Dinuba Healthcare
1730 South College Ave., Dinuba, CA 93618 · For profit - Partnership · 97 certified beds · (559) 591-3300 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 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 held steady at 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.
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 | 8.1% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.8% | 4.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.6% | 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 | 0.6% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 17.6% | 9.8% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 12.6% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.5% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 7.0% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.6% | 12.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.2% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.3% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.1% | 11.2% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.79 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.87 | 1.57 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
52.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 47.8% 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 23 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 52.5%CMS range 40.3–62.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 6.2–13.9 | 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 | 47.8% | 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 | 43.5% | 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 | 34.8% | 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 | 95.1% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 2.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.1%CMS range 4.2–14.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 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 97 beds and averages 89.6 residents a day — about 92% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.71 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.69 hrs/resident/day on weekends vs 4.04 on weekdays — 9% thinner on weekends. RN hours go from 0.28 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · Gcited before2023-08-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 supervise and monitor one of three sampled residents (Resident 1) when Resident 1 was outside of the facility during a hot weather. This failure resulted in Resident 1 eloping (to leave a healthcare facility without permission, authorization, or supervision) and being admitted to the hospital for two days due to heat stroke (a heat-related illness, occurs when the body can no longer control its temperature and the body's temperature rises rapidly). Findings: During a review of the facility's Risk Review Note (RRN-summary of investigation), dated July 6, 2023, the RRN indicated, [On 7/4/23] Resident [1] was observed by staff member to be sitting in the wheelchair in the front patio with another resident at approximately 4:10 p.m. Was noted to have left the premises at approximately 4:35 p.m. At approximately 5:10 p.m., fire department alerted staff he [Resident 1] was being transported to hospital after he was found in close by neighborhood. During an observation on 7/18/23 at 10:20 a.m., at the front patio 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 · Dcited before2026-02-09 · 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 ensure one of two sampled residents (Resident 1)'s care plan was implemented after a fall incident. This failure had the potential for Resident 1 to experience subsequent falls.Findings:During a review of Resident 1's IDT (interdisciplinary team-group of professionals who work together to provide comprehensive, patient-centered care)-Post Fall Review (IDTPFR) dated 2/3/26, the IDTPFR indicated, 2/3/2026 1:50 p.m. fall was unwitnessed.Approx (approximately) 1347 (1:47 p.m.) writer heard shouting from staff member that resident is found on the floor, noted to be bleeding.upon arrival residentis [sic] laying on right side in cradle positioning.Indicate all intervention recommendations and IDT Referrals.nonskid tape (adhesive tape with a textured, abrasive surface designed to increase traction and prevent slips and falls on slippery or hazardous surfaces) at bedside.During a review of Resident 1's Care Plan (CP) dated 2/4/26, the CP indicated, The resident is at risk for falls related to her poor…
