Valley Vista Post Acute
1025 W. Second Avenue, Escondido, CA 92025 · For profit - Limited Liability company · 59 certified beds · (760) 745-1842 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 3 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 | 5.6% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.5% | 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 | 0.7% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 8.1% | 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 | 4.1% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 11.9% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 25.9% | 13.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 94.7% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.6% | 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 | 5.6% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.1% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.5% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 16.5% | 11.2% | 12.0% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
68.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 70 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.2% 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 38 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.58 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% 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 | 68.1%CMS range 57.0–77.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 7.8–14.4 | 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 | 63.2% | 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 | 71.0% | 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 | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 94.4% | 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 | 1.1% | 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 | 1.1% | 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 | 7.2%CMS range 3.9–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 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 59 beds and averages 54.2 residents a day — about 92% occupied, or roughly 5 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 4.01 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.47 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.59 hrs/resident/day on weekends vs 4.19 on weekdays — 14% thinner on weekends. RN hours go from 0.65 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · E2025-09-11 · tag F0605 — failed to not use drugs as a restraint — patternPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 that four out of five sampled residents (Residents 2, 10, 19 and 49) were free from unnecessary psychotropic (affecting brain activities associated with mental processes and behavior) medications when: 1. For Resident 10, the facility did not implement resident specific non-pharmacological interventions (NPIs, behavioral treatments that do not involve medications) for the use of clonazepam (medication used to treat anxiety), mirtazapine (medication used to treat depression), risperidone (antipsychotic medication that balances certain chemicals in the brain to help a person feel calmer and think clearly), buspirone (medication used to treat anxiety) and sertraline (medication used to treat depression).2. For Resident 49, the facility did not implement resident specific NPIs for the use of duloxetine (medication used to treat depression), lamotrigine (medication used to treat mood disorders), trazodone (medication used to treat depression) and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-09-11 · 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 provide pharmacy services in accordance with accepted standards of practice when:1. Random controlled medication (medications with a high abuse potential) use audit for five of six sampled residents (Residents 3, 7, 25, 40 and 55) showed that medications were signed out of the controlled drug record (CDR, count sheet used to track controlled medications), but were not documented on the Medication Administration Record (MAR) to indicate they were administered to the residents. This failure had the potential for diversion (unlawful distribution or use), mismanagement of controlled medications, and the potential to not meet the needs of the residents in the facility. 2. Medications were not available for two of five sampled residents (Residents 2 and 42) when they were scheduled to be administered. This failure had the potential for Resident 2 to experience high blood pressure and Resident 42 to experience heartburn and pain.3. Two diabetes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-11 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater, when observation of 42 opportunities during medication administration resulted in five errors. The calculated medication error rate was 11.9%.This failure resulted in1. Placing Resident 29 at risk of not breaking down and absorbing nutrients from food when Licensed Nurse (LN) 1 crushed and administered pancrelipase (digestive enzymes used to break down food during digestion) Delayed Release (DR, designed to release medication slowly over a period).Placing Resident 29 at risk of inadequate pain relief when LN 1 crushed and administered gabapentin (medication used for pain).2. Placing Resident 42 at risk of high blood pressure when LN 31 did not administer hydralazine (a medication used to treat high blood pressure).3. Placing Resident 2 at risk for heartburn, indigestion and upset stomach when LN 32 did not administer calcium carbonate (medication used to decrease acid in the stomach).Placing Resident 2 at risk for inadequate…
