges, detracting from the homelike appearance of the resident rooms. This failure had the potential to negatively affect the residents' quality of life and homelike environment.During a concurrent observation and interview with Housekeeping Supervisor (HS) on 12/18/25 at 9:29 a.m., the bottom hems of the privacy curtains in room A and B were frayed with loose threads that were hanging down, and the fabric linings/nettings were exposed and detached near the lower edge. The side hem of the privacy curtain in room C appeared worn and frayed. The HS stated the curtains were torn and in need of replacement. HS stated there was no schedule for the facility staff to routinely check and inspect the curtains; instead, inspections were conducted on an as-needed basis. HS stated checking the condition of the privacy curtains was on his to-do…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · tag F0641 — isolated
    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 interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 3 (Residents #24, #54, and #87) of 18 sampled residents. Findings included: A facility policy titled, Health Information Record Manual, revised [DATE], specified, The assessment portion (Minimum Data Set - MDS) will describe the resident's ability to perform daily life functions and significant impairment in functional capacity. 1. An admission Record revealed the facility admitted Resident #24 on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of spinal stenosis, chronic obstructive pulmonary disease, dementia, and major depressive disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident's code status…

    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 · D2025-03-06 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    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 refer the resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASARR) evaluation once a resident was identified to have a new mental illness diagnosis for 1 (Resident #22) of 1 sampled resident reviewed for PASARR. Findings included: A facility policy titled, Preadmission Screening & Resident Review, revised 11/30/2023, revealed, 1. Facility will: a. Coordinate assessments with the pre-admission screening and resident review program under Medicaid to the maximum extent practicable to avoid duplicative testing to include: F644 483.20(c) i. Incorporating the recommendations from the [PASARR] level II determination and the [PASARR] evaluation report into a resident's assessment, care planning, and transitions of care. ii. Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status…

    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 · D2025-03-06 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 assess a resident for the use of a bed rail for 2 (Resident #20 and Resident #34) of 4 sampled residents reviewed for accidents. Findings included: A facility policy titled, Proper Use of Bed Rail Policy, dated 01/30/2025, indicated, 1. An assessment will be made to determine the resident's symptoms or reason for using bed rails. This assessment may be completed at the following intervals: upon admission, readmission, quarterly and change of condition status. 1. An admission Record indicated the facility readmitted Resident #20 on 10/30/2021. According to the admission Record, the resident had a medical history that included diagnoses of polymyalgia rheumatica (an inflammatory disorder that caused muscle pain and stiffness) and a history of falling. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/2025, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2025-03-06 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and document review, the facility failed to provide timely follow up of medically related social services to obtain dental services related to the replacement of dentures for 1 (Resident #54) of 1 sampled resident reviewed for dental services. Findings included: The undated Social Service Designee/Discharge Planner job description, revealed, The primary purpose of your job position is to assist in planning, developing, organizing, implementing, evaluating, and directing social service programs in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. The job description specified the duties and responsibilities included, Assist in obtaining resources from community social, health and welfare agencies to meet the needs of the resident. An admission Record revealed the facility admitted Resident #54 on 08/15/2022. According to the admission Record, the resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-06 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to: implement enhanced barrier precautions for 1 (Resident #34) of 1 sampled resident reviewed for tube feeding; perform hand hygiene when gloves were removed during the provision of care for 1 (Resident #29) of 1 sampled resident reviewed for pressure ulcer/injury and 1 (Resident #34) of 1 sampled resident reviewed for tube feeding; and store respiratory equipment for 1 (Resident #24) of 4 sampled residents reviewed for respiratory care. Findings included: A facility policy titled, Enhanced Standard (Barrier) Precautions, last reviewed 01/30/2025, indicated, Policy: The facility will implement Enhanced Standard Precautions (ESP), also known as Enhanced Barrier Precautions (EBP), when performing any direct patient care where close body contact presents the potential of transmitting known or unknown organisms. Definitions: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 address and make prompt efforts to resolve complaint allegation for one (Resident 1) of three sampled residents when facility did not thoroughly investigate and provide timely response to Resident 1 ' s allegation that Certified Nursing Assistant (CNA1) dragged and bumped his right foot into a wall while pushing him in wheelchair. This failure had the potential to cause Resident 1 emotional distress. Findings: During a review of Resident 1's Admission-Minimum Data Set (MDS - a federally mandated resident assessment and care guide tool), dated 10/3/24, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15 and indicated intact mental status. MDS indicated Resident 1 was able to recall the correct year, month and day of the week. Resident 1 had…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-27 · 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 interview and record review, the facility failed to ensure a licensed vocational nurse (LVN 1) administered medication accurately and safely to one of two sampled residents (Resident 1) according to the physician orders when Bengay cream (used to treat minor aches and pains of the muscles/joints) was administered instead of a skin barrier cream on Resident 1 ' s moisture associated skin damage (a form of incontinence-associated dermatitis, which is inflammation of the skin from extended exposure to urine or stool). This failure resulted in pain and discomfort for Resident 1. Findings: A review of the admission Record for Resident 1 indicated Resident 1 was initially admitted in March 2018 with diagnoses that included dementia, diabetes, asthma, and osteoarthritis. 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 8/14/24, indicated a score of 3 on her Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident ' 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
  • Potential for harm · D2024-03-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one resident (Resident 1) of three sampled residents received care to prevent the development of a pressure injury (damage to skin because of continuous pressure) when Resident 1 developed a Stage 3 pressure injury on the sacrococcygeal (the area between the hip bone on person ' s back and the tailbone) region. This failure resulted in Resident 1 obtaining a facility acquired Stage 3 pressure injury (the loss of skin which extends to the tissue beneath the skin). Findings: A review of an admission record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses which included rheumatic tricuspid insufficiency (a heart condition in which the valve between two heart chambers does not close properly resulting in the heart working harder than it should), chronic combined systolic and diastolic heart failure (a condition in which the heart does not pump blood as well as it should) , and pulmonary hypertension (high blood…

