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Granada Rehabilitation & Wellness Center, LP

2885 Harris Street, Eureka, CA 95503 · For profit - Limited Liability company · 87 certified beds · (707) 443-1627 Medicare & Medicaid certified

Call the home — (707) 443-1627 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 20262 actual-harm citations$38,445 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • 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
  • the CMS record shows $38,445 in federal fines (most recent 2025-11-25)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 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

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2752 Harrison Ave · (707) 268-0190 · Call to confirm hours
Pharmacy
2525 Harris St · (707) 444-0521 · Call to confirm hours
Grocery
Safeway<0.1 mi
2555 Harris St · (707) 269-0133 · Call to confirm hours
Park
Dolbeer St · (707) 443-2980 · Typically dawn to dusk
Place of worship
3230 Harrison Ave · (707) 445-0671

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 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 4 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased21.5%10.2%15.4%worse
Long-stay residents who lose too much weight3.1%4.0%5.4%better
Long-stay residents with a catheter left in their bladder1.5%0.8%0.9%worse
Long-stay residents with a urinary tract infection1.0%1.2%2.0%better
Long-stay residents with depressive symptoms14.9%7.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.0%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened26.9%9.8%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.8%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers4.2%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control34.8%10.2%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table7.8%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine98.7%93.2%79.4%better
Short-stay residents rehospitalized after admission23.2%23.0%22.6%typical
Short-stay residents with an outpatient ER visit18.7%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.632.251.67better
Long-stay outpatient ER visits per 1,000 resident days1.451.571.80better

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.

50.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 196 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.6%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
73.0%U.S. median 56.6%
Met the expected recovery
0.72U.S. median 0.31
Therapy hours / resident / day
0.42hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 73.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 174 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 0.72 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.6%CMS range 43.1–57.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.5–13.210.7%Oct 2022–Sep 2024no 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 discharge73.0%56.6%Oct 2024–Sep 2025CMS 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 discharge70.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge66.7%50.0%Oct 2024–Sep 2025CMS 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 identified99.2%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge97.1%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.1%CMS range 4.8–13.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.191.02Oct 2022–Sep 2024CMS 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

0.59
RN hours/ resident / day
1.13
LPN hours/ resident / day
2.21
Aide hours/ resident / day
3.93
Total nurse hours/ resident / day
0.42
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 87 beds and averages 81.8 residents a day — about 94% 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 3.93 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.75 hrs/resident/day on weekends vs 4.01 on weekdays — 6% thinner on weekends. RN hours go from 0.66 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

7
deficiencies at the latest standard inspection (2026-04-24)
2
at the previous standard inspection (2024-08-02)

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.