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 · E2025-09-11 · tag F0865 — failed to run a quality-improvement (QAPI) program — patternHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to identify and develop an effective quality assessment and performance improvement plan (QAPI- a data driven proactive approach to improvement used to ensure services are meeting quality standards) in the following areas related to:1) cross reference F 755- Pharmacy services- the facility failed to ensure the control drug record (CDR) matches the medication administration record (MAR) of controlled drugs of the residents for five out of six residents reviewed. 2) cross reference F 677- ADL care provided for dependent residents- the facility failed to provide nail care assistance for two out of 17 residents reviewed.These failures had the potential to affect the resident's health and condition. On 9/11/25 at 3:45 P.M., a QAPI meeting with the Director of Nursing (DON) and the Administrator (ADM) was conducted.The ADM stated fingernail trimming and the controlled drug record not matching the medication administration record was new to us. The DON stated it was important to identify issues affecting the residents 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 · E2025-09-11 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to implement infection control standards of practice when an air vent blew out dust balls during meals in the dining room. This deficient practice had the potential to contaminate residents' food and affect the residents' respiratory status.Findings:During the dining room meal observation on 9/8/25 at 11:30 AM, there were 15 residents seated around eight separate tables. The air conditioner was on and a round air vent in the ceiling was directly above a table with residents. The air vent blew out three dust balls and the Activity Director (AD) swept up the dust balls from the floor. The air vent was observed with gray dust above a table with residents. At 11:51 A.M. a staff member brought the meal cart which was also near the air vent with gray dust. Staff proceeded with passing out meal trays with the cart wide open and the round dusty air vent blew air from the ceiling. Another observation in the dining room was conducted on 9/9/25 at 7:36 A.M. The air conditioner was on and the air vent still had gray dust.…
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 · D2025-09-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an alternative call light system to one of 17 sampled residents (Resident 68). This failure had the potential for Resident 68 to experience a delay in care. Findings: According to the admission Record, Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's Disease (a movement disorder that worsens over time) and generalized muscle weakness. During a review of Resident 68's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/29/25, Resident 68 had a Brief Interview of Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) of 9 which indicated moderate cognitive impairment. On 9/8/25 at 8:24 A.M., an observation was conducted. Resident 68 was observed laying in bed and stated, I'm ready to get up.I'm waiting to eat breakfast, I can't use my hands. Resident 68…
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 · D2025-09-11 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 reviews, the facility failed to provide a written notice and duration of bed hold for one of three residents (Resident 65) reviewed for bed hold notice. This failure had the potential for the resident and/or resident's representative to not have information regarding bed hold rights. Per the facility's admission Record, Resident 65 was admitted to the facility on [DATE] with diagnoses which included, chronic kidney disease (a condition in which the kidneys gradually lose their ability to filter waste products from the blood). A review of the progress notes dated, 6/25/25 indicated, Resident 65 was transferred to the acute hospital due to wounds on his buttocks.A review of Resident 65's medical record indicated, there was no documentation to confirm Resident 65 was notified of the bed hold when Resident 65 was transferred to the acute hospital.A review of Resident 65's Minimum Data Set (MDS-a federally mandated assessment tool) dated, 6/7/25 indicated, Resident 65's brief interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a baseline care plan was developed for 2 of 17 residents (Residents 2 and 19) reviewed for baseline care plans. This failure had the potential for Resident 2 and Resident 19 to not receive appropriate care. Findings:1) Per the facility's admission Record , Resident 2 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder(a mental illness that could affect thoughts, mood and behavior) and Major Depressive Disorder.A review of Resident 2's minimum data set (MDS-a federally mandated assessment tool) dated, 7/22/25 indicated, Resident 2's Brief Interview for Mental Status (BIMS) score was 15 which indicated Resident 2's cognition (thought process) was intact.A review of Resident 2's order summary report indicated, Resident 2 was on the following psychotropic medications (drugs that affect mental processes and behaviors): Fluoxetine 20 mg 1 capsule by mouth daily for depression; Lorazepam 0.5 mg…
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 · D2025-09-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 17 residents (Resident 10 and Resident 49), who needed to carry out activities of daily living (ADL- self-care activities such as grooming, bathing, and toileting), received assistance with nail care (cleaning, trimming and/or filing of nails). As a result of this deficient practice, residents' fingernails were long and had the potential for skin injury and infection. Findings:1. Resident 10 was admitted to the facility on [DATE] with diagnoses including dementia (an impairment of brain function, such as memory loss and judgment) and chronic pain according to the facility's admission Record. During an interview and observation on 9/8/25 at 8:09 A.M., Resident 10 was in her room sitting at the edge of bed with breakfast tray calling out, Hello, hello, hello. Resident 10's fingernails were observed to be long and with gray debris under the nails. Resident 10's right forefinger nail was observed to be jagged. Resident 10 stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure intake and output (I & O- the measurement of the fluids that enter the body and the fluids that leave the body) was documented and monitored for one of 17 sampled residents (Resident 68). This failure placed Resident 68 at risk for edema (swelling), retaining fluid in the lungs or dehydration (loss of body fluids).Findings: According to the admission Record, Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently) and Parkinson's Disease (a movement disorder that worsens over time). During a review of Resident 68's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/29/25, Resident 68 had a Brief Interview of Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) of 9 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.
