Bradley Court
675 E Bradley, El Cajon, CA 92021 · For profit - Limited Liability company · 56 certified beds · (619) 448-6633 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (5/5) — 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 (5/5)
- lower-than-typical staff turnover (14% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (19) — 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 | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 |
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 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 | 8.3% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.9% | 4.0% | 5.4% | better |
| 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 | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 7.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 1.6% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 12.3% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 35.6% | 13.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.3% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 0.0% | 10.2% | 21.2% | check this* — see note marked star below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 100.0% | 12.0% | 17.1% | check this† — see note marked dagger below the table |
| Long-stay hospitalizations per 1,000 resident days | 0.44 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.36 | 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.
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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.
Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality 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 data for this measure is missing or was not submitted. 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 data for this measure is missing or was not submitted. 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 | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality 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 56 beds and averages 55.4 residents a day — about 99% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. 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 3.16 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.79 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 2.83 hrs/resident/day on weekends vs 3.30 on weekdays — 14% thinner on weekends. RN hours go from 0.63 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 14% is below the national median of 45%. 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 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.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · E2025-03-13 · 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 proper food storage and sanitation practices were met in the kitchen according to standards of practice when: 1. A cut up onion was undated, covered in a clear plastic wrap, and stored in a bin with uncut onions. 2. Whipped topping 11 days past the use-by date was stored in the refrigerator. 3. A floor sink had piping without an air gap (space) of at least 1 (inch) between the pipe and drain. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing foodborne illness. Findings: 1. During the initial kitchen tour on 3/10/25 at 7:50 A.M., an observation and interview with the Food Service Director (FSD) was conducted. A plastic bin filled with fresh onions were observed on a storage shelf at the food preparation area. The plastic bin was labeled with a Received Date of 2/25/25, and a Use By date of 4/25/25. An onion that had been peeled and cut into was observed inside the bin, atop the fresh onions. The peeled/cut onion 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 · D2025-03-13 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Facility failed to ensure the facility was free of medication errors less than 5% or higher. The facility's medication error rate was 7.69 %. Two (2) medication errors were observed, a total of 28 opportunities, during the medication administration process for two (2) of 4 randomly observed residents (Residents 5, 52 ). As a result, the Facility could not ensure medications were correctly administered to all residents. Findings: 1) Resident 52 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (abnormal blood sugar) and schizoaffective disorder (a mental illness that can affect thoughts and mood) per the admission Record. On [DATE] at 7:30 A.M., an observation during medication administration was conducted with licensed nurse (LN) 6. LN 6 administered vitamin C 500 mg to Resident 52 from a bottle that read vitamin C 500 mg, dated opened on [DATE] and expired on [DATE]. A joint interview and record review on 3/12/ 25 at 9:15…
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 · D2025-03-13 · 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
Based on observation, interview and record review, the facility failed to ensure a medication storage room was free of staff's food and personal belongings. This failure had the potential for lack of oversight and contamination for medications stored in the facility. Findings: On 3/12/25 at 11:02 A.M., a joint observation and interview was conducted with licensed nurse (LN) 6. in the medication storage room. The medication storage room was observed with staff's personal belonging including two large purses. In addition, a box of donuts, a large carafe of coffee was observed on the counter. LN 6 stated the purses and food items belonged to staff, and did not belong to any residents in the facility. LN 6 stated personal belongings should not be stored in a medication storage room which stores medications including controlled drugs (medications which have a potential for abuse and addiction). On 3/13/25 at 9:12 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated personal belongings should never be stored in the medication storage area to prevent drug…
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 · D2024-11-07 · 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 identify a trash bin as a means for a resident to elope (leave without notice) the facility for one of one sampled resident (Resident 1). As a result, Resident 1 used the trash bin, jumped off the fence and left the facility unnoticed on 11/4/24. Findings: On 11/5/24, the Department received a facility reported incident (FRI) related to quality of care and resident safety. On 11/6/24, an unannounced onsite to the facility was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (serious mental illness) and psychosis (a symptom that refers to a loss of touch with reality), per the facility ' s admission Record. A record review was conducted of Resident 1. Resident 1 ' s History and Physical (H&P), dated 10/23/24, indicated the attending physician documented Resident 1 did not have the capacity to understand and make decisions, and was admitted for Special Treatment Program (STP, a mental…