ABCDEFGHIJKL

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 12 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · G2025-11-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 interviews and record reviews, the facility failed to provide services for one resident (Resident 1) when licensed nurses did not provide care for Resident 1's surgical drains (tubes placed in the body after surgery to remove excess blood, pus, or other fluids from a wound or cavity, preventing buildup that could slow healing or cause infections) upon admission to the facility.This failure resulted in Resident 1 having to be readmitted to the hospital for care of a preventable infection.Findings:A review of Resident 1's undated hospital referral form titled [NAME] [Artificial Intelligence Discharge Agent, a software platform used to streamline a patient 's discharge process to skilled nursing facilities] Facesheet indicated Resident 1 had a drain located on the right lateral flank (the side area of the body between the last rib and the hip bone) and another on the right medial upper quadrant (the central part of the upper abdomen) surgically placed on 10/5/25 after surgeons drained a liver abscess (a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-05-08 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a fall risk care plan to meet the medical, nursing, mental, and psychosocial needs for one (Resident 1) of three sampled residents. This deficient practice resulted in Resident 1 experiencing injury and pain secondary to an unwitnessed fall on 4/26/25. Findings: A review of Resident 1's, admission Record, dated 5/7/25, showed Resident 1 was initially admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness) affecting the right side, morbid obesity (a complex chronic disease in which you have a body mass index [BMI] of 40 or higher, with normal range for adults considered to be between 18.5 and 24.9), muscle weakness, dementia (a general term for a group of symptoms that affect thinking, memory, and other cognitive [relating to, being, or involving conscious intellectual activity-such as thinking, reasoning, or…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-06-24 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure nursing services met professional standards for one (1) of six (6) sampled residents (Resident 2) when complete neurological assessments (subjective and objective data collected through interview and detailed physical examination of the central nervous system [brain, spinal cord] and the peripheral nervous system [other body nerves] was not documented following a head injury.This failure had the potential to delay identification of neurological changes indicative of brain injury or other clinical decline. Cross reference F726).A review of Resident 2's Face Sheet (a facility demographic), dated 6/10/26, indicated he was admitted to the facility on [DATE], with diagnoses including dementia (a decline in memory, reasoning, and cognitive skills severe enough to interfere with daily life), depression (a serious mood disorder characterized by persistent feelings of sadness, emptiness, and a loss of interest in activities), anxiety, and unsteadiness 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-06-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 protect one of six sampled residents (Resident 2) from abuse when Resident 2 was struck by Resident 3 during an physical altercation on 6/06/26.This failure resulted in Resident 2 being struck on the right temple and suffering a lingering headache.A review of Resident 2's Face Sheet (a facility demographic), dated 6/10/26, indicated he was admitted to the facility on [DATE], with diagnoses including dementia (a decline in memory, reasoning, and cognitive skills severe enough to interfere with daily life), depression (a serious mood disorder characterized by persistent feelings of sadness, emptiness, and a loss of interest in activities), anxiety, and unsteadiness on feet.A review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/16/26, indicated he had mild cognitive impairment (involves noticeable declines in memory, language, or thinking skills, but are not severe enough to disrupt daily…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-06-24 · tag F0646 — isolated
    Notify 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 interview and record review, the facility failed to notify the state mental health authority (Department of Health Care Services [California agency responsible for overseeing the state's required screenings to identify individuals with serious mental illness]) for two (2) of six (6) sampled residents (Resident 3 and Resident 5), who had significant changes in mental health status.This failure had the potential to result in residents not receiving appropriate mental health services based on their most current clinical needs1. A review of Resident 3's Face Sheet (facility demographic) indicated he was admitted to the facility 9/08/25 with diagnosis of congestive heart failure (CHF, occurs when the heart muscle becomes too stiff or weak to pump blood efficiently), malnutrition (when the body does not receive the proper balance of nutrients and calories required to maintain healthy tissues and organ function), and muscle weakness.A review of Resident 3's Notice of PASRR Level 1 (Preadmission Screening 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · F2026-04-24 · tag F0802 — failed to prepare enough nourishing food — widespread
