Sunny View Manor
22445 Cupertino Road, Cupertino, CA 95014 · Non profit - Corporation · 48 certified beds · (408) 454-5600 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (14% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,176 in federal fines (most recent 2024-04-18)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 improved from 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.3% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.2% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.8% | 0.8% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 1.7% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.0% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 1.6% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 24.9% | 9.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 8.5% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 91.7% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.0% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.9% | 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 table | 9.6% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 85.4% | 93.2% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 20.0% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 4.4% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.22 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.00 | 1.57 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
65.0% 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 140 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 83.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 49 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 0.31 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 65.0%CMS range 57.9–71.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.2%CMS range 6.3–12.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 83.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 81.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 75.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.8%CMS range 3.2–9.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.73 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 48 beds and averages 36.5 residents a day — about 76% occupied, or roughly 12 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 4.92 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.98 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.86 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 4.32 hrs/resident/day on weekends vs 5.16 on weekdays — 16% thinner on weekends. RN hours go from 1.04 to 0.83 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 14% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2024-04-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 staff promptly reported a significant change in condition to the physician for one of two sampled residents (Resident 1). Staff failed to promptly report a significant change in condition to the physician when Resident 1 showed a reduced level of alertness and Resident 1's Glasgow Coma Scale (a scale used to reliably measure a person's level of consciousness after a brain injury) was 9 out of 15 (where a score of 13 or higher correlates with mild brain injury, a score of 9 to 12 correlates with moderate brain injury, and a score of 8 or less represents severe brain injury). This failure resulted in Resident 1 not being seen promptly by a physician at the time of a change in condition (on 12/11/23) and/or to receive an acute care hospital evaluation, and as a result was subsequently not deemed a candidate for any intervention when admitted to an acute care hospital admission on [DATE], due to Resident 1's late presentation. Resident 1was then…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-17 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure 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
Based on observation, dietary staff interview and document review, the facility failed to conserve nutritional food value. The cooked food prepared for lunch on 4/14/25 were placed on the steamtable 1 1/2 hours prior to service. This failure had the potential to compromise nutritional quality and palatability of residents who received meals from the kitchen. Findings: Processing and cooking conditions cause variable losses of vitamins. Losses vary widely according to cooking method and type of food. Degradation of vitamins depends on specific conditions during the culinary process, e.g., temperature, presence of oxygen, light, moisture, pH, and, of course, duration of heat treatment (Journal of Food Composition and Analysis, June 2006). The molecular structure of vitamins makes them easily degradable under various conditions such as temperature. During kitchen observation on 4/15/25 beginning at 8:50 a.m., the following cooked food were placed in the steamtable; Tray 1 corned beef, Tray 2 chicken stew, Tray 3 potatoes, and Tray 4 pureed carrots. During an interview at the time of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-17 · tag F0801 — patternEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, dietary staff interview and document review, the facility failed to ensure staff competency when two of two kitchen staff did not follow manufacturer's instruction when testing the potency of a chemical used to sanitize kitchen cookware. This failure had the potential of cookware not being sanitized and placed residents at health risk. Findings: During a kitchen observation on 4/16/25, at 3:52 p.m., a kitchen staff was asked to test the potency of the sanitizer from the red bucket (standard receptacle containing sanitized solution used to clean food contact surfaces). The kitchen sous chef (SC, second in command of a kitchen) dipped the test strip into the red bucket for less than 5 seconds three times and began reading the results. On the third time the dipping of the test strip was timed and it was 4.97 seconds. During the observation the SC stated the solution was used to sanitize pots and pans. On 4/16/25, at 4 p.m., the registered