Show the remaining 18 citations
- Potential for harm · D2025-09-11 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide Restorative Nursing Assistant (RNA- a program to restore abilities or maintain function) program intervention with a hand splint (a device used to immobilize and keep the hand in one position) for one of 17 sampled residents (Resident 68). This failure had the potential for Resident 68 to experience further hand stiffening and/or skin breakdown.Findings: According to the admission Record, Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's Disease (a movement disorder that worsens over time) and generalized muscle weakness. On 9/8/25 at 8:19 A.M., an observation was made in Resident 68's room. Resident 68 had a red plastic device in his right hand. Both hands were stiffened and maintained in a semi-closed position. On 9/8/25 at 12:22 P.M., an interview was conducted with Resident 68's family member (FAM) 1. FAM 1 stated Resident 68's hands were contracted [stiffened]…
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 · D2025-09-11 · 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 provide supervision with feeding in one of 17 residents (Resident 43) reviewed for activities of daily living (ADL- self-care activities such as feeding, grooming, bathing, and toileting) assistance.This failure had the potential to affect Resident 43's health and well being. Findings:Per the facility's admission Record, Resident 43 was admitted to the facility on [DATE] with diagnoses which included Dementia (progressive state of decline in mental abilities) and Parkinson's disease (a progressive disease of the nervous system). On 9/8/25 at 12:10 P.M., an observation was conducted during lunchtime in the main dining room. Resident 43 was seated in a reclined position on a wheelchair. Resident 43 was served a lunch tray far from her reach with the cover removed and left untouched. On 9/09/25 at 3:15 P.M., an interview and record review with Licensed Nurse (LN) 1 was conducted. LN 1stated Resident 43 gets agitated if staff gets close to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 urology (specialty which deals with diseases of kidneys and bladder) follow up for one of two residents (Resident 4) reviewed for urinary catheter. This failure had the potential for Resident 4 to have a recurrent urinary tract infection (UTI-an infection affecting the kidneys, bladder or urethra) and other complications.Findings:Resident 4 was admitted to the facility on [DATE] with diagnoses including obstructive and reflux uropathy (problems with urine flow in the urinary tract due to structural or functional issues) according to the facility's admission Record. During an observation and interview on 9/9/25 at 10:04 A.M., Resident 4 was in her room sitting on a wheelchair with a urine bag hanging at the back of the wheelchair. Resident 4 stated she had a urine tube because she could not control her urine and was not able to walk to the bathroom. A review of Resident 4's physician's orders titled Order Summary was conducted. 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 · D2025-09-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 nutrition interventions were implemented for one of 17 sampled residents (Resident 68). This failure had the potential to result in further weight loss and/or compromise Resident 68's health. Findings: According to the admission Record, Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's Disease (a movement disorder that worsens over time) dysphagia (difficulty swallowing), nutritional anemia (a deficiency in nutrients essential for red blood cell formation). On 9/8/25 at 8:46 A.M., Certified Nursing Assistant (CNA) 13 was observed walking out of Resident 68's bedroom with his breakfast tray. CNA 13 stated Resident 68 only ate the oatmeal, but did not eat anything else on the tray. CNA 13 stated Resident 68 usually ate less than half of breakfast and lunch. During a review of Resident 68's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · 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 a physician's order for oxygen was placed for one of three residents (Resident 2) reviewed .This failure had the potential to affect Resident 2's respiratory condition. Findings:Per the facility admission Record , Resident 2 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (absence of enough oxygen).On 9/8/25 at 8:26 A.M., an observation and interview was conducted with Resident 2. Resident 2 was on oxygen at 6 liters per minute via nasal cannula (a flexible tube with two prongs that fit into the nostrils). Resident 2 stated that she returned from the hospital last Friday, 9/5/25 due to pneumonia. Resident 2 stated she used oxygen continuously and cannot breathe without it. A review of Resident 2's Minimum Data Set (MDS- a federally mandated assessment tool) dated 7/22/25 indicated Resident 2's brief interview for mental status (BIMS) score was 14 which indicated Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · 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 ensure the one of 17 residents (Resident 6) reviewed for food palatability was served meals that were palatable.As a result, Resident 6 refused his meals and was at risk for weight loss.Cross reference F805Findings:Resident 4 was admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease (GERD- when stomach contents flow back up into the tube that connects the mouth to the stomach) according to the facility's admission Record. During an observation and interview on 9/8/25 at 8:24 A.M. with Resident 4, Resident 4 stated he was on a puree diet, but the food did not taste good. Resident 4 stated the puree he received was gritty. During an interview on 9/10/25 at 9:17 A.M. with Certified Nurse Assistant (CNA) 3, CNA 3 stated Resident 4 had complained about the food served to him because it was not prepared correctly. An interview and joint record review on 9/10/25 at 10:30 A.M. was conducted with 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 · D2025-09-11 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 recipes were followed during the preparation of pureed foods. This failure placed the resident at risk for choking and/or aspiration (inhaling food into the lungs) and compromised the flavor and texture of the foods. Findings: On 9/10/25 at 10:20 A.M., a joint observation and interview was conducted with [NAME] 1 in the kitchen. [NAME] 1 stated she was preparing instant mashed potatoes for residents who were on a pureed diet. [NAME] 1 was observed pouring flaked potatoes from the manufacturer's bag into a stainless steel container. [NAME] 1 then poured approximately 1000 ml (milliliters- a unit of measurement) into the container. [NAME] 1 stated, I put in about [2000 ml of water]. [NAME] 1 was observed putting a white powdery substance into the container of mashed potatoes. [NAME] 1 stated, I put too much water [in the mashed potatoes]. This is to make it thicker. [NAME] 1 stated there is a recipe with instructions available, but…
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 · D2025-06-10 · 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 reviews the facility failed to develop and implement a comprehensive person focused care plan for one of one resident (Resident 1) related to Oxygen use. This failure had the potential to affect Resident 1 ' s health condition and possible decline. Findings. Per the undated admission Record , Resident 1 was admitted to the facility on [DATE] with diagnoses that included Unspecified Atrial Fibrillation (irregular heart rhythm). On 6/10/25 at 11 A.M., an observation and interview with Resident 1 was conducted. Resident 1 was alert, verbal, and receiving oxygen through nasa cannula (NC- a device that delivers oxygen through the nose) at 2 liters per minute while sitting up in her wheelchair in her room. Resident 1 stated, she used the oxygen all the time because she cannot breathe without the oxygen. A record review of Resident 1's Minimum Data Set ( MDS- an assessment tool) dated, 5/14/25 indicated, Resident 1's brief interview for mental status (BIMS) was 13 which meant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-10 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 residents were safe from abuse when a one to one (1:1) supervision was not consistently followed as recommended for one resident (Resident 1), who had a history of abusive behavior. As a result, Resident 1 hit another resident (Resident 2). In addition, this failure placed all residents at the facility at risk of being harmed by Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia (condition that impairs mental function, reasoning, and memory), with behavioral disturbance, per the resident's admission record. Resident 2 was admitted to the facility on [DATE] with a diagnosis of down syndrome (a genetic disorder that causes intellectual delays and physical disabilities), per the resident's admission record. A review of Resident 1's clinical record, titled SBAR-Alleged Abuse Report of Incident - 8hr -V3 (Incident Report), dated 11/29/23 at 8:47 A.M., indicated that on 11/29/23 at 6:45…
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 · E2023-08-17 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility did not ensure proper safe and sanitary food practices, storage, and sanitation requirements were met when: 1. Expired foods in the refrigerator were not discarded, 2. Two blenders had residual food debris encrusted on them, and 3. A cabinet for equipment had a missing door, and the inside surface had a buildup of dust, dirt and black substances stuck on all sides. These failures had the potential to result in harmful bacteria growth and cross contamination, which would cause food borne illness to 51 vulnerable residents who receive food from the kitchen and who were medically compromised. Findings: 1. On 8/14/23 at 8:49 A.M., an observation of the refrigerator was conducted. The following expired/undated food items were identified: 1 - 8-ounce shredded carrots dated 6/23/23. 1 - 4-ounce bag shredded purple cabbage dated 7/9/23. 1 - 12-ounce bag of grapes dated 7/26/23. 1 - Bin containing nine yellow squash dated 7/2/23. 1 - Bin containing five undated romaine lettuce heads with dark brown discoloration 1- Plastic bag…
