No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Fairfield Post Acute Rehabilitation

1255 Travis Blvd, Fairfield, CA 94533 · For profit - Limited Liability company · 99 certified beds · (707) 425-0623 Medicare & Medicaid certified

Call the home — (707) 425-0623 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Jan 2026
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • 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)
Worth asking about
  • 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 (27) — 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.

4/5
CMS overall
4 of 5
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

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1620 Pennsylvania Ave · (707) 428-4878 · Call to confirm hours
Pharmacy
Grocery
1350 Gateway Blvd · (707) 434-0144 · Call to confirm hours
Park
754 Great Jones St · (707) 427-6927 · Typically dawn to dusk

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 held steady at 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
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 increased10.4%10.2%15.4%better
Long-stay residents who lose too much weight3.8%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.8%0.9%better
Long-stay residents with a urinary tract infection0.8%1.2%2.0%better
Long-stay residents with depressive symptoms3.6%7.3%6.5%better
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 injury0.4%1.6%3.3%better than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened11.0%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.2%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine98.4%98.2%95.3%typical
Long-stay residents with pressure ulcers3.4%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control9.3%10.2%21.2%typical for the state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table8.7%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine93.7%93.2%79.4%better
Short-stay residents rehospitalized after admission26.8%23.0%22.6%worse
Short-stay residents with an outpatient ER visit14.8%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.972.251.67worse
Long-stay outpatient ER visits per 1,000 resident days1.291.571.80better

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.

57.0% 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 308 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.0%U.S. median 51.5%
Got home and stayed home
12.8%U.S. median 10.7%
Went back to hospital
70.2%U.S. median 56.6%
Met the expected recovery
0.51U.S. median 0.31
Therapy hours / resident / day
0.31hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 70.2% 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 121 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 0.51 therapist hours per resident per day in 2026Q1 — more than 82% 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 SNF57.0%CMS range 51.6–61.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.8%CMS range 9.7–15.810.7%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 discharge70.2%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 discharge74.4%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 discharge71.1%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 identified100.0%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 setting93.5%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 discharge96.0%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 hospitalization8.3%CMS range 5.5–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 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

1.00
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.43
Aide hours/ resident / day
4.31
Total nurse hours/ resident / day
0.73
RN hoursweekends
38.7%
Total nursing turnover
26.1%
RN turnover

How full it usually is: this home is certified for 99 beds and averages 93.3 residents a day — about 94% occupied, or roughly 6 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 4.31 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.00 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.43 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 3.85 hrs/resident/day on weekends vs 4.49 on weekdays — 14% thinner on weekends. RN hours go from 1.10 to 0.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2026-01-09)
6
at the previous standard inspection (2024-09-13)

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Dcited before2026-06-25 · 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

    Based on interview, and record review the facility failed to ensure one of three sampled residents, Resident 1 received care in accordance with professional standards of practice when facility staff did not follow physician orders and inaccurately documented medical notes during an emergent change of condition.These failures decreased the facility's potential to safely and effectively provide care to a resident with worsening health conditions.Findings:1a. Licensed Nurse 1 (LN 1) did not follow a physician's order to regulate Resident 1's oxygen flow rate to 3 LPM (LPM, liters per minute, it's a measurement of how much oxygen Resident 1 received) via nasal cannula (NC-nasal cannula, oxygen tubing).A review of Resident 1's Clinical Record indicated Resident 1 was admitted to the facility in May 2026 with diagnoses that included COPD (Chronic Obstructive Pulmonary Disease- a progressive, long-term lung disease that blocks airflow and makes it difficult to breathe), and Acute Respiratory Failure with Hypoxia (a condition where the body's tissues do not receive enough oxygen 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-20 · tag F0628 — isolated
    Provide 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 review, the facility failed to ensure medication was accurately reconciled before discharge when Resident 1 was sent home with the wrong insulin (a hormone produced by the body or given artificially to removes excess sugar from the blood) medication.This failure had the potential to cause sudden, severe hypoglycemia (low blood sugar) leading to confusion, seizures, or sudden death.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 he was admitted to the facility on [DATE] for diagnosis including Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 1 was discharged home on 4/11/26.A review of Resident 1's Order summary report for 4/26, indicated he was prescribed NovoLIN R (brand name for man-made human insulin used to treat diabetes) using a FlexPen/Pen-injector (a pre-filled, disposable device used to inject…