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 before2026-01-08 · tag F0578 — failed to honor advance directives / code status — patternHonor 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 their Advance Directive (legal document that specifies a person's medical care and end of life wishes, should the person become unable to communicate those wishes) questionnaire contained all the necessary regulatory requirements for five of eleven sampled residents (Resident 1, Resident 10, Resident 8, Resident 76, and Resident 3). 2.Ensure one of 22 sampled residents (Resident 13) had a signed and dated Advance Directive. These failures had the potential for residents' rights to formulate an advanced directive and for medical care wishes and/or end of life issues to not be honored.Findings: 1.During a record review on 1/6/26 at 2:26 p.m., Resident 1's Advance Directive Questionnaire (ADQ) was reviewed. The ADQ did not have a question that asked if Resident 1 wanted more information on how to execute an advance directive. During a record review on 1/6/26 at 2:34 p.m. Resident 10's ADQ was reviewed. The ADQ did not have a question that asked if…
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 before2026-01-08 · 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
Based on observation, interview, and recorded review, the facility failed to follow its policy and procedure (P & P) titled, Assistance with Meals, for three of four sampled Residents (Resident 11, Resident 32, Resident 22) when the Certified Nursing Assistant's (CNA)'s was standing while assisting Resident 11, Resident 32, and Resident 22 during lunch meal. This failure had the potential for Resident 11, Resident 32, and Resident 22 to negatively impact their dignity while being assisted with meals.Findings:During an interview on 1/5/26 at 12:25 p.m. with CNA 3, CNA 3 stated there was usually two staff members assisting in the dining room. CNA 3 stated today she was the only one assisting in the dining room. During an observation on 1/5/26 at 12:37 p.m. in the dining room, CNA 3 was standing over Resident 32 while assisting her with feeding.During an observation on 1/6/26 at 12:33 p.m. in the dining room, CNA 4 placed a spoonful of pureed food into Resident 22's mouth while standing over her.During an interview on 1/7/26 at 1:41 p.m. with CNA 5, CNA 5 stated the process for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS- resident assessment tool) assessment was accurate for one of five sampled residents (Resident 76). This failure resulted in an inaccurate medical record.Findings:During an interview on 1/6/26 at 10:08 a.m. with Resident 76, Resident 76 stated a hospice (program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) aide took her outside to smoke three times a week. Resident 76 stated she smoked two cigarettes each time she was taken outside to smoke.During an interview on 1/7/26 at 10:17 a.m. with Director of Nursing (DON), DON stated Resident 76 is on hospice care and is the only resident in the facility who has smoking privileges. During a concurrent interview and record review on 1/7/26 at 11:11 a.m. with DON, Resident 76's MDS was reviewed. MDS Section J- Health Conditions question J1300, dated 11/20/25 was reviewed. Question J1300 indicated, Current Tobacco Use. No. DON stated the tobacco use MDS assessment 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 · D2026-01-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure communication services were available for one of 22 sampled residents (Resident 58) who did not speak English. This failure had the potential for Resident 58's needs go unmet.Findings:During a concurrent observation and interview on 1/5/26 at 10:30 a.m. with Certified Nursing Assistant (CNA) 2 in Resident 58's room, Resident 58 was speaking in her native language. CNA 2 stated Resident 58 speaks [NAME] (language spoken in [NAME]). CNA 2 stated there was no communication board or any picture board to know what Resident 58 was saying. CNA 2 stated she did not speak [NAME]. During an interview on 1/6/26 at 10:40 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was not aware of any translation services offered by the facility. LVN 1 stated one staff member, Registered Nurse (RN) 1, spoke [NAME] and could communicate with Resident 58, when she was working. During a review of the facility's current January schedule, RN 1 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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 an activity assessment and activity care plan was completed for one of five sampled residents (Resident 10). This failure resulted in Resident 10 not having the opportunity to discuss his activity preferences and have his preferences honored. Findings:During an interview on 1/6/26 at 9:07 a.m. with Resident 10, Resident 10 stated he had never been asked if he wanted to participate in any activities. During an interview on 1/6/26 at 9:41 a.m. with Resident 10, Resident 10 stated he cannot voluntarily move his arms or legs due to a motorcycle accident and can only shrug his shoulders.During a concurrent interview and record review on 1/8/26 at 9:36 a.m. with Director of Nursing (DON), Resident 10's medical record (MR) was reviewed. DON stated she was unable to find an activities assessment or activities care plan. DON stated Activities Director (AD) is responsible for completing the activities assessment and activities care plan.During an interview on 1/8/26 at 9:45 a.m. with AD, AD stated she had not completed an…
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 before2026-01-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 interview and record review, the facility failed to:Complete a care plan for smoking for one of one sampled resident (Resident 76). 2. Ensure a smoking assessment was available to facility staff. 3. Conduct an Interdisciplinary Team (IDT- various healthcare staff meet to share information and updates, collaborate to solve problems, and develop and update the resident's care plan) meeting that included Resident 76's smoking. These failures had the potential to jeopardize Resident 76's safety.Findings:1.During a concurrent observation and interview on 1/6/26 at 10:08 a.m. with Resident 76, in her room, Resident 76 stated a hospice (program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) aide took her outside to smoke three times a week. Resident 76 was unable to stop moving both of her arms in a shaking, tremor (uncontrolled movement) -like manor. Resident 76 stated she does not have Parkinson's (disease which causes involuntary tremors of body parts). Resident 76 stated her tremors were caused by too…
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 · D2026-01-08 · 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 the safe administration of medications when:1. IV (Intravenous- method of delivering fluids, medicine or nutrition directly into a vein) Emergency Infusion Supply (E-kit- basic supplies for IV access, fluids, and antibiotics) was expired.2. Discontinued narcotics (a drug or substance that affects mood or behavior) were not stored safety.3. Medication was left unattended on top of the medication cart.These failures had the potential for medications to be administered incorrectly and unsafely.Findings:During a concurrent observation and interview on [DATE] at 3:10 p.m. with Assistant Director of Nursing (ADON), in medication storage cabinet in the hallway, there was an expired e-kit dated [DATE]. Upon reviewing the e-kit medications the following medications were expired:D5W (sterile IV solution contains 5% sugar in normal saline) 1000 ML (milliliters- unit of measure) expired on [DATE].NACL (sodium chloride 0.9%) 250 ML expired on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure 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, interview, and record review, the facility failed to ensure food was served according to the facility's policy and procedure for two of two sampled residents (Resident 84 and Resident 92). These failures had the potential to result in food borne illness to Resident 84 and Resident 92.Findings:During an observation on 1/5/26 at 12:24 pm, in the B-Wing hallway rehab dining room. Two residents' meal trays were seen on bed side tables, no staff or residents were present in the rehab dining room. The meal tray identification tickets indicated one of the meal trays belonged to Resident 84 and the second meal tray belonged to Resident 92.During a concurrent observation and interview on 1/5/26 at 12:27 pm, with Restorative Nurse Aide (RNA) 1, RNA 1 stated she had just taken a resident back to their room. RNA 1 stated, These two trays belonged to residents in their bedrooms, and I'm going to take them [resident meal trays] to them.During a concurrent observation and interview on 1/5/26 at 12:27 pm, with Dietary Manager (DM) 1, DM 1 arrived at the rehab dining room where…
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 · D2026-01-08 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 one Oxygen e-tank (highly flammable, compressed gas cylinder) was transported in a safe and secure manner by staff. This failure had the potential to result in injury and death to residents, staff, and visitors.Findings:During an observation on 1/5/26 at 12:47 pm, on the B-wing hallway, Certified Nurse Assistant (CNA ) 1 was seen walking down the hallway carrying an Oxygen e-tank by the straps of the fabric wheelchair Oxygen e-tank holder.During a concurrent observation and interview on 1/5/26, at 12:48 pm, with CNA 1 and Social Service Director (SSD), CNA 1 stated, We have a metal stand we use [to transport oxygen e-tanks]. SSD stated, Both residents [present in the hallway at the time] were dependent assistance, and were unable to ambulate without assistive device [unable to move without staff assistance in the event of an emergency].During a review of the facility policy and procedure (P&P) titled Oxygen Administration,(undated), the P&P indicated, Equipment and Supplies The following…
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 15 citations
- Potential for harm · D2024-10-01 · tag F0745 — failed to provide medically-related social services — isolatedProvide 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 observation, interview, and record review, the facility failed to ensure the transportation for one of five sampled residents (Resident 1) was arranged for a dialysis (a treatment or people whose kidneys are failing, removing waste products and excess fluid from the blood) appointment. This failure resulted in Resident 1 crying waiting for almost five hours (5 p.m. until 9:51 p.m.) waiting for transportation, late medication administration, and potential for adverse health outcomes and emotional distress. Findings: During an observation on 10/18/24 at 2:10 p.m. in Resident 1's room, Resident 1 was lying in bed sleeping with a feeding tube (tube mainly inserted into the stomach to provide route for enteral nutrition) connected, and a floor mat on the floor. During a review of the facility ' s Dialysis Transportation Log (DTL), dated August 22, 2024, the DTL indicated, Resident [1] left the facility at 2:30 p.m. [ to go to a dialysis appointment]. During an interview on 10/1/24 at 2 p.m. with Social Services (SS), SS stated the facility had a problem with the transportation…
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 before2024-07-18 · 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, interview, record review, and facility document and policy review, the facility failed to ensure food was palatable, which affected 3 (Residents #6, #8, and #41) of 3 residents reviewed for food concerns and had the potential to affect all residents receiving meals from the dietary department. Findings included: A facility policy titled, Food and Nutrition Services, revised in 10/2017, reflected, 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it served at a safe and appetizing temperature. Resident Council meeting notes, dated 05/03/2024, revealed the residents complained that Food is too tough and dry. Resident Council meeting notes, dated 06/07/2024, revealed the residents complained that Food is always cold, food has no taste, and Food is too dry. During an interview on 07/15/2024 at 12:14 PM, Resident #41 said the food at the facility was awful. According to an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 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 · Fcited before2024-07-18 · 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, record review, and facility policy review, the facility failed to ensure dietary staff utilized proper hand hygiene during meal service on 07/16/2024, which had the potential to affect all residents receiving meals from the dietary department, aside from the 12 residents with pureed diet orders, as the pureed trays were served by a different staff member. Findings included: A facility policy titled, Food Preparation and Service, revised in 11/2022, revealed the section of the policy titled, General Guidelines specified, 2. Cross-contamination can occur when harmful substances i.e. [id est, that is], chemical, or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. 3. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness. The section of the policy titled, Food Distribution and Service specified, 5. Food and nutrition services staff, including nursing services…
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 · E2024-07-18 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and facility policy review, the facility failed to provide a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN), Centers for Medicare and Medicaid (CMS) Form 10055 prior to being discharged from Medicare Part A skilled nursing services when residents had not exhausted all of their allotted Medicare days and planned to remain in the facility. The deficiency affected 2 (Resident #57 and Resident #61) of 3 residents reviewed for beneficiary notifications. Findings included: An undated facility policy titled, Medicare Advanced Beneficiary Notice revealed, Residents are informed in advance when changes will occur to their bills. The section titled Policy Interpretation and Implementation, revealed, 1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and facility document and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 (Resident #41 and Resident #63) of 2 residents reviewed for MDS discrepancies. Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, reflected, 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods. An admission Record revealed the facility admitted Resident # 41 on 08/02/2021. According to the admission Record, the resident had a medical history that included a diagnosis of schizophrenia. Resident #41's Preadmission and Resident Review (PASRR) Level I Screening, dated 08/03/2021, revealed the resident had a diagnosed mental disorder and received psychotropic medications. The Level I Screening was positive for a suspected serious mental illness (MI), and a Level II evaluation was required. Resident #41's Individual…
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 · D2024-01-03 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices when: 1. One of three sampled Certified Nursing Assistant's (CNA 1) failed to sanitize blood pressure (BP) cuff (an inflatable cuff, which measures the systolic (the measure of pressure within the arteries while the heart beats) and diastolic pressure (the measure of pressure your blood is exerting against the artery walls while the heart muscle is resting) after use. 2. One of three sampled CNA's (CNA 1) did not perform hand hygiene after providing resident care. These failures had the potential to result in the transmission of infection and communicable diseases to residents and staff. Findings: 1. During an observation on 1/3/24 at 2:10 p.m. CNA 1 entered room Resident 1's room with a BP machine and stated I'm gonna check your blood pressure. During an observation on 1/3/24 at 2:12 p.m. CNA 1 exited Resident 1's room with BP machine, walked down hallway A and entered Resident 2'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 · Fcited before2022-05-12 · 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 staff did not use residents' nutrition freezer to store personal food items. This failure had the potential to cause food-borne illness and affect the residents' health. Findings: During a concurrent observation and interview on 5/10/22, at 9:55 AM, with Licensed Vocational Nurse (LVN) 2, at the C wing nurses' station, an unlabeled and undated frozen food bowl was observed in the freezer section of the residents' nutrition refrigerator. LVN 2 stated the frozen food bowl should have been dated and labeled. During an interview on 5/11/22, at 2:16 PM, with Director of Nursing (DON), the findings of a frozen food bowl in the C wing nurses' station freezer were reviewed. DON stated, the frozen food bowl was a staff member's food. DON stated, the residents' refrigerator/freezer was not to be used to store staff food items. DON stated, no frozen foods, requiring reheating, were to be stored in the residents' freezer. Staff were not allowed to reheat food items for residents. During a review of the facility'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 · Ecited before2022-05-12 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop and update the person-centered comprehensive care plan for three of 24 sampled residents (Resident 7, Resident 51, and Resident 58). This failure had the potential for unmet care needs. Findings: 1. During a review of Resident 7's admission Record (AR), dated 2/2/17, Resident 7 was initially admitted to the facility with diagnoses including End Stage Renal disease (kidney failure) and diabetes. During a concurrent interview and record review, on 5/11/22, at 2:29 PM, with Director of Staff Development (DSD), Resident 7's Emergency Department Discharge Instructions (EDDI), dated 4/11/22, were reviewed. The EDDI indicated, Resident 7 was admitted to a local hospital for Altered Mental Status (AMS- alteration in mental status characterized by acute onset and impaired attention). DSD stated, Resident 7 was seen by the nurse lying in bed, with opened eyes but not verbally responding. DSD stated, Resident 7 was sent to the hospital and was diagnosed positive for Cannabis (marijuana). During an interview on 5/12/22, at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-05-12 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's 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 on-going activities based on comprehensive assessments and preferences for three of 24 sampled residents (Resident 29, Resident 25, and Resident 49). This failure had the potential to negatively affect residents' self-worth, psychosocial well-being, and satisfaction with daily living. Findings: During an observation on 5/11/22, at 9:12 AM, in the Television (TV) room, Resident 29 was sitting in her wheelchair staring at the TV. The TV was on and the volume was low. During a concurrent observation and interview on 5/11/22, at 10:30 AM, with Activities Assistant (AA) 1, in the TV room, Resident 25 was observed sitting in her wheelchair. AA 1 stated, she (Resident 25) participated with activities before she fell, but now she only liked observing people passing by the TV room. During a concurrent observation and interview on 5/12/22, at 11 AM, with Certified Nursing Assistant (CNA) 4, in the hallway outside Resident 49's room, Resident 49 was sleeping in bed. CNA 4 stated, Resident 49 usually preferred to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-12 · 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 follow their policy and procedure titled Quality of Life - Dignity for two of 24 residents. (Resident 67 and Resident 55) when: 1. DSD informed Resident 67 he had to change rooms against his will. 2. Certified Nursing Assistant (CNA) 1 referred to Resident 55 in a disrespectful term. These failures had the potential to decrease Resident 67 and Resident 55's feelings of self-worth and self-esteem. Findings: 1. During a concurrent observation and interview on 5/9/22, at 10:26 AM, with Resident 67, Resident 67 stated, he was told by the charge nurse he had to move to another room today. Resident 67 stated, he liked his room, and he told the charge nurse he did not want to move. During an interview on 5/9/22, at 10:35 AM, with DSD, DSD stated, she was the charge nurse today for Resident 67. DSD stated, I convinced him (Resident 67) to move and told him it was only temporary. During an interview on 5/9/22, at 10:35 AM, with DSD and 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.