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 · E2024-05-17 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation and record review, the facility did not ensure food was served in a sanitary manner. This failure potentially put residents at risk for foodborne illness as well as bacterial contamination of foods. Tray line observation was conducted on 5/15/24, at 11:40 A.M. in the kitchen. The menu consisted of meatloaf, vegetables, mashed potatoes, and garlic bread. During plating, the cook picked up the meatloaf from the tray with his gloved left hand and a spatula on the right hand, then place the meatloaf on the first plate. The cook then picked up a garlic bread with his right hand and placed it on the same plate. The cook continued to use his gloved left hand and spatula on the right hand to pick up the meat loaf and placed the meatloaf on the second and third plates. When the diet aide called out pizza for the next plate, the cook opened the oven behind him, applied oven mittens over his left gloved hand, pulled out a hot pan of pizza from the oven, removed the oven mitten, and did not change gloves. The cook then went to a small drawer to get a pizza…
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 · D2024-05-17 · 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 observation, interview, and record review, the facility failed to accurately code the MDS (MDS- a comprehensive assessment tool) for two of two sampled residents (Resident 11 and Resident 5) reviewed for MDS coding. This deficient practice had the potential for residents to not receive an individualized plan of care. In addition, inaccurate information was provided to the Federal database. Findings: 1.Resident 11 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebrovascular disease (group of conditions affecting blood flow and blood vessels in the brain) according to the facility's admission Record. On 5/16/24, at 7:47 A.M. Resident 11 was observed in bed with his eyes closed. The bed was against the wall on the right side of the bed. Resident's head was at the foot side of the bed and a 1/4 length bed rail was up on the left side, at the head of the bed.…
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 · D2024-05-17 · tag F0646 — isolatedNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
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 Pre-admission Screening and Resident Review Level I (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was re-evaluated after a resident's isolation was discontinued for one of two residents reviewed for PASRR (Residents 9). This failure had the potential for Resident 9 to not receive the appropriate mental health services. Findings: Resident 9 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental health disorder with combination of hallucinations or delusions and mood disorder symptoms, such as depression or mania) according to the facility's admission Record. On 5/14/24, at 10:45 A.M., Resident 9 was observed sitting alone in the dining room. Resident 9 spoke in a low voice and stated she had been at the facility for one year. During an interview 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 · D2024-05-17 · 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 and implement a comprehensive patient centered care plan for one of 16 residents (Resident 48) reviewed for care plans. This deficient practice had the potential to not meet the resident's needs for comfort and physical well-being. Findings: Resident 48 was admitted to the facility on [DATE] with diagnoses including other abnormalities of gait (walking) and mobility according to the facility's admission Record. An observation and interview was conducted on 5/14/24, at 9:16 A.M. with Resident 48. Resident 48 was observed in her room sitting at edge of her bed rubbing her right knee. Resident 48 stated her right knee was painful. Resident 48 stated her pain level was ten out of ten and dropped to seven out of ten after medication. Resident further stated a stronger pain medication was not recommended by her physician. An interview and joint record review on 5/16/24, at 10:11 A.M. was conducted with licensed nurse (LN) 1. LN 1…
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 · D2024-05-17 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 48) received Trauma Informed Care (TIC- an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health). This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past torture experience). Findings: Resident 48 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) according to the facility's admission Record. On [DATE], at 9:16 A.M., Resident 48 was observed in her room sitting at the edge of her bed with a flat affect (without showing emotional expressions). During an interview on [DATE], at 7:51 A.M. with CNA 2, CNA…
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 · D2024-05-17 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately record the discharge date of one of three residents (Resident 47) reviewed for closed medical records. This deficient practice resulted with Resident 47's discharge record to be inaccurately transmitted (submitted) to the federal database and the potential to cause confusion of Resident 47's discharge status. Findings: A review of Resident 47's admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses which included a history of bipolar disorder (a serious mental illness that causes unusual shifts in mood). On 5/15/24 at 9:34 A.M., a record review on Resident 47's medical record was conducted. Resident 47's progress note dated 5/8/24 indicated .Resident discharged to B&C [sic], left the facility around 0925 transported by facility van with discharge instructions. All medications and personal belongings sent with resident with instructions provided and voiced understanding . On 5/15/24 at 3:20 P.M., a 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.