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility failed to ensure a sufficient number of dietary staff were maintained to carry out required Food and Nutrition Services functions when dietary staff responsible for cleaning and sanitation were reassigned to cover vacant food preparation roles. This failure resulted in insufficient staffing to complete essential duties and placed a census of 78 residents who ate food from the kitchen at risk for potential foodborne illnesses.Findings:During a concurrent observation and interview with the Certified Dietary Manager (CDM) in the kitchen on 4/21/26 at 8:09 a.m., the facility stove was noted to have large amounts of grease and food debris built up around and beneath all burners. The backsplash behind the grill of the stove was stained with grease. The CDM stated she was an interim traveler CDM until the current CDM In Training (CDMIT) was able to resume classes to become certified. The CDMIT was pulled to work as a cook until the position could be filled. The CDM stated the kitchen was short staffed and had been employed by the facility for three months. During an 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-04-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 kitchen and maintenance staff failed to ensure food was stored, prepared and served safely in accordance with professional standards of food service when:Dietary staff did not apply hair restraints properly;Expired food and drink were found in the refrigerator;Moldy strawberries were found in the refrigerator and moldy onions found in a bin in the dry storage area;The stovetop was encrusted with hardened black residue, the backsplash was stained with grease, the side of the oven was encrusted with white and rust-colored residue and the toaster had accumulated amounts of dust in the upper vents above the serving tray. The space between the back of the stovetop, oven and wall had clumps of dust adhering to the wall, pipe and floor; and,Ice buildup was found on the inner gasket of the freezer door.These failures posed a risk for foodborne illness for a census of 78 residents.1. During an observation in the kitchen on 4/22/26 at 10:35 a.m., the [NAME] In Training (CIT) and [NAME] 2 wore hair restraints which did not fully cover 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-24 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the licensed nurse failed to ensure that resident information was protected during a medication pass when Licensed Nurse 3 (LN 3) did not lock the computer screen after preparing medication for three residents (Resident 1, Resident 11, and Resident 29) of 23 sampled residents.This failure decreased the facility's potential to protect residents' personal information from the public.Findings:During a medication pass observation with LN 3 on 4/22/26 at 11:52 a.m., 11:55 a.m., and 11:59 a.m. with, LN 3 closed the laptop lid halfway down and did not lock the screen after preparing medications. Visitors were observed walking past the laptop with the screen partially visible.During an interview with LN 3 on 4/22/26 at 12:10 p.m., LN 3 confirmed she did not lock the computer screen or log out of the resident chart. LN 3 further stated it was possible for someone to see the resident information if they lifted the laptop screen.During an interview with the Assistant Director of Nursing (ADON) on 4/23/26 at 2:24 p.m., the ADON stated she expected LN 3 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-24 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the licensed nurses failed to remove the following from one of two medication carts:One unlabeled bottle of eye drops,Two inhalers without open dates, andThree loose pills.In addition, one expired insulin (medication used to treat diabetes) pen was found in one of two medication storage room fridges.These failures decreased the facility's potential to safely administer medications and prevent drug diversion (the illegal redirection of prescription or controlled medication from their intended medical use to unauthorized or illicit use).Findings:During a concurrent observation and interview with Licensed Nurse 2 (LN 2) on [DATE] at 11:23 a.m. during a medication cart inspection, LN 2 confirmed that:One bottle of [brand name] contact lens drops was found without a resident identifier,Two budesonide (medication to treat breathing problems) inhalers were found without open dates, andThree loose pills were found in Side Two Top medication cart.LN 2 stated medications…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-24 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 nursing, therapy, and maintenance staff failed to ensure infection prevention and control practices were implemented for a census of 78 residents when:Staff did not wear Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for residents three residents (Resident 25, Resident 40, and Resident 96) on Enhanced Barrier Precautions (EBP- to reduce transmission of multidrug-resistant organisms in nursing homes. EBP involves gown and glove use during high-contact resident care activities such as transferring and changing bed linen); and,12 rooms were observed without proper infection precaution signage or easily accessible PPE supply containers; and,Staff failed to maintain a clean oxygen concentrator for Resident 46.These failures decreased the facility's potential to prevent the spread an infection amongst residents and decreased the facility's potential to prevent bacteria and debris from directly entering Resident 46's lungs, placing…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-24 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility's admissions or social service staff failed to ensure residents were asked about their Advanced Directives (a legal document indicating resident preference on end-of-life treatment decisions), for one resident (Resident 20) of eight sampled residents when there was no documented evidence in Resident 20's medical record that a discussion was had about an Advanced Directive.This failure decreased the facility's potential to ensure Resident 20's wishes were carried out during an emergency.Findings:A review of Resident 20's admission record indicated the resident was admitted in February 2026 with a diagnosis of cellulitis (a common, potentially serious bacterial infection affecting the deep layers of skin and underlying tissue) of the buttocks. This document also indicated Resident 20 had a Public Guardian (a court-appointed official or agency that acts as the decision-maker for individuals unable to care for themselves) as their Responsible Party (RP, a person who is appointed as the decision-maker for a resident who is no longer able…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-24 · tag F0655 — isolated
    Create 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

    Based on interview and record review, the licensed nurses and social service staff failed to provide written summaries of resident baseline care plans to communicate the initial goals of care for two residents (Resident 8 and Resident 14) of three sampled residents.This failure decreased the facility's potential to safeguard against adverse events right after admission to the facility by ensuring continuity of care and communication of residents' care needs.Findings:A review of Resident 8's Face Sheet, indicated admission to the facility in February 2026 with diagnoses of age-related osteoporosis (a chronic bone disease characterized by a weakened bone structure and high fracture risk), muscle weakness, a pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of the right heel, and repeated falls. The face sheet also indicated Resident 8 was her own Responsible Party (a person designated as the decision-maker).A review of Resident 8's Baseline Care Plan, indicated Resident 8 was her own RP yet she did not sign 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2026-02-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 interview and record review, Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) failed to provide urinary catheter care for one resident (Resident 1) out of three sampled residents when Resident 1 developed a facility acquired mucosal membrane skin injury (damage to the skin and/or underlying soft tissue caused by pressure from a medical device used for therapeutic purposes) and urinary tract infection (UTI- an infection of the bladder/urinary tract) from an indwelling urinary catheter (flexible tube remaining in the bladder to continuously drain urine into an external bag).This failure resulted in Resident 1 sustaining a laceration which measured 1.3 centimeters (cm-a unit of measure) long and 0.5 cm wide to Resident 1's urinary meatus (the external opening of the penis) and a severe infection with Pseudomonas Aeruginosa (a serious, often antibiotic-resistant bacteria that causes UTI).Findings:A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-05 · tag F0655 — pattern
    Create 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 interviews and record reviews, the facility failed to ensure a baseline care plan (BCP, a document created within 48 hours of a resident's admission to a nursing home, outlining the initial care needed to ensure residents' safety and well-being, focusing on basic needs and resident-specific information) was completed timely, for two out of two sampled residents (Resident 1 and Resident 2), when neither BCPs were completed within 48 hours of admission and Resident 1's BCP did not address her Pressure Ulcers (PUs, a localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for nearly one month after admission.These failures had the potential to result in newly admitted residents receiving unsafe care and put Resident 1 at an increased risk for further skin breakdown and worsening of PUs.Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date of 1/7/2026…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-05 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and record reviews, the facility failed to ensure professional standards of quality were provided, for one out of two sampled residents (Resident 3), when:1. Resident 3 administered a nebulizer (a machine that turns liquid medication into a fine mist that is inhaled into the lungs through a mouthpiece or mask) treatment herself without physician order or assessment for self-medication administration,2.LN B inaccurately documented in Resident 3's Electronic Medication Administration Record (EMAR, a digital system used to track and document the administration of medications, ensuring accuracy and timeliness in medication delivery) polyethylene glycol (a laxative/stool softener use to treat occasional constipation [stool that is hard, dry, or difficult and painful to pass]) had been given.These failures could lead to Resident 3 receiving incorrect dosing of medication, worsening of condition and lead to incorrect treatment decisions.Findings:A review of Resident 3's face sheet (front page of the chart that contains a summary of basic information about…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-28 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to implement their abuse policy for one resident (Resident 1) of nine sampled residents when licensed nurses did not document an assessment, a Change of Condition (COC), notification of the incident to the physician (MD), and 72-hour monitoring for Resident 1 immediately after an alleged abuse incident.This failure decreased the facility's potential to ensure Resident 1's needs were met after his involvement in an altercation.Findings:A review of Resident 1's admission record indicated he was admitted in September 2025 with a diagnosis of chronic systolic (congestive) heart failure (CHF - a heart disorder which causes the heart to not pump blood efficiently, sometimes resulting in leg swelling), hypertensive heart disease (heart failure due to high blood pressure), and muscle weakness (generalized). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/22/25, indicated Resident 1 had no memory impairment.A review of Resident 1's Health Status Note dated 12/25/25 at 7:49 p.m.…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-08 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and facility record review, the facility did not ensure an allegation of verbal abuse involving one resident (Resident 1) was reported to the California Department of Public Health (the Department) within the required timeframe of the incident.This failure delayed the Department from investigating the allegation of abuse to ensure resident safety.Findings:A review of Resident 1's admission record indicated admission to the facility on 9/27/25 with a diagnosis that included, Developmental Delay (occurs when a child reaches milestones in physical, cognitive, communication, social-emotional, or adaptive skills later than typically expected), Rheumatoid Arthritis (a chronic autoimmune disease where the immune system mistakenly attacks the joint lining , causing pain, swelling, stiffness, warmth, fatigue, and potential joint damage), Major Depressive Disorder (a serious mood disorder causing persistent sadness, loss of interest, and impacts how you feel, think, and act), and Anxiety Disorder (mental health conditions marked by excessive, persistent worry and fear…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-06 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility nursing staff failed to follow professional standards when one licensed nurse gave a dose of one of four sampled residents, Resident 1's, prescription medications to a staff member who was experiencing symptoms of anxiety. This failure resulted in the potential misuse of Resident 1's medication when the nurse, who was entrusted with full access to the medication cart, gave the medication to someone to whom it was not prescribed, and resulted in the loss of a dose of Resident 1's medication when the dose was thrown away.During an observation on 8/6/25 at 9:45 a.m., two medication carts were parked next to the nurses' station. Two security cameras were noted mounted on the ceiling pointed at the nurses' station.During an interview on 8/6/25 at 11:29 a.m., Licensed Staff B stated nurses were not allowed to give medications to staff from the medication cart because the medications belonged to the residents, staff did not have a doctor's order for the medications, and the nurses did not know whether the staff members might…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-02 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and facility policy review, the facility failed to ensure they referred the resident to the appropriate state-designated authority for a Level II preadmission and resident review (PASARR) when the resident was diagnoses with a new mental illness diagnosis for 1 (Resident #11) of 1 sampled resident reviewed for PASARR. Findings included: A facility policy titled, P-NP04 Pre-admission Screening Resident Review, revised 09/01/2023, revealed, 5. The facility MDS [Minimum Data Set] Coordinator will be responsible to access and ensure updates to the [PASARR] are completed per MDS guidelines. An admission Record indicated the facility admitted Resident #11 on 05/05/2011. According to the admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following cerebral infarction, ataxia, protein-calorie malnutrition, and unspecified mental disorder due to known physiological condition. Per the admission Record, the resident received a diagnosis of bipolar disorder on 11/20/2015 and schizoaffective disorder 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-02 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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, record review and facility policy review, the facility failed to implement enhanced barrier precautions (EBP) during wound care for 1 (Resident #64) of 1 sampled resident reviewed for pressure ulcer/injury. Findings included: A facility policy titled, IPC303 Enhanced Barrier Precautions, revised 07/05/2024, revealed, 2. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities for those at risk of transmission or acquisition of MDROs [multi-drug resistant organisms]: a. Dressing b. Bathing/showering c. Transferring within the resident room d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator i. CDC [Centers for Disease Control and Prevention] does not currently consider peripheral I.V. [intravenous], continuous glucose monitors, and insulin pumps as indications for Enhanced Barrier Precautions. h. Wound care: any skin opening requiring a dressing i. Per 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-08 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two (2) of four (4) residents (Resident 1 and Resident 4) were treated with respect and dignity when Resident 1 had to wait 20 minutes to be assisted to the toilet, and Resident 4 was not provided appropriate size adult diapers, not assisted to the toilet, and not changed and left to lie in bed in her wet adult diaper, clothes and linen. These failures made Resident 1 feel like she was not important and Resident 4 often wet and smelling of urine. Findings: During an interview on 11/29/23, at 3:46 p.m., Resident 1 stated she was admitted to the facility because she fell and broke her hip. Resident 1 stated she needed assistance with transfer from bed to chair, and to toilet. Resident 1 stated it is acceptable to wait 10 minutes, but she sometimes has incontinence (loss of control) of urine and had to wait 20 minutes to be assisted to the toilet. Resident 1 stated she felt like an old shoe (not important) when she must wait 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-11 · tag F0676 — failed to keep up residents' daily-living abilities — pattern
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure three residents (Resident 39, 2 and 261) were provided services to improve and maintain grooming. This failure resulted in: 1. Resident 39 and 2 not getting haircuts in the facility, and 2. Resident 261 not getting shaved Findings: Resident 39 and 2 During an interview on 6/8/21, at 10:28 a.m., Resident 39 stated, there was nobody in the facility to provide a haircut. Resident 39 stated, she cut her own hair. During an observation on 6/10/21, at 8:09 a.m., Resident 2 was observed in the lobby exercising with shoulder length hair, untied. Resident 2 stated, he wanted to have a haircut and nobody in the facility could do it. During an interview on 6/8/21, at 2:36 p.m., Management Staff A stated, facility was unable to find a barber or hairdresser to come to the facility to do haircut for residents. During an interview on 6/10/21, at 10:57 a.m., Management Staff E stated, management was planning on finding a hairdresser or barber to go in all facilities in Eureka and do haircut for residents. Resident #261 Resident 261's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-11 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide 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 interview and record review, the facility failed to provide scheduled showers for two dependent residents (Resident 113 and Resident 261). This had the potential to result in discomfort, unpleasant body odor, and skin infections to the