dietitian (RD) was observed dipping three test strips each for less than five seconds. The temperature of the solution was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-17 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, dietary staff interview and document review the facility failed to ensure cooked foods were stored under safe temperatures and failed to cover meats and vegetables in the walk-in refrigerator. The failure of not verifying meat temperatures after blast chilling (rapidly chilling food with cold air) had the potential of causing food borne illness had the foods were not chilled to the correct temperature. The failure of not covering refrigerated foods had the potential to diminish its taste and placed the risk for food contamination. Findings: 1. During kitchen observation with the dietary supervisor (DS) on 4/14/25, at 9:30 a.m., there were food racks approximately five feet in length storing uncovered vegetables and meats of chicken, fish, beef and pork in the walk-in refrigerator. One of the tray contained marked or seared [NAME] broil beef, with four pork chop trays under. Another rack stored raw asparagus, partially cooked onion, bell pepper and eggplant on the top rack, foiled macaroni…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow the physician's order for administering oxygen (colorless and odorless gas which is essential for life) for one of two residents (Resident 83). This failure had the potential to compromise Resident 83's well- being. Findings: Review of Resident 83's clinical record indicated, Residet 83 was admitted to the facility with diagnoses which included heart failure (the heart is not pumping blood as effective), vascular dementia (a type of dementia (a general term for the loss of memory and other thinking abilities that interfere with daily life) caused by brain damage resulting from impaired blood flow, often due to stroke or other conditions affecting blood vessels), and iron deficiency. During an initial observation, of Resident 83, on 4/14/25, at 2:21 p.m., it was observed that the oxygen flow rate was set to 2 1/2 liters per minute (lpm, liters of oxygen flowing per minute). During an observation on 4/16/25, at 9:13 a.m., the oxygen flow rate was observed to be set at 2 3/4 lpm. During an observation and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-01-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage and preparation in the kitchen when: 1. Produce was not labeled or dated in the walk-in refrigerator. 2. Hot foods were not kept at 135 degrees Fahrenheit during meal service tray line. These failures had the potential for all residents in the facility to be introduced to food borne illnesses. Findings: 1. During a concurrent observation and interview on 1/8/24, at 8:43 a.m., with Director of Dining Services (DDS) in the kitchen, eight raw whole honeydew melons were noted to be in a non-manufacturer hard plastic container in the walk-in refrigerator. No labels or dates were noted on honeydew melons or the container. Three bags of raw shredded carrots, 1 bag of whole raw radish, 2 bags of raw wedged carrots, and 2 bags of raw pre-cut celery were noted in one non-manufacturer hard plastic container with no labels or dates. DDS stated, the honeydews, carrots, radishes and celery all do not have a date or label on them. They should be labeled and dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to implement infection control practices when: 1. Certified Nursing Assistant F (CNA F) did not perform hand hygiene in between Resident 83's bed making task and glove changed; 2. Certified Nursing Assistant G (CNA G) did not perform hand hygiene in between serving food to residents (Residents 15, 184, 16 and 8) and when assisting two residents with meals (Residents 5 and 83); and 3. Registered Nurse C (RN C) did not perform hand hygiene in between medication administration task and glove changed (Residents 134 and 233). These failures had the potential to compromise resident's health and safety in the facility. Findings: 1. During an observation on 1/8/2024 at 9:15 a.m., inside Resident 83's room, CNA F donned (put on) a new pair of gloves without performing hand hygiene. CNA F removed Resident 83's dirty linens and placed them in a laundry bag. She removed her dirty gloves and stepped out of the room to get clean linens located at the hallway without performing hand hygiene. CNA F went back to Resident 83'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.
- Potential for harm · D2024-01-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan when one of 12 sampled residents (Resident 233) did not have application of left-arm brace included in the Care Plan (CP). This failure had the potential to result in inadequate communication between staff in providing necessary treatment. Findings: During a review of Resident 233's physician orders dated 1/10/24, it indicated applying left hand resting brace everyday for up to two hours in the morning, two hours in afternoon as tolerated, monitor skin for redness/swelling or changes in skin integrity. During a review of Resident 233's CP, indicated there was no CP for the use of brace. During an interview on 1/12/24 at 12:25 p.m. with Director of Nursing (DON), DON stated there should be a care plan for the brace application. The DON confirmed there was no CP for the left-hand brace. She stated CP should be updated right away with a new order. She further stated to do so, Certified Nursing Assistants (CNA) would know the need and frequency of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-12 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure care and services were provided to meet the professional standards of practice for one of five sampled residents (Residents 233) when registered nurse C (RN C ) did not shake the Med Plus (nutritional supplement) as directed prior to pouring in the medication cup; the Med Plus was not dated when opened; and RN C provided a wrong consistency of Med Plus to Resident 233, nectar thick