Show the remaining 9 citations
- Potential for harm · D2023-06-16 · 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 provide the needs and preferences for one resident, (Resident 17), reviewed for accommodation. This failure had the potential for Resident 17's needs to be unmet. Findings: A review of Resident 17's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental health problem where a person experiences mood instability and the inability to recognize reality), bipolar type (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and unspecified psychosis (inability to recognize reality) not due to a substance or known psychological condition. On 6/13/23 at 12:12 P.M., a dining observation of lunch was conducted. Residents were seated together at tables in the dining room. Soft music played quietly in the background. There were conversations between residents and staff. The dining room had homelike…
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 · D2023-06-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide quality of care for one resident, (Resident 46), reviewed for quality of care. This failure had the potential for Resident 17's care needs to be unmet. Findings: A review of Resident 46's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that include foot drop of the left foot (the inability to raise the front part of the foot due to weakness or paralysis of the muscles that lift the foot, or skeletal abnormality). On 6/13/23 at 11:33 P.M., an observation was made of Resident 46 dragging his left foot while mobile in a wheelchair without a leg support. Resident 46 stated he hits his foot on objects at times and it causes stinging. Resident 46 stated his left ankle had previously been fractured and the bone was not set, so it did not heal in the proper position and nothing had been done while admitted to the facility to help with this problem. Resident 46's left foot was noted to be…
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 · D2023-06-16 · 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 a medication was administered according to the physician's order for one of six residents (Resident 28) during a medication administration observation. As a result, the facility could not ensure medications were administered accurately to residents. Findings: A review of Resident 28's admission Record indicated the resident was admitted to the facility on [DATE]. On 6/15/23 at 4 P.M., a medication administration observation was conducted with licensed nurse (LN) 1. LN 1 prepared 15 milliliters (ml) of lactulose (a medication to promote bowel movements) and then administered it to Resident 28. A review of Resident 28's physician orders dated 9/21/22, indicated the resident was to be administered 30 ml of lactulose twice a day for bowel management. On 6/16/23 at 8:05 A.M., an interview was conducted with LN 1. LN 1 stated she had incorrectly administered Resident 28's lactulose on 6/15/23. LN 1 stated she had made a mistake and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2025-03-13 · tag F0911 — patternEnsure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and review of the Analysis of Accommodations (document with measurements of the square footage of the useable living space of individual resident rooms and approved capacities), the facility failed to ensure that 1 of 10 resident rooms (room [ROOM NUMBER]) in Building 2 accommodated 4 or less residents. Findings: During the initial tour of Building 2 on 3/10/25, room [ROOM NUMBER] was observed to have 6 resident beds in the room. During a review of the facility's Analysis of Accommodations on 3/13/25, the document indicated room [ROOM NUMBER] had 6 residents housed in the room. There were no quality of care or quality of life issues identified during the survey for the six residents that resided in room [ROOM NUMBER]. A contuinance of a waiver allowing the six-bed room was therefore recommended.