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 · D2023-08-17 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to allow personal items to be posted on the walls of their rooms for two of two residents screened for personal property (Residents 6 and 16). This failure had the potential to negatively affect the resident's well-being. Findings: 1. Resident 6 was admitted to the facility on [DATE], per the facility admission Record. On 8/14/23 at 10:11 A.M., a concurrent interview and observation of Resident 6 was conducted in her room. Resident 6's room was painted white, and had no decorations on the walls. A corkboard was on the wall, with facility documents pinned to it. Resident 6 stated she was told she could not put personal items on her wall. Resident 6 stated she had a quilt she would like to put up, but facility staff had removed it when they painted, and she had stored the quilt in her closet. Resident 6 stated she would also like to display some family photos but was told she was not allowed. Resident 6 stated she had lived in the facility for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-17 · 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 observation, interview and record review, the facility failed to administer medications according to accepted professional practice for one of 52 residents screened (Resident 41). This failure had the potential for Resident to suffer harm. Findings: A review of Resident 41's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Essential Hypertension (high blood pressure that is not due to another medical condition) and Overactive Bladder (muscles of the bladder contract even when the bladder is not full). On 8/14/23 at 10:29 A.M., a concurrent interview and observation of Licensed Nurse (LN) 11 preparing medications for administration to Resident 41 was conducted. LN 11 crushed four medications together, added them to pudding and administered them to Resident 41. LN 11 stated the medications included mirabegron ER (extended-release: slowly released into the body over a period of time. A medication used to treat overactive bladder). LN 11 stated, 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 · D2023-08-17 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and 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 provide services and treatment for mental health needs for one of 52 residents screened (Resident 50). This failure had the potential for the mental health needs of Resident 50 to be unmet. Findings: A review of Resident 50's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Generalized Anxiety Disorder (a condition where you worry about everyday issues) and Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood, causing significant impairment in daily life). On 8/14/23 at 9:09 A.M., an observation and interview was conducted with Resident 50 in her room. Resident 50 stated she had a history of Post Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering from a terrifying event). Resident 50 stated the physical therapy gait belt (a device that helps to prevent falls) brought on her PTSD. On 8/17/23 at 1:15…
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 · Dcited before2023-08-17 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 6.45%. Two medication errors were observed, a total of 31 opportunities, during the medication administration process for two of five randomly observed residents (Residents 2 and 24). As a result, the facility could not ensure medications were correctly administered to all residents. Findings: 1. On 8/16/23 at 8:55 A.M., an observation of medication administration was conducted with Licensed Nurse (LN) 1. LN 1 prepared and administered medications to Resident 24, including aspirin, 81 milligram (mg) tablet. On 8/17/23, a record review was conducted. Resident 24's physician's orders, dated 4/14/23, included aspirin EC (enteric coated) Delayed Release 81 mg tablet. LN 1 was not available for interview on 8/17/23. 2. On 8/17/23 at 8:09 A.M., an observation of medication administration was conducted with LN 2. LN 2 prepared and administered medications to Resident 2, including a multivitamin with minerals. 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 · E2019-09-06 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 expired oral medications and topical creams were removed from the current medication supplies. In addition, nasal sprays, eye drops, and pain patches were commingled with the current medication supplies readily available for residents' use. Also, the medication room temperature was not consistently monitored as required. These failures had the potential for unsafe storage of medications thereby losing the efficacy of the medications. Findings: 1a. On 9/4/19 at 9:32 A.M., a medication storage inspection of the treatment cart and interview was conducted with Licensed Nurse (LN) 1. The treatment cart had five drawers. In the first drawer, there was half a box of individual packets of hydrocortisone cream (topical medication used to help relieve redness, itching, swelling) with an expiration date of 8/19. In the fifth drawer, there was one opened tube of benzoyl peroxide 10 % (medication used to treat mild to moderate acne) with an expiration date of 9/18, and one tube ointment of a soothe and cool barrier…
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 before2025-09-11 · 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
Based on observation, interview and review of the analysis of client accommodations , the facility failed to meet the required minimum square footage requirements of at least 80 square feet per resident (sq/ft/resident) in three resident rooms (6,8,and 11) This failure had the potential to impact resident care and quality of life. A record review was conducted from 9/8/25 through 9/11/25. The following resident rooms contained less than 80 square feet for each resident.Room Number Room Size6 accommodated 3 residents 216 (72 sq ft/ resident)8 accommodated 3 residents 216 (72 sq ft/ resident)11 accommodated 2 residents 138 (69 sq ft /resident) Additionally, observations were conducted. There were no observed quality of care , or quality of life concerns that negatively affected the residents residing in the identified rooms during the recertification survey visit. A continuance of the waiver (variation) from the requirements of code 42 of the federal regulations (cfr) sections 483.70 (d)(I)(ii) as granted, allowing less than 80 square feet per resident room, is hereby recommended.…
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 before2023-08-17 · 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
Based on observation, interview, and review of the Analysis of Client Accommodations, the facility failed to meet the required minimum square footage requirements of at least 80 square feet per resident (sq ft/resident) in three resident bedrooms (6, 8, and 11). This failure had the potential to impact resident care and quality of life. Findings: A record review was conducted from 8/14/23 through 8/17/23. The following resident rooms contained less than 80 square feet for each resident: Room number Room Size 6 accommodated 3 residents 216 (72 sq ft/resident) 8 accommodated 3 residents 216 (72 sq ft/resident) 11 accommodated 2 residents 138 (69 sq ft/resident) Additionally, observations were conducted. There were no observed quality of care, or quality of life concerns that negatively affected the residents residing in the identified rooms during the recertification survey visit. A continuance of the waiver (variation) from the requirements of Code 42 of the Federal Regulations (CFR) section 483.70(d)(1)(ii) as granted, allowing less than 80 square feet per resident room, is hereby…
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 before2019-09-06 · 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
Based on observation, interview, and review of the Analysis of Client Accommodations, the facility failed to meet the required minimum square footage requirements of at least 80 square feet per resident (sq ft/resident) in 3 resident bedrooms (6, 8, and 11). This failure had the potential to impact resident care and quality of life. Findings: An observation from 9/3/19 through 9/5/19 was conducted during the survey. The following resident rooms contained less than 80 square feet for each resident: Room number Room Size 6 accommodated 3 residents 216 (72 sq ft/resident) 8 accommodated 3 residents 216 (72 sq ft/resident) 11 accommodated 2 residents 138 (69 sq ft/resident) Additionally, interviews and records reviews were conducted. There were no observed quality of care, or quality of life concerns that negatively affected the residents residing in the identified rooms during the recertification survey visit. A continuance of the waiver (variation) from the requirements of Code 42 of the Federal Regulations (CFR) section 483.70(d)(1)(ii) as granted, allowing less than 80 square feet…
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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 $948K paid to related parties — landlords or management companies under common ownership — equal to about 11% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 055500. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-11, 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.