consistency (liquids that are easily pourable and are comparable to heavy syrup found in canned fruit) instead of thin liquids as diet ordered. These failures had the potential to jeopardize the health and safety of the residents. Findings: 1a. Review of Resident 233's face sheet (a document that gives a patient's information at a quick glance), dated 12/27/2023, indicated Resident 233 was admitted to the facility with diagnoses including hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness or the inability to move on one side of the body), and dysphagia (difficulty swallowing). During medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-12 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide care and services for effective communication when a facility did not provide language assistance or other communication aid to two of three sampled residents with language barrier (speaking in foreign language) (Residents 83 and 4). This failure had the potential to affect the psychosocial well-being of these residents and a decline in their activities of daily living. Findings: 1. During a concurrent observation and interview on 1/8/2024 at 9:08 a.m., Resident 83 was sitting up on a wheelchair and the certified nursing assistant F (CNA F) was also inside the room. CNA F stated Resident 83 was Mandarin speaking only. There was no communication binder/board or descriptive pictures observed inside the room. During a follow up observation on 1/8/2024 at 11:24 a.m., inside Resident 83's room, there were no communication binder/board or descriptive pictures on Resident 83's bedside drawers. Another observation on 1/9/2024 at 9:28 a.m., inside Resident 83's room, there was no on-site communication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-12 · tag F0700 — isolatedTry 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 and record review, the facility failed to ensure one of three sampled residents (Resident 16) remained free from accident hazards due to the use of bed rail (side rail) when Resident 16 had the left upper bed rail raised up while in bed without bed rail assessment, physician's order and care plan. This failure had the potential to put Resident 16 at risk for entrapment and serious injury. Findings: Review of Resident 16's face sheet (a document that gives a patient's information at a quick glance), last updated 12/21/2023, indicated Resident 16 was admitted to the facility with diagnoses including encounter for palliative care ( a specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), Alzheimer's disease ( a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and adult failure to thrive (when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). 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.
Show the remaining 16 citations
- Potential for harm · D2024-01-12 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a safe administration of medication and accurate accountability of controlled medications (those with high potential for abuse or addiction) when: 1. Registered nurse E (RN E) left the medication at resident's overbed table without ensuring Resident 136 had swallowed the solution. This failure had the potential for resident not taking the medications or having swallowing difficulty or choking without the nurse present for immediate help; and 2. Random controlled medication use audits for 2 out of 5 residents (Residents 135 and 8) did not reconcile. Two medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented in the Medication Administration Record (MAR) and two medications were signed out of the CDR, wasted with a witnessed nurse but was documented given in the MAR. There was a total of 4 controlled medications unaccounted for. This failure had the potential for misuse or abuse of controlled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that all drugs and biologicals (therapeutic substance like a vaccine or drug) are labeled in accordance with professional standards, when expired Prostat (liquid protein supplement) bottles were found in the medication storage room. This failure could potentially compromise the health and safety of the residents. Findings: During a concurrent observation and interview with Minimum Data Set Nurse (MDSN) on [DATE] at 8:38 a.m., inside the facility's medication room, two bottles of Prostat were stored with labeled expiration date of [DATE]. MDSN stated it should have been discarded and not stored inside the medication room. MDSN also stated nurses and central supply staff were responsible for making sure medications stored were not expired. During an interview with the Director of Nursing (DON) on [DATE] at 8:33 a.m., DON stated the expired Prostat should not have been stored in the medication room. DON further stated all expired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-12 · tag F0800 — isolatedProvide 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 record review, the facility failed to provide the correct therapeutic diet (A therapeutic diet is a meal plan that controls the intake of certain foods and food consistency) to one of 41 sampled residents (Resident 4) as ordered by Resident 4's physician. This failure had the potential for Resident 4 to choke on foods not prepared in the correct consistency. Findings: During an observation on 1/9/24, at 10:35 a.m. in the kitchen, [NAME] A requested a mechanical soft ground meal for Resident 4 from [NAME] B. [NAME] A was given a regular consistency (whole meat, not ground) and placed it onto Resident 4's meal tray in the meal cart, then moved onto the next resident's tray. During an interview on 1/9/24, at 10:45 a.m., with [NAME] A, [NAME] A stated, I asked for a mechanical soft ground meat, but was given a regular meal consistency. I plated the regular meal consistency for Resident 4, and the meal ticket tray shows mechanical ground soft is needed, not regular. During an interview on 1/9/24, at 11 a.m., with Registered Dietician (RD), RD 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.