    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 · F2026-01-09 · tag F0761 — failed to label and store drugs safely — widespread
    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 ensure medications were stored properly, when an unlabeled loose pill and three labeled blister packs (a type of unit-dose packaging with clear plastic bubbles (blisters) holding individual pills) were found on the bottom of a drawer and in the back of the drawers for one out of five sampled medication carts. These failures had the potential for medication error, misuse, or drug diversion.Findings: During an inspection of Medication Cart 5 on 1/6/26 at 12:20 p.m., one unlabeled loose pill and three labeled blister packs were found on the bottom of the drawer and behind the drawers in the back of medication cart 5.During an interview on 1/6/26 at 9:48 a.m. with Nursing Supervisor (NS), NS removed the pill found on the bottom of the drawer and confirmed there was 1 loose pill. NS also confirmed there were three labeled blister packs found behind the drawer at the back of cart 5. The NS stated the carts were cleaned regularly but admitted she did not think of looking behind the drawers. The NS confirmed 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-01-09 · 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 facility document review, the facility failed to store cookware pans and utensils in accordance with professional standards for food service safety when: Frying pans were stacked wet while stored away; and, Ladles and cake slicer were found wet while stored in the drawer.These failures had potential to cause food-borne illnesses in a highly susceptible population of 97 residents who received food from the kitchen.Findings:During a concurrent initial tour observation and interview on 1/6/26 at 8:45 a.m. at the kitchen with the Certified Dietary Manager (CDM), several wet pans and ladles were stacked and stored at the clean and ready-to-use storage areas as indicated below:6 frying pans- different sizes6 ladles - various sizes1 cake slicerThe CDM confirmed that the 6 frying pans, 6 ladles, and 1 cake slicer were wet. CDM stated, the frying pans, ladles, and a cake slicer should have been completely air dried before being stored away.During an interview on 1/8/26 at 10 a.m. with Registered Dietician (RD), the RD stated, the expectation was: 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 · E2026-01-09 · tag F0578 — failed to honor advance directives / code status — pattern
    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 failed to ensure 4 of 24 sampled residents (Resident 7, Resident 32, Resident 53, Resident 90) were offered an advance directive (a legal document where a competent adult specifies their future medical care wishes in the event they cannot communicate them themselves, often due to illness or injury). This failure had the potential to result in the residents' medical wishes not being honored.Findings:During a review of Resident 7's admission record (AR), the AR indicated Resident 7 was admitted in November 2025 with several diagnosis including aftercare following surgical amputation (surgical removal of part or all of a body part).During a review of Resident 32's AR, the AR indicated Resident 32 was admitted in November 2025 with several diagnosis including encephalopathy (a condition where brain dysfunction occurs due to a chemical imbalance in the body, often triggered by systemic illnesses or organ dysfunction). During a review of Resident 53's AR, the AR indicated Resident 53 was admitted in December 2025 with several diagnosis…

    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 · E2026-01-09 · tag F0813 — pattern
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    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 store resident food in a safe and sanitary manner in the refrigerators for residents for a census of 97 when:One opened bottle of soda stored past their use by date,Two bottles of opened salad dressings, and one fruit spread found unlabeled,One bag of loaf of bread was unlabeled, undated, and expired; and,Opened container of clam chowder with expired use by date.These failures had the potential to cause foodborne illnesses in a vulnerable resident population. Findings:During a concurrent observation and interview on 1/8/26 at 10:30 a.m. with Certified Dietary Manager (CDM), several resident food items were found in the refrigerators for residents at Nursing Station 1 and Nursing Station 2. The food items found were as follows:Nursing Station 1 refrigerator for residents:One opened bottle of soda stored past their use by date 12/27/25.Two opened salad dressings, and one fruit spread found unlabeled, undatedOpened Clam Chowder with use by date 1/7/26 and unlabeled.Nursing Station 2 refrigerator for residents:One…

    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 before2026-01-09 · 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 ensure proper infection prevention measures were implemented for a census of 97 when:One facility staff did not sanitize the blood pressure (BP-measures the force of blood against artery walls) cuff in between two residents (Resident 2 and Resident 61).These failures had the potential to spread germs.Findings:A review of Resident 2's clinical record indicated Resident 2 was admitted [DATE] with diagnosis that included Chronic Viral Hepatitis C (a long term viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood), Immunodeficiency (the immune system can't effