Brookfield Healthcare Center
9300 Telegraph Road, Downey, CA 90240 · For profit - Corporation · 70 certified beds · (562) 869-2567 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
- a high payroll-based staffing rating (4/5)
- 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
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) | 4 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 | 16.4% | 10.2% | 15.4% | typical |
| Long-stay residents who lose too much weight | 0.0% | 4.0% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.7% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 10.0% | 7.3% | 6.5% | worse |
| 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 | 8.6% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.0% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.8% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.3% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 11.8% | 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 | 3.2% | 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 | 96.9% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.3% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.1% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.16 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.51 | 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.
46.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 239 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 62.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 108 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 1.01 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | 46.1%CMS range 40.4–52.1 | 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 | 11.1%CMS range 8.5–14.7 | 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 | 62.0% | 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 | 56.5% | 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 | 49.1% | 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 | 99.5% | 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 | 97.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 8.5%CMS range 6.0–11.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.66 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 70 beds and averages 63.3 residents a day — about 90% 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 4.02 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.93 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.33 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.70 hrs/resident/day on weekends vs 4.15 on weekdays — 11% thinner on weekends. RN hours go from 1.01 to 0.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% is about the same as 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 before2023-10-13 · 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 implement interventions to prevent a fall with injury for one of three residents (Resident 19) with history of falls by failing to: 1. Ensure Resident 19 performed toilet transfers toward the left, unaffected side and did not place weight onto the right leg after toileting. 2. Provide Resident 19 with two-persons assistance for toilet transfers and toilet hygiene (toileting, includes managing undergarments, clothing, and incontinence products and performing cleansing before or after voiding or having a bowel movement). 3. Provide Resident 19 with two-persons assistance for sit to stand transfers (transfers from a seated position to a standing position) after toileting. These failures resulted in Resident 19 falling from a standing position onto the floor in the restroom on 7/30/2023. On 7/31/2023, Resident 19 complained of right shoulder pain and received an X-ray (used to create images of the inside of the human body) which indicated Resident 19 had a right humeral (shoulder bone) fracture (break in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-05 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 19) was free of significant medication errors, when:1. Resident 19's orders for Percocet (medication used to treat moderate or severe pain) and methocarbamol (a muscle relaxer used to relieve muscle, bone, and joint pain) were not clarified.2. Resident 19 was administered methocarbamol and Percocet together.These deficient practices had the potential to result in Resident 19 experiencing sedation (when given too much a medication that makes an individual sleepier or less conscious than intended) and respiratory arrest (when an individual stops breathing).Findings:During a review of Resident 19's admission Record (Face Sheet), the admission Record indicated Resident 19 was admitted to the facility on [DATE]. Resident 19's diagnoses included displaced fracture of the greater trochanter of the left femur (a break in the prominent, bony knob on the outer part of the left thigh bone and the broken pieces are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan with interventions for two of eight sampled residents (Resident 19 and 48) to address:1. Resident 19's use of methocarbamol (a muscle relaxer used to relieve muscle, bone, and joint pain).2. Resident 48's lack of dentures (a removable dental appliance that replaces missing teeth and surrounding tissues).This deficient practice had the potential to negatively affect Resident 19 and 48's mental, physical, and psychosocial well-being and had the potential to delay the delivery of necessary care and services.Findings:1. During a review of Resident 19's admission Record (Face Sheet), the admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses included displaced fracture of greater trochanter of the left femur (a break in the prominent, bony knob on the outer part of the left thigh bone and the broken pieces are moved out of their normal alignment), displaced fracture of distal phalanx 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 before2025-12-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement fall prevention interventions for one of three sampled residents (Resident 1) when staff failed to:1. Complete all sections of Resident 1's Fall Risk Evaluation, and develop a short-term fall care plan, following his fall on 11/13/2025.2. Conduct a Fall Risk Evaluation after Resident 1's fall on 11/21/2025.3. Revise Resident 1's fall risk care plan following his falls on 11/13/2025 and 11/21/2025.These deficient practices placed Resident 1 at risk for repeat falls and potential injury.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses including reduced mobility, abnormal posture, limited ability or inability to move one side of the body following a stroke (loss of blood flow to a part of the brain) affecting his left side. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment…
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 · D2025-12-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen therapy (a medical treatment that provides extra oxygen to breathe, typically prescribed for individuals with conditions causing low blood oxygen levels) was administered as ordered by the physician for two of 18 sampled residents (Residents 72 and 19). This deficient practice placed Resident 72 and Resident 19 at risk of sustaining complications of receiving too much supplemental oxygen.Findings: 1. During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 72's diagnoses included congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), upper respiratory infection, and asthma (a long-term condition that affects the airways in the lungs). During a review of Resident 72's Minimum Data Set (MDS, a resident assessment tool)…
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 · D2025-12-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a meal that was attractively appeasing and palatable for one of two sampled residents (Resident 71).This deficient practice had the potential for Resident 71's individual dietary and nutritional needs not being met, causing Resident 71 to not want to eat. Findings: During a review of Resident 71's admission Record, the admission Record indicated Resident 71 was newly admitted to the facility on [DATE]. Resident 71's diagnoses included diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and congestive heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 71's History and Physical (H&P), dated 12/4/2025, the H&P indicated Resident 71 was awake, alert, and was able to answer questions appropriately. During a review of Resident 71's Order Summary Report, dated 12/2/2025, the Order Summary…
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 · D2025-12-05 · 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 maintain infection control measures for one of five sampled residents (Resident 61) when:1. Resident 61 was placed on contact precautions (using extra barriers, like gowns and gloves, to stop germs from spreading by touching a sick person or things in their room) with no visual signage to ensure hands were washed with soap and water. 2. Licensed Vocational Nurse (LVN) 2 performed hand hygiene with alcohol-based hand rub (ABHR- a liquid that is rubbed on the hands to quickly kill germs and stop their spread, without needing soap and water) instead of soap and water upon exiting Resident 61's room.These deficient practices had the potential to result in the spread of clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) to the residents and staff.Findings:During a review of Resident 61's admission Record (Face Sheet), the admission Record indicated Resident 61 was initially admitted to the facility 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 before2025-07-24 · 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 conduct an accurate fall reassessment for one of seventeen residents (Resident 3), after a fall.This deficient practice had the potential for Resident 3 not to receive the proper interventions to prevent further falls and injuries. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including muscle weakness and diabetes mellitus (DM- abnormal blood sugar level), hemiplegia (paralysis on one side of the body).During a review of Resident 3's History and Physical (H&P), dated 10/17/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Fall Risk Evaluation dated 10/15/2024, the evaluation did not indicate Resident 3 had a fall in the past 3 months. The evaluation indicated Resident 3 was incontinent, had balance problems with standing/walking and required use of assistive devices…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a resident-centered plan of care after one of three sampled residents (Resident 3), had a fall.This deficient practice resulted in the facility not having a care plan to implement for the resident's safety after the fall and had the potential to cause recurrent falls.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including muscle weakness and diabetes mellitus (DM- abnormal blood sugar level), hemiplegia (paralysis on one side of the body).During a review of Resident 3's History and Physical (H&P), dated 10/17/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's SBAR Communication Form ([Situation, Background, Assessment, Recommendations] form that ensures all relevant information is conveyed in a structured manner) dated 10/29/2024, the SBAR indicated Resident 3…
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 · E2024-10-18 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Residents 30) would not be administered any unnecessary medication in the form of duplicate drug therapy. (Cross Reference F756) The deficient practice created the risk for Resident 30 to receive excessive dosages of salmeterol (long-acting bcta2-adrcnergic agonist [[NAME]] medication, used to treat asthma - chronic inflammatory disease of the lungs) which are contained in both oral inhalers, Serevent Diskus (salmeterol) and Advair Diskus (a medication that contains both salmeterol and fluticasone propionate, an anti-inflammatory medicine, used to treat asthma and chronic obstructive pulmonary disease (COPD - lung disease that makes it difficult to breathe) which could lead to the resident experiencing serious side effects that include, high blood pressure, fast heart rate, irregular heart rhythm, which could result in an overdosage or hospitalization. Findings: During a review of Resident 30's admission Record…
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 · D2024-10-18 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a complete informed consent form (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) included the medication dosage, frequency, and behavioral manifestations prior to the administration of citalopram (medication used to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest]) for one of five sampled residents (Resident 32). This deficient practice had the potential to result in Resident 32 and their Responsible Party (RP) being unaware of the medication treatment ordered, thus, being unable to make an informed decision regarding Resident 32's care. Findings: During a review of Resident 32's admission Record (Face Sheet), indicated Resident 32 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 32's diagnoses included Parkinson's disease (a progressive…
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 · Dcited before2024-10-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessment entries on the Minimum Data Set ([MDS], a federally mandated resident assessment tool) were accurate for four of six sampled residents (Residents 3, 9, 32, and 253) when the facility failed to: 1. Include a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) per information in Resident 32 and Resident 3's medical record. 2. Include Resident 9's five (5) percent (%) weight loss in one month. 3. Include a diagnosis of seizure disorder (a disorder where a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) per information in Resident 253's medical record. These deficient practices had the potential to negative affect Residents 3, 9, 32, and 253's plan of care and delivery of necessary care and services. Findings: a. During a review of Resident 32's admission Record (Face Sheet), the admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) in a timely manner for three out of six sampled residents (Resident 153, Resident 42, and Resident 21) when the facility failed to ensure the following: 1. Ensure a care plan was developed after the discovery of Resident 153's cancer of the left eye and skin. 2. Ensure a care plan was developed for Resident 42's use of a nicotine patch (a patch worn on the skin by a person trying to give up smoking). 3. Ensure care plan interventions were developed for the care of Resident 21's ileostomy (a surgical procedure that creates an opening in the abdominal wall to divert waste from the body through the small intestine instead of the anus), and stoma (a surgically created opening in the abdomen that…
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 before2024-10-18 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 licensed nurses failed to review, update, and/or revise a care plan (written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual) to reflect the attempts to prevent future falls for one out of one sampled resident (Resident 21). This deficient practice resulted in the facility having no interventions in the prevention for further falls for Resident 21 and could have potentially led to Resident 21's third fall. Findings: During a review of Resident 21's admission Record, the admission record indicated Resident 21 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 21's diagnoses included history of falls and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · 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 observation, interview, and record review the facility failed to ensure an interdisciplinary team (IDT, group of different disciplines working together towards a common goal of a resident) meeting was held after a resident fall on 9/16/2024 for one of one sampled resident (Resident 21). This deficient practice delayed the plan of care for reducing the risk of falls and could potentially have caused Resident 21 to sustain another subsequent fall. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 21's diagnoses included history of falls and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). During a review of Resident 21's History and Physical (H&P) dated 9/30/2024, the H&P indicated Resident 21 was alert and had appropriate mood, affect and insight.…
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 before2024-10-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 12 sampled residents (Residents 253 and 21) were free of accidents and hazards by failing to: 1. Ensure floor mats (a cushioned floor pad designed to help prevent injury should a person fall) were utilized for Resident 253. 2. Ensure Resident 21 had an interdisciplinary team ([IDT], a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) review after a fall on 9/16/2024. These deficient practices had the potential to result in Resident 253 sustaining injuries during a seizure (a disorder in which nerve cell activity in the brain is disturbed) by potentially falling and hitting his head or other body parts on the bare floor. These deficient practices also resulted a delay in the plan of care for reducing the risk of falls and could have potentially caused Resident 21 to fall for a third time. Findings: a. During a review of Resident 253's admission Record (Face…
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 before2024-10-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff practiced safe and effective medication administration practices for four out of five sampled residents (Resident 19, 25, 48, and 49) when: 1. Registered Nurse (RN 2) did not administer medication to Resident 19 in a timely manner. 2. RN 3 left Resident 25's medications at the resident's bedside to self-administer. 3. Licensed Vocational Nurse (LVN) 2 did not administer medication to Resident 25 in a timely manner. 4. LVN 2 did not administer medication to Resident 48 in a timely manner. 5. LVN 1 signed the medication administration audit report for Resident 49 after another LVN administered pain medication. These deficient practices caused Resident 19, 25, 48, and 49 to have an interruption with their medication therapy and exposed the residents to a potential medication error and adverse effect to their medications. Findings: 1. During an observation on 10/17/2024 at 10:15 a.m., in Resident 19's room,…
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 · D2024-10-18 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify a drug irregularity (any deviation in the proper use, dosage, or administration of medication) during the Monthly Regimen Review (MRR - a regular assessment of a resident's medication and treatment plan every month to ensure it is effective, safe, and still necessary) for one of three residents (Resident 30) receiving duplicate drug therapy in the use of two orally inhaled medications, Serevent Diskus (salmeterol, a long-acting bronchodilator used to treat asthma by relaxing and opening air passages in the lungs, making it easier to breathe) and Advair Diskus (a medication that contains both salmeterol and fluticasone propionate, an anti-inflammatory medicine, used to treat asthma and chronic obstructive pulmonary disease (COPD - lung disease that makes it difficult to breathe) between 9/13/2024 through 10/15/2024. (Cross Reference F757) This deficient practice created the risk for Resident 30 to receive excessive dosages of salmeterol which…
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 · D2024-10-18 · 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 and interview, the facility failed to ensure opened boxes of oral inhalation medications with a shortened expiration date once opened, had an open date (the date the medication was first opened) for three of three sampled residents (Resident 30, Resident 53, and Resident 54). The deficient practice of failing to label oral inhalation medications, per the manufacturers' requirements increased the risk that residents with asthma (chronic inflammatory disease of the lungs) or chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing) could have received expired or ineffective medications which could result in health complications, difficulty breathing, or hospitalization. Findings: During a review of Resident 30's admission Record (document containing diagnostic and demographic information), the admission Record indicated Resident 30 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 30's diagnoses included asthma and COPD.…
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 · D2024-07-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents' (Resident 1) itchy area was assessed, location/ site identified and ensure the physician's order contained the site of treatment order administration. This failure had the potential for Resident 1's skin itchiness not resolved. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including primary generalized (osteo) arthritis (a disease that worsens over time, caused by the breakdown of cartilage, a rubbery material that eases the friction in joints), other seizures (a sudden, uncontrolled burst of electrical activity in the brain), and acute (severe and sudden) kidney failure (a condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance). During a review of Resident 1's Minimum Data Set…
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 before2023-10-13 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer Folic Acid (a medication used as a supplement for heart health) 1 mg tablet as ordered by the physician for one of four sampled residents during medication administration (Resident 28) and failed to administer Norco (a brand name for hydrocodone-acetaminophen, a combination medication used to treat pain) on time for one of five sampled residents (Resident 21.) As a result, Residents 21 and 28 did not receive medication in accordance with the physician's orders and standards of practice and had the potential to experience adverse effects (unwanted effects from a medication) and negative impact to their health and well-being. Findings: a. During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 21 had diagnoses of displaced (out of alignment) fracture of the right femur (broken…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-13 · 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
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Margarine was observed at 74 Degrees (º) Fahrenheit (F). b. The ice machine baffle (slanted component used to keep ice from falling out of the bin when the door is opened) was observed with black and pink residues. c. The storage areas for the pots and pans were observed with dust and dirt residue. d. The mixer attachments were found with oil residue. e. Seven (7) resident's food trays were observed chipped and cracked. f. The refrigerator shelves were observed chipped with black and orange metal discoloration exposed. g.The trayline area was observed with black, reddish dirt and grease build up. h. One expired resident yogurt in the resident's refrigerator. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illness in sixty (60) of sixty-one (61) medically compromised residents who received food and ice from the kitchen. Findings: a. During a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-13 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition in the kitchen and the rehabilitation room by failing to: a. Maintain the kitchen refrigerator by the preparation area in a safe operating condition. b. Annually calibrate (process of setting a measure device to conform with a reference standard) three of three physical agent modalities (treatments to produce a response in soft tissue through the use of light, water, temperature, sound, or electricity) in accordance with the facility's policy, including one diathermy (use of electric currents to generate heat in layers of the skin below the surface) unit and two combination ultrasound (use of sound waves to penetrate soft tissues which increases blood flow) and electrical stimulation (use of mild electrical pulses through the skin to help stimulate injured muscles or manipulate nerves to reduce pain) units. These deficient practices had the potential to result in food stored in the danger zone temperatures (a temperature range in which disease-causing bacteria…
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 · D2023-10-13 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 a code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) was ordered and an Advance Directive (a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was readily available to facility staff for one of three sampled residents (Resident 2) This failure had the potential for harm to Resident 2 as staff and emergency medical personnel would perform life-sustaining measures in the event of an emergency, which did not align with the wishes expressed and documented by Resident 2 and her family. Findings: During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (when the respiratory system [nose, mouth, throat, voice box, windpipe, and lungs]…
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 · D2023-10-13 · tag F0582 — isolatedGive 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the responsible party (RP) for one of three sampled residents (Resident 11) was appropriately notified regarding changes to Resident 11's Medicare coverage through provision of the Notice of Medicare Non-Coverage (NOMNC) form and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) form. This deficient practice had the potential to result in Resident 11, or Resident 11's RP, not being able to exercise their right to file an appeal and to unknowingly paying for non-covered care expenses. Findings: During a review of Resident 11's admission Record, the admission record indicated Resident 11 was admitted to the facility on [DATE], with admitting diagnoses that included Alzheimer's disease (a progressive disease that involves parts of the brain that control thought, memory, and language; begins with mild memory loss, and possibly leads to loss of the ability to carry on a conversation and respond to the environment).…
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 · D2023-10-13 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 effectively manage a resident's pain for one of five sampled residents (Resident 21). This failure caused Resident 21 to endure pain for almost three (3) hours before being treated with pain medication. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 21 had diagnoses of displaced (out of alignment) fracture of the right femur (broken thigh bone), periprosthetic fracture (a broken bone that occurs around the implants of a hip replacement) around internal prosthetic right hip joint and reduced mobility (ability to move). During a review of Resident 21's Minimum Data Set (MDS- a comprehensive assessment), dated 8/5/2023, the MDS indicated Resident 21's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 21 required extensive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-01 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 nursing staff failed to revise a care plan for falls for one of three sampled residents (Resident 1), who was found sitting on the floor at his bedside while attempting to ambulate to the restroom. This deficient practice had the potential to place Resident 1 at risk for recurrent falls. Findings: A review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included encephalopathy (a decrease in blood flow or oxygen to the brain), urinary tract infection (bacterial infection in any part of the kidneys, bladder, or urethra), and abnormality of gait and mobility. A review of the Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/4/2023, indicated Resident 1 did not have the capacity to understand and make decisions. The MDS indicated Resident 1 required extensive assistance from one staff with bed mobility, locomotion (how resident moves in and around the facility), dressing, eating,…
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 THE ENSIGN GROUP — 342 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 | 3.2 | +1.8 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 4 of 5 | 2.7 | +1.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BURNAM, SOON | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 01/30/2006 |
| FRISCHER, ALAN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2024 |
| HOWELL, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/24/2012 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | since 03/01/2011 |
| KIM, JESSE | Individual | CORPORATE OFFICER | since 05/09/2023 |
| PORT, BARRY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/03/2025 |
| CARETRUST GP LLC | Organization | ADP OF THE SNF | since 06/01/2003 |
| CARETRUST REIT INC | Organization | ADP OF THE SNF | since 06/01/2003 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | since 05/09/2023 |
| THE ENSIGN GROUP INC | Organization | ADP OF THE SNF | since 05/09/2023 |
| TROUSDALE HEALTH HOLDINGS LLC | Organization | ADP OF THE SNF | since 06/01/2003 |
CMS files one row per role, so the 16 rows in the source record cover these 11 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.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 056014. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-05, 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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