residents involved. Findings: Resident 113 Resident 113 was admitted to the facility on [DATE] with medical diagnoses including Obesity, Type 2 Diabetes with Diabetic Peripheral Angiopathy (Blood vessel disease caused by high blood glucose) with Gangrene (A condition where a loss of blood supply causes body tissue to die), and a Pressure Ulcer (Injury to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) on the Sacral Region (Area at the base of the spine), according to the facility Face Sheet (Facility demographic). Resident 113's MDS (Minimum Data Set-An assessment tool) dated 5/25/21, indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) score was 13, which indicated her cognition was intact. Resident 113's MDS…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-06-11 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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: 1. Ensure that expired medications were removed from medication carts. This failure had the potential for expired, and therefore less effective or ineffective, medications to be given to residents, which could impact the residents' health. Findings: During an observation and concurrent interview with Licensed Staff I at medication cart on 6/9/21 at 11:08 a.m., the following medications were observed: Nephro vite, vitamin C and B complex (Vitamin Supplement) with an expiration date of 4/21, and Ferrous sulfate (Iron) 325 mg tabs, with an expiration date of 3/21. During an interview with Management Staff B on 6/9/21 at 2:18 p.m. when asked what the expectation was regarding expired medications in medication carts, Management Staff B stated: We expect the nurses to check the expiration date as part of the medication pass. If the medication is expired, they are to take the medication out of the medication cart. During an interview with Management staff A on 6/10/21 at 13:00 p.m., a Medication storage policy 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-11 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 ensure documentation for Activities of Daily Living (ADLs-Basic tasks of daily life) was complete for two of five sampled residents (Resident 17 and Resident 40). The records had missing documentation for personal hygiene and toileting, among other categories. This failure had the potential to result in inability for staff to respond to the status and needs of the residents, and lack of availability of information to facilitate communication among the interdisciplinary team. Findings: Resident 17 Resident 17 was admitted to the facility on [DATE] with medical diagnoses including Anemia (A blood disorder in which red blood cells are unable to carry enough oxygen around the body) and Hyperlipidemia (An abnormally high concentration of fats or lipids in the blood), according to the facility Face Sheet (Facility demographic). Resident 17's MDS (Minimum Data Set-An assessment tool) dated 5/19/21 indicated she required supervision with eating and toilet use.…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-06-11 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow infection control principles when: 1. A facility staff did not disinfect a thermometer per facility's policy during visitor screening, 2. Facility staff did not wear appropriate PPE (Personal Protective Equipment- Protective clothing or equipment designed to protect the wearer's body from injury or infection) in the Yellow Zone (Area on quarantine for housing newly admitted residents)of the facility, and; 3. The facility did not follow their mitigation plan when they did not quarantine residents who were exposed to a confirmed COVID-19 positive staff. These findings had the potential to result in spread of infections, including COVID-19, among staff and residents at the facility. Findings: 1. During an observation on 6/07/21 at 8:10 a.m., Unlicensed Staff R was observed using a thermometer to screen visitors and staff temperatures, including surveyors' temperatures, as part of the COVID-19 screening protocol. The thermometer touched…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-11 · tag F0641 — isolated
    Ensure 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 assess one resident's (Resident 21) hearing ability. This failure resulted in the facility not providing necessary treatment to improve Resident 21's activities of daily living due to impaired hearing. Findings: During a concurrent observation and interview on 6/7/21, at 12:08 p.m., Resident 21 was observed sitting in a wheelchair in her room. Resident 21 stated, she was hard of hearing in both ears and could not afford a hearing aid. During an interview on 6/9/21, at 2:43 p.m., Resident 21 stated, she was hard of hearing in both ears but worst in the right ear and never had a hearing aid before. During a review of Resident 21's admission MDS (Minimum Data Set-standardized, primary screening and assessment tool of health status for residents in long term care facilities) dated 8/15/20, it indicated Section B0200 Hearing was coded as 1 with minimal difficulty. MDS indicated, Section B0300 Hearing Aid was coded as 1 meaning Yes,…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-11 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and document pain levels accurately for one of five sampled residents (Resident 29). In addition, the facility failed to ensure physician orders for pain medication were followed as prescribed. This failure could have resulted in increased pain levels and decreased quality of life and suffering to Resident 29. Findings: Resident 29 was admitted to the facility on [DATE] with medical diagnoses including Fibromyalgia (A disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues), Myalgia (Pain in a muscle or group of muscles) and Chronic Pain, according to the facility Face Sheet (Facility demographic). During an interview on 6/08/21 at 10:15 a.m., Resident 29 stated she experienced a lot of pain from migraine headaches, and her prescribed pain medication had not been able to manage it. Resident 29 stated her pain often reached a level of eight or nine out of ten (on a scale from zero to ten,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$38,445 in federal fines across 2 penalties.