- Potential for harm · Fcited before2022-10-14 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based of observation, interview, and facility document review, the facility failed to ensure the registered dietitian effectively carried out the functions of the Food and Nutrition Services as evidenced by lapses in the delivery of services associated with staff competency (Cross-reference F802), portion sizes for puree diets (cross-reference F803), food safety and sanitation (Cross-reference F812), and pests in the kitchen (Cross-reference F925). This failure to ensure food and nutrition services systems are accurately and effectively delivered may result in food borne illness for a highly susceptible population and/or not meeting the nutritional needs of the 31 residents who ate food by mouth from the kitchen out of a facility census of 32. Findings: Review of the facility job description titled Registered Dietitian (RD), revised October 2019 and signed 3/23/20 by Registered Dietitian (RD) and Administrator (ADMIN), indicated under Job summary: under the direction of the Director of Dining Services, the Registered Dietitian .works as a team with the [NAME] President of Nutrition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-10-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure safe sanitary practice in the kitchen. The facility failed to ensure food was stored and prepared under sanitary conditions when: 1. Time temperature control for safety foods (TCS - another name for Potentially Hazardous food)) that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation) were not properly cooled down, 2. Cups for fruit, and mugs for juice were stored with residue inside; 3. The meat slicer was stored with food particles on it; 4. The can opener had residue build-up around the blade and base; 5. No use by dates labeled on the eight pieces of vacuumized flat iron steak inside the walk -in refrigerator and thawing meat had no dates to indicate when it was put in the refrigerator; and 6. Four food storage bins and three utensil drawers had residue build-up, These failures had the potential to cause foodborne illness for the 31 residents receiving food from the kitchen out of a census…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-14 · tag F0802 — failed to prepare enough nourishing food — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service when one staff did not properly prepare pureed foods (a texture modified diet that minimizes the amount of chewing required and increases the ease of swallowing). This failure had the potential to decrease the attractiveness, flavor, and nutrients, possibly resulting in decreased dietary intake and may result in not meeting the nutrition needs for six residents receiving puree foods out of a facility census of 32. Findings: During a review of the facility menu titled Daily Therapeutic Menu dated 10/11/22 indicated for Lunch Tuesday the puree diet was to get puree chicken cacciatore, pureed risotto, and pureed mixed vegetables. The regular diet was to get chicken cacciatore, risotto, and mixed vegetables. a. During a concurrent observation and interview on 10/11/22, at 10:05 a.m., in kitchen, Food Service Worker H (FSW…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-14 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
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 a resident group agreed to a meal span of more than 14 hours between a substantial evening meal and breakfast the following day. This failure had the potential to not meet the needs of 31 residents eating meals at the facility out of a census of 32. Findings: During an observation on 10/12/22 at 11:56 a.m., the mealtimes posted in the dining room were Breakfast 7:35 a.m., Lunch 11:30 a.m., Dinner 4:55 p.m. The waiting time was about 14 hours and 40 minutes between dinner and breakfast. During the resident council meeting on 10/11/22 at 10:06 a.m., four residents stated the waiting time from dinner to breakfast takes too long. During an interview on 10/13/22 at 9:02 a.m., Resident 16 confirmed it was not ok for them to wait from dinner to breakfast more than 14 hours to have something to eat and she does not remember signing an agreement for it to be longer than 14 hours. During an interview on 10/13/22 at 1:35 p.m., Registered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-14 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure the proper disposal of garbage in the dumpster container when it was not properly contained, overflowing, and left open. This failure had the potential for a hazardous environment for the residents and staff due to possible harborage and feeding of pest. Findings: During a concurrent observation and interview on 10/11/22, at 10:57 a.m., at the garbage building outside the facility had two dumpsters, one was inside the covered garbage disposal site located outside by the facility's parking lot near the kitchen back entrance. The other dumpster was outside and open about three inches with trash bags sticking out. Registered Dietitian (RD) confirmed the observation, lid was not completely shut. During a concurrent observation and interview on 10/11/22, at 11:01 a.m., with the Maintenance Manager (MM), the MM verified the observation stating the garbage was overflowing and garbage pickup was every Monday, Wednesday, and Friday. The dumpster should have been inside the garbage building and should have been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-10-14 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure effective infection control process when: 1. An incentive spirometer's (I.S. medical device to improve lung function) hose was touching the table surface; 2. A dirty oxygen concentrator (medical device for oxygen therapy) was stored in the clean utility room; 3. Used hand sanitizing wipes were left on the dining table accessible to resident; 4. An opened dirty laundry bag was exposed on top of a dirty linen cart; 5. A nasal cannula tubing (device used to deliver oxygen to a person) did not have a date of placement and monitoring sheet; 6. Licensed Vocational Nurse F (LVN F) did not wash her hands before administering the eye drop to Resident 231, and LVN F did not wash or sanitize her hands after administering medication to Resident 231; 7. Resident 5's yankuer (suction tip), suction tubing, and canister (container for storing) had oral secretion inside, and they were not changed and undated; 8. Resient 9's nasal cannula was undated and was not monitored; and 9. Resident 229's used facial mask was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-10-14 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure the environment was free of pests as evidenced by flying insects seen near the kitchen drains and ant on the kitchen wall near the freezer. This failure to maintain an effective pest control program had the potential to cause a health hazard to the residents and staff eating food from the kitchen. Findings: During a concurrent observation and interview, on 10/10/22 at 08:50 a.m., noted one ant in the wall crawling near the freezer wall which verified by the Registered Dietitian (RD). During a concurrent observation and interview on 10/10/22 at 09:47 a.m., a black small flying insect was in the kitchen sink floor drain area with food particles in the strainer on the top of the kitchen drain. Registered Dietitian (RD) and Director of Dining Services (DDS) confirmed the observation. DDS further stated the sink drains are cleaned nightly and she would expect it to be emptied now. During a concurrent observation and interview on 10/10/22 at 09:49 a.m., three black small insects (one flying, two crawling)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-14 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dignity and respect for one of twelve sampled residents (Resident 2) when staff did not assist Resident 2 during lunch while another resident at the same table was already eating with staff assistance. This deficient practice violated the resident's right to be treated with dignity. Findings: During dining observation on 10/10/22 at 11:37 a.m., Resident 2 was sitting in the dining room waiting for staff to assist her with lunch. Another resident (Resident 8) at the same table was already eating with staff assistance. During a concurrent observation and interview with licensed vocational B (LVN B) on 10/10/22 at 11:52 a.m., LVN B confirmed the above observation and stated Resident 2 needed staff assistance with eating. LVN B further stated after the certified nursing assistants (CNAs) are done passing the lunch trays. LVN also stated the CNA would assist Resident 2 when she eat her food. During a concurrent observation and interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-14 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 safety when Resident 24 administered his own medication and it was not stored properly for one of twelve sampled residents (Resident 24). This failure had the potential to results in improper use of the medications. Findings: During the facility initial tour observation on 10/10/22 at 9:48 a.m., one tube of Neosporin ointment (used to prevent and treat minor skin infections caused by small cuts, scrapes, or burns) medication was observed on Resident 24's bedside table unattended. During a concurrent observation and interview on 10/10/22 at 9:54 a.m., with the director of staff development (DSD), She acknowledge the above observation and she stated that it was not the facility's practice to leave medication at bedside table. DSD also stated there was no physician order for Resident 24 to apply the medication. She further stated the medication should have been kept inside the treatment cart. During an interview on 10/11/22 at 8:30 a.m., with Resident 24 he stated the Neosporin ointment was brought by his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-14 · tag F0574 — isolatedThe resident has the right to receive notices in a format and a language he or she understands.
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 contact information of the California Department of Public Health District Office (CDPH DO) was accessible for four of four residents (Residents 4, 15, 16, and 20). This failure had the potential for residents not to file for complaints and grievances. Findings: During an interview with Residents 4,15,16, and 20 on 10/11/22 at 10:41 a.m., in the dining room for resident council meeting. All of them stated they did not know how to contact CDPH DO. They have not seen posters or signages indicating CDPH DO contact information. During an interview with Resident 16 on 10/22/22 at 10:45 a.m., she stated there was no information provided to them on the filing of complaints with CDPH DO since February 2022. She further stated no posters were available for them inside the facility on how they could call, e- mail, and contact CDPH DO. During a concurrent observation and interview on 10/11/22 at 11:03 a.m. with Life Enrichment Specialist (LES, activity director), there was no accessible postings or signages…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 necessary care and services in accordance with professional standards of practice for three of 12 residents (12, 14 and 16) when: 1. Resident 12 had an arteriovenous (AV) shunt (a connection made between an artery and a vein) for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) on her left upper arm. Certified nursing assistant