- Potential for harm · Dcited before2022-05-12 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Advance Directives to determine, on admission, whether residents had advance directives (a document indicating a person's wishes for end-of-life care) for two of 24 sampled residents (Resident 51 and Resident 68). This failure had the potential for residents' end-of-life care requests not to be honored. Findings: During a concurrent interview and record review, on 5/11/22, at 10:30 AM, with Social Services Assistant (SSA), Resident 51 and Resident 68's Acknowledgement of Receipt of Advance Directive Information (ARADI), dated 5/10/21 and 8/11/21, were reviewed. The ARADI indicated, An advance directive has ____ has not _____ been executed. SSA stated, this part of the form should be filled out to indicate if a resident has or has not executed an advance directive. SSA stated, this was left blank for Resident 51 and Resident 68. SSA stated, there was no way of knowing if these residents had executed advance directives. During a concurrent interview and record review, on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-12 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their Policy and Procedure (P&P) to conduct and submit two of 24 sampled resident assessments (Resident 17 and Resident 83) in accordance with current federal and state submission timeframes. This failure had the potential to negatively affect the provision of individualized care and services. Findings: 1. During a concurrent interview and record review, on 5/11/22, at 8:30 AM, with MDS Coordinator (MDSC) Resident 17's admission MDS (AMDS), dated [DATE], was reviewed. The AMDS indicated, the facility admitted Resident 17 on 4/12/19 and completed Resident 17's assessment on 4/30/19. MDSC stated, the AMDS should be completed within 14 days (on 4/25/19). 2. During a concurrent interview and record review, on 5/12/22, at 11:05 AM, with Social Services Assistant (SSA), Resident 83's Minimum Data Set (MDS - a comprehensive assessment and screening tool) assessment, dated 10/16/21, was reviewed. The MDS indicated, Activities of Daily Living (ADLs…
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 before2022-05-12 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document physical assessments on the Minimum Data Set (MDS- a comprehensive assessment screening tool) for two of 24 sampled residents (Resident 81 and Resident 79). This failure had the potential to negatively impact the care of Resident 81 and Resident 79. Findings: 1. During a concurrent interview and record review, on 5/10/22, at 11:22 AM, with Licensed Vocational Nurse (LVN) 3, Resident 81's MDS, dated [DATE], was reviewed. Resident 81's MDS indicated, Resident 81 had an indwelling urinary catheter (tube in the bladder continuously draining urine). LVN 3 stated, [Resident 81] didn't have a catheter in place when she was moved to C wing and still doesn't. During an interview on 5/11/22, at 9:35 AM, with MDS Coordinator (MDSC), MDSC stated, Resident 81 was moved to C wing on 3/14/22. That [indwelling urinary] catheter noted to be in place on the MDS dated [DATE] is incorrect. During a concurrent interview and record review on 5/11/22, at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-12 · 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 interview and record review, the facility failed to follow their policy and procedure (P&P) for documenting telephone orders for one of 24 sampled residents (Resident 23). This failure had the potential to result in confusion regarding Resident 23's physician-ordered care. Findings: During a review of Resident 23's Physician's Order Sheet (PO), dated 5/2/22, the PO indicated, 1. DC [discontinue] feeding tube. 2. DC Feeding Orders. 3. DC all routine labs and appointments. 4. DC acetaminophen [medication used to treat pain] tablet. 5. DC amlodapine (sic.) [medication used to treat high blood pressure] tablet. 6. DC aspirin [medication used to prevent blood clots]. 7. DC atorvastatin [medication used to reduce fats in the blood]. 8. DC carvedilol [medication used to slow heart rate]. 9. DC Imodium [medication used to treat diarrhea]. 10. DC lisinopril [medication used to lower blood pressure]. 11. DC multivitamin. 12. DC flush orders [orders to flush feeding tube with water]. The PO indicated, Physician (MD) 1 signed the order on 5/2/22. Handwritten in the lower left corner 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.
- No harm found · C2024-07-18 · tag F0732 — widespreadPost nurse staffing information every day.
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 post daily staffing in a conspicuous location and failed to update the posting with any changes due to changes in staffing. This had the potential to affect all residents that resided in the facility. Findings included: A facility policy titled, Posting Direct Care Daily Staffing Numbers, revised 08/2022, revealed Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. The section titled, Policy Interpretation and Implementation, revealed, 1. The number of licensed nurses (RNs [registered nurses], LPNs [licensed practical nurses], and LVNs [licensed vocational nurses]) and the number of unlicensed personnel (CNAs [certified nurse assistants] and NAs [nurse assistants]) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The policy revealed, Shift staffing information is recorded…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to MADISON CREEK PARTNERS — 13 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 | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 4 of 5 | 3.0 | +1.0 vs chain |
| Staffing | 3 of 5 | 3.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 12 homes this chain runs (chain average 3.2★, 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 | Since |
|---|---|---|---|
| CHRISTENSEN, COVEY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/28/2014 |
| CLEGG, MICHAEL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/26/2023 |
| MADISON CREEK PARTNERS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/11/2025 |
| BIGELOW, BRANDON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/29/2020 |
| HOPKINS, AMBER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2021 |
| SWEHLI, EHAB | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2023 |
CMS files one row per role, so the 14 rows in the source record cover these 6 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.
This home reported $855K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055448. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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