- No harm found · Bcited before2025-03-13 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Bedrooms must measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms. Based on observation and record review, the facility did not meet the minimum requirement of 80 square feet per resident in Building 1 (rooms 2, 3, 4, and 5) and in Building 2 (rooms [ROOM NUMBERS]). Findings: A review of the facility's Analysis of Accommodations indicated there were 6 of 24 resident rooms that did not meet the minimum room size requirement, as follows: 1. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 2. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 3. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 4. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 5. Building 2, room [ROOM NUMBER] with 4 resident occupancy, 64.5 sq. ft. per…
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 · Bcited before2024-05-17 · tag F0911 — patternEnsure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Bedrooms must accommodate no more than four residents. This requirement was not met as evidenced by: Based on observation, interview, and review of the current Client Analysis of Accommodations (document that shows room size and occupancy number), the facility failed to ensure one of 10 resident rooms in building 2, room five, accommodated no more than four residents. Findings: During the survey from 5/14/24 to 5/17/24, one resident room (room [ROOM NUMBER]) in Building 2 was observed to accommodate six residents. There was no observed quality of care or quality of life concerns that negatively impacted the residents residing in room five of Building 2. On 5/17/24 at 9:05 A.M., a concurrent interview and review of Client Accommodation Analysis was conducted with ADM. ADM stated that rooms 5 in building 2 has 6 residents; 2 more than regulation. ADM stated that he has a waiver for that room and provided copy of waiver. Continuance of a waiver allowing the six-bed room was therefore recommended.
- No harm found · Bcited before2024-05-17 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Bedrooms must measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms. This requirement was not met as evidenced by: Based on observation and record review, the facility did not meet the minimum requirement of 80 square feet per resident in Building 1, Rooms 2, 3, 4, and 5 and in Building 2, rooms [ROOM NUMBERS]. Findings: A review of the facility's Client Analysis of Accommodations (document that shows room size and occupancy number) indicated there were 6 of 24 resident rooms that did not meet the minimum room size requirement, as follows: 1. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 2. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 3. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 4. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per…
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 · Bcited before2023-06-16 · tag F0911 — patternEnsure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Bedrooms must accommodate no more than four residents. This requirement was not met as evidenced by: Based on observation and review of the current Analysis of Accommodations, the facility failed to ensure one of 10 resident rooms in building 2, room five, accommodated no more than four residents. Findings: During the survey from 6/13/23 to 6/16/23, one resident room (room [ROOM NUMBER]) in Building 2 was observed to accommodate six residents. There was no observed quality of care or quality of life concerns that negatively impacted the residents residing in room five of Building 2. Continuance of a waiver allowing the six-bed room was therefore recommended.
- No harm found · Bcited before2023-06-16 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Bedrooms must measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms. This requirement was not met as evidenced by: Based on observation and record review, the facility did not meet the minimum requirement of 80 square feet per resident in Building 1, Rooms 2, 3, 4, and 5 and in Building 2, rooms [ROOM NUMBERS]. Findings: A review of the facility's Analysis of Accommodations indicated there were 6 of 24 resident rooms that did not meet the minimum room size requirement, as follows: 1. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 2. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 3. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 4. Building 1, room [ROOM NUMBER] with 2 resident occupancy, 75 sq. ft. per resident, totaling 150 sq. ft. 5. Building 2, room [ROOM NUMBER]…
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 GENERATIONS HEALTHCARE — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.1 | +0.9 vs chain |
| Health inspection | 5 of 5 | 3.6 | +1.4 vs chain |
| Staffing | 5 of 5 | 3.7 | +1.3 vs chain |
| Quality measures | 5 of 5 | 4.6 | +0.4 vs chain |
The other 26 homes this chain runs (chain average 4.1★, 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 |
|---|---|---|---|
| BMO BANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER SECURITY INTEREST | since 09/20/2023 |
| MASTROCOLA, LOIS | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER | since 03/01/2020 |
| OLDS, THOMAS | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 03/01/2020 |
CMS files one row per role, so the 6 rows in the source record cover these 3 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.
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 555140. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.