  • $30,167 — penalty dated 2025-11-25
  • $8,278 — penalty dated 2025-05-08

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to CORPORATE INTERFACE SERVICES — 40 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 →

RatingThis homeChain avg
Overall 2 of 52.5-0.5 vs chain
Health inspection 2 of 52.4-0.4 vs chain
Staffing 3 of 52.4+0.6 vs chain
Quality measures 4 of 53.9+0.1 vs chain
The other 39 homes this chain runs (chain average 2.5★, per CMS)
1 of 5Autumn Creek Post AcuteChico, CA 1 of 5Coral Cove Post AcuteLong Beach, CA 1 of 5East Terrace Rehabilitation & Wellness Centre, LPLos Angeles, CA 1 of 5Four Seasons Healthcare & Wellness Center, LPNorth Hollywood, CA 1 of 5Hawthorne Healthcare & Wellness Centre, LPHawthorne, CA 1 of 5Los Feliz Healthcare & Wellness Center, LPLos Angeles, CA 1 of 5Mar Vista Country Villa Healthcare & WellnessLos Angeles, CA 1 of 5Oakwood Healthcare CenterChico, CA 1 of 5Pioneers Memorial Skilled Nursing CenterBrawley, CA 1 of 5Plaza Healthcare CenterSanta Ana, CA 2 of 5Anaheim PointAnaheim, CA 2 of 5Bay Vista Healthcare & Wellness Centre, LPLong Beach, CA 2 of 5Chico Terrace Care CenterChico, CA 2 of 5Claremont Heights Post AcuteClaremont, CA 2 of 5Eureka Rehabilitation & Wellness Center, LPEureka, CA 2 of 5Fortuna Rehabilitation And Wellness Center, LPFortuna, CA 2 of 5Montecito Heights Healthcare & Wellness Centre, LPLos Angeles, CA 2 of 5Pasadena Park Healthcare And Wellness CenterPasadena, CA 2 of 5San Rafael Healthcare & Wellness Center, LPSan Rafael, CA 2 of 5Tulare Healthcare & Wellness Center, LPTulare, CA 2 of 5Westwood Post Acute CareLos Angeles, CA 2 of 5York Healthcare & Wellness CentreLos Angeles, CA 3 of 5Alhambra Healthcare & Wellness Centre, LPAlhambra, CA 3 of 5Bay Marina Post AcuteOakland, CA 3 of 5Monterey Healthcare & Wellness Centre, LPRosemead, CA 3 of 5Ontario Grove Healthcare & Wellness Centre, LPOntario, CA 3 of 5Overland Terrace Healthcare & Wellness Centre, LPLos Angeles, CA 3 of 5Pavilion On Pico Healthcare & Wellness Centre, LPLos Angeles, CA 3 of 5Princeton Manor Healthcare Center, LLCOakland, CA 3 of 5Seaview Rehabilitation & Wellness Center, LPEureka, CA 4 of 5Ivy Creek Healthcare & Wellness CentreSan Gabriel, CA 4 of 5Kings Healthcare & Wellness Center LPHanford, CA 4 of 5Pine Grove Healthcare & Wellness Centre, LPSan Gabriel, CA 4 of 5River Valley Healthcare & Wellness Centre, LPRedding, CA 4 of 5West Hollywood Healthcare & Wellness Centre, LPLos Angeles, CA 5 of 5Delta Healthcare & Wellness Center, LPVisalia, CA 5 of 5North Point Healthcare & Wellness Centre LPFresno, CA 5 of 5Oxnard Manor Healthcare CenterOxnard, CA 5 of 5West Pico Terrace Healthcare & Wellness Centre LPLos Angeles, CA

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 / managerTypeRoleSince
CORPORATE INTERFACE SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/18/2024
ROCKPORT ADMINISTRATIVE SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2011
O'NEILL, ALICEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/05/2005
WINGET, LEIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/15/2025
GRANADA WELLNESS GP LLCOrganizationGENERAL PARTNERSHIP INTERESTsince 04/01/2011
RECHNITZ, SHLOMOIndividualLIMITED PARTNERSHIP INTERESTsince 04/01/2011
EUREKA-LET LPOrganizationADP OF THE SNFsince 06/17/2025

CMS files one row per role, so the 11 rows in the source record cover these 7 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.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$12.4M
Net patient revenuemost recent cost report
-10.3%
Operating marginrevenue minus expenses
$1.1M
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 24%Other / private 7%

This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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

$481per resident / day
operating cost
$14,618per month
≈ monthly operating cost
$436per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

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 056300. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-24, 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.

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