    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 · D2023-08-30 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to notify and consult with the physician when Resident 1 had a change in condition. This failure had potentially resulted in delayed management of a change in health status. Findings: During a review of Resident 1's Order Summary Report dated 3/1/22, the Order Summary Report indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture of the right thigh, elevated white blood cell count (WBC, blood component that fights infection), and diabetes mellitus. During a telephone interview on 8/30/23 at 8:13 a.m. with Family Member (FM) 1, FM 1 stated there was a big change in Resident 1's health condition during a visit at the facility on 3/18/22 that licensed nurses failed to see. FM 1 stated Resident 1 had refused to eat and was lethargic (sluggish). During an interview and concurrent record review on 8/30/23 at 12:06 p.m. with Director of Nursing (DON), Resident 1's Progress…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 was administered doxycycline (a prescription antibiotic, treats infection) with adequate monitoring of adverse effects from the medication. This failure had the potential to result in delayed management of adverse effects and unnecessary use of medication. Findings: During a review of Resident 1's Order Summary Report dated 3/1/22, the Order Summary Report indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture of the right thigh and elevated white blood cell count (WBC, blood component that fights infection). The report also indicated Resident 1 received doxycycline monohydrate (antibiotic, treats infection) 100 milligram tablet one tablet every 12 hours. During a review of Resident 1's Medication Administration Record (MAR) for March 2022, the MAR indicated Resident 1 received doxycycline twice daily from 3/1/22 to 3/18/22. The MAR did not…

    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 · F2023-06-28 · tag F0655 — widespread
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop Baseline Care Plan (BCP) and provide written summary of the care plan to resident (s) and /or resident's representative for 31 of 31 sampled residents (Residents 9, 22, 28, 31, 43, 73, 74, 77, 281, 431, 180, 280, 430, A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q and R) when: 1. For Resident 9, 22, 28, 31, 34, 73, 74, 77, 281, 431, K, L, M, N, O, P, Q and R's BCP for dietary, therapy and social services were not developed within 48 hours of admission. There was no evidence a copy of the BCP summary was provided to the resident or resident's representative. 2. For Resident 180, 280, 430, A, B, C, D, E, F, H, I and J, there was no evidence that a copy of BCP summary was provided to resident and /or resident's representative These failures had the potential to result in lack of communication, increased risk of adverse events due to inappropriate and inadequate care and services. And potentially had the staff, resident, and resident's family…

    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 · F2023-06-28 · tag F0802 — failed to prepare enough nourishing food — widespread
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    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 kitchen staff were competent in job duties related to 1. Testing the sanitizer liquid in the red sanitization bucket. 2. Using the three compartment sink This failure has the potential for improper cleaning and sanitization which could lead to increase in risk for food-borne illness for 82 out of 82 residents. Findings: 1. During a concurrent observation and interview on 6/26/23 at 12:55 p.m., in the kitchen, [NAME] (CK 1) was observed filling a red sanitization bucket with sanitizer liquid. CK 1 then demonstrated how she filled the buckets and stated she tests the solution with test strip. She was observed testing the sanitizing solution with sanitizer strip by removing a test strip from a quaternary ammonium (a type of sanitizer) from the sanitizer strip container. She held the test strip in the solution for 8 seconds and compared the color of the test strip to the color chart inside the test strip container. CK 1 stated, she should have held the test strip in the solution for 2 seconds. During a…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-06-28 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility failed to provide palatable food when food was served bland (lacking flavor). This failure has the potential for 82 out of 82 residents to consume less food resulting in consumption of less calories and nutrients provided by the planned menu. Findings During a review of the Diet Extensions dated Tuesday, Week 3, [NAME] SS 2023 and used for lunch on 6/27/23, the Diet Extension indicated, the regular consistency food included Baked Pork Chop, Cornbread Dressing, and Squash Medley. The Minced and Moist food included minced and moist pork chop, pureed cornbread dressing, and minced and moist squash medley. During a review of the undated recipe titled Pork Chop Baked f/Bnls (Baked Pork Chop), the recipe indicated, the ingredients included pork chop, ground black pepper, paprika, garlic powder, all purpose flour, low sodium chicken base paste, and tap water. During a review of the undated recipe titled Dressing Stuffing Cornbread, the undated recipe…