D (CNA D) stated he took Resident 12's blood pressure on her left wrist; 2. Restorative nursing assistant (RNA) program was not followed for Resident 12 to provide two times per week instead of three times per week. Resident 16's RNA program three times per week instead of five times per week as ordered by the physician; and 3. Resident 14 had a Foley catheter (FC, tube that is inserted into the bladder to drain urine) drainage was not monitored and recorded. These failures had the potential to result in residents not receiving proper…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-14 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility had a 12 percent (% unit of measurement) error rate when three medication errors out of 25 opportunities were observed during a medication pass for three of 11 residents (9, 17, and 231). These failures resulted in medications not given in accordance with prescriber's orders, which had the potential for residents to not receiving the full therapeutic effect of the medications or had the potential for preventable side effects for the residents. Findings: 1. During a medication pass observation on 10/11/22 at 4:18 p.m., licensed vocational nurse E (LVN E) administered Artificial Tears to Resident 17 one drop to her right eye and two drops to her left eye. Review of Resident 17's physician order, dated 8/28/19, indicated she had an order for Refresh Tears ophthalmic solution 0.5%, instill one drop to both eyes two times a day for dry eyes. During an interview with LVN E on 10/11/22 at 5:59 p.m., she confirmed she administered Artificial Tears to Resident 17 one drop to her right eye and two drops to her left eye instead…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-14 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and facilty record review, the facility failed to ensure the planned menu was followed when two out of two residents (Residents # 20, 22) on regular pureed diets (texture modified diets for people with chewing or swallowing difficulties) were served the wrong portion size for the entrée. This failure had the potential to result in not meeting the nutritional needs thus further compromising the nutritional status of these residents, out of a facility census of 32. Findings: Review of the facility menu titled Daily Therapeutic Menus for Monday 10/10/22 Lunch indicated for the Puree diet, the following items: Puree Stuffed Bell Pepper (6 oz) (ounce), Puree Yellow Squash ½ cup, Mashed Potato (4 oz). During an observation of the lunch meal service on 10/10/22 starting at 10:41 a.m., in the presence of the Registered Dietitian (RD), Foodservice Worker G (FSW G) portioned foods onto plates and used a gray scoop to serve all the puree stuffed bell pepper. During a concurrent interview on 10/10/22 at 11:05 a.m., after all the plates were served, FSW G…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,176 in federal fines across 1 penalty.
- $8,176 — penalty dated 2024-04-18
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to FRONT PORCH — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.8 | +0.2 vs chain |
| Health inspection | 4 of 5 | 4.2 | -0.2 vs chain |
| Staffing | 5 of 5 | 4.9 | ≈ chain avg |
| Quality measures | 5 of 5 | 4.8 | +0.2 vs chain |
The other 8 homes this chain runs (chain average 4.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FRONT PORCH COMMUNITIES AND SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 10/01/2006 |
| DURANTEAU, NANCY | Individual | CORPORATE DIRECTOR | — | since 04/01/2021 |
| FORTE, VINCENT | Individual | CORPORATE DIRECTOR | — | since 04/01/2021 |
| HANDY, JOANNE | Individual | CORPORATE DIRECTOR | — | since 04/01/2021 |
| JACOBS, LAURA | Individual | CORPORATE DIRECTOR | — | since 01/01/2019 |
| KROEKER, KEVIN | Individual | CORPORATE DIRECTOR | — | since 01/01/2018 |
| MCGOVERN, MARION | Individual | CORPORATE DIRECTOR | — | since 01/01/2017 |
| SPENCER, PETER | Individual | CORPORATE DIRECTOR | — | since 01/01/2026 |
| TONNU, DIEMLAN | Individual | CORPORATE DIRECTOR | — | since 01/01/2018 |
| WESSON, OLIVER | Individual | CORPORATE DIRECTOR | — | since 01/01/2017 |
| WHITTAKER, SUSAN | Individual | CORPORATE DIRECTOR | — | since 01/23/2018 |
| KELLY, SEAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/06/2023 |
| SALVADOR, EDUARDO | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/03/2017 |
| VRANICH, RACHEL | Individual | CORPORATE OFFICER | — | since 06/17/2022 |
| AKOPYAN, GEVORK | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/12/2022 |
| BALAAN, MARITES | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/21/2014 |
| BURGOYNE, BRADLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/11/2024 |
| HUMPHRIES, SHEILA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2002 |
| ICHIEN, CHRISTOPHER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/04/2018 |
| MACANGO, SUSAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/04/2026 |
| MCMULLIN, MARY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2025 |
| OLSON, KARI | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2001 |
| MERKIN, NICKOLAS | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/05/2025 |
| NELSON, HARRY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/05/2025 |
| PENNINGTON, PAIGE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/05/2025 |
CMS files one row per role, so the 30 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
This home reported $383K 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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555342. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, 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 →
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