    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 before2023-06-28 · 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 record review, the facility failed to store, prepare, distribute, and serve food safely when 1. Kitchen staff did not follow approved hand hygiene and glove use procedures when changing gloves 2. 7 clear containers of various powders, 18 servings of frozen dessert, and one bag of green lettuce was not dated and labeled. These failures have the potential of placing 82 out of 82 residents at risk for food borne illness. Findings: 1 During a concurrent observation and interview on 6/26/23 at 12:55 p.m., with [NAME] (CK 1) in the dishwashing area of the kitchen, CK 1 was observed taking off her gloves and putting on new gloves when asked to fill a red sanitization bucket without washing her hands. CK 1 stated, she forgot to wash hands when changing gloves. CK 1 also stated, that it is important to wash hands to lower risk of spreading infection. During a review of facility's policy and procedure titled Handwashing and Glove Use, dated 2022, indicated 2. When gloves are used, hand washing must occur .prior to putting on gloves and whenever gloves are…

    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 · E2023-06-28 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 56 and Resident 62) received finger nail care. Resident 56 and Resident 62 had long, thick fingernails with black matter underneath in both hands. This failure placed Resident 56 and Resident 62 at risk for infection. Findings: During a review of Resident 56's admission record titled Resident Information dated 6/26/23, the record showed Resident 56 was admitted on [DATE] with primary diagnosis of Alzheimer's Disease (loss of memory). During a review of Resident 56's Minimum Data Set (MDS- an assessment used to plan resident care) dated 4/16/23, the MDS indicated, Resident 56's Brief Interview for Mental Status (BIMS- a cognition status assessment) was three, indicating impaired mental status. Resident 56 required one staff physical assist to maintain her personal hygiene. During a concurrent observation and interview on 6/25/23, at 2:46 p.m., with Certified Nursing Assistant (CNA) 40, in 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-28 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 trim and clean toenails for one of one sampled resident (Resident 62). Resident 62's both great toenails were dark yellow-brown, thick, curved-in and long about one inch in length. This failure resulted in Resident 62 to not receive toenail care for three months, placed Resident 62 at risk to get toenails yeast infection and dislocate her both great toenails. Findings: During a review of Resident 62's admission record titled Resident Information dated 6/27/23, Resident 62 was admitted on [DATE] with diagnosis of Right Hemiplegia (complete paralysis). During a review of Resident 62's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/7/23, showed Resident 62's Brief Interview for Mental Status (BIMS- a mental status exam) was three (3) out of 15, indicating severely impaired mental status. The MDS assessment also indicated, Resident 62 required one staff's extensive assist with personal hygiene. During a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-28 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide upper and lower body Range of Motion (ROM) and walking exercises to one of three sampled residents (Resident 65) per plan of care. Resident 65 received walking exercises for four (4) out of 12 scheduled visits and upper/lower body ROM exercises for three (3) out of 12 scheduled visits over a period of one month. This failure had the potential to result in Resident 65 feeling not receiving good care and placed her at risk for further decreased in limitation of (ROM) and walking. Findings: During a review of Resident 65's admission record titled Resident Information dated 6/27/23, Resident 65 was admitted on [DATE] with diagnosis of Repeated Falls. During a concurrent observation and interview on 6/25/23, at 3:36 p.m., Resident 65 was lying in bed. Resident 65 stated, she was not receiving enough therapy/exercises on a regular basis, and it made her feel she was not getting good care at the facility. During a concurrent record review…

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

    Quality of Life and Care 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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

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

$12,735 in federal fines across 1 penalty.

  • $12,735 — penalty dated 2026-03-23

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
HEALTH MANAGEMENT INCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2011
HIGHTOWER, TODDIndividualDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2011
COOPER, LORIIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2016
RONCAGLIOLO, YVETTEIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2016

CMS files one row per role, so the 16 rows in the source record cover these 4 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.

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

Follow the money — this home’s finances

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

$18.8M
Net patient revenuemost recent cost report
-10.1%
Operating marginrevenue minus expenses
$939K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 54%Medicare 8%Other / private 38%

This home reported $939K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$639per resident / day
operating cost
$19,439per month
≈ monthly operating cost
$581per 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 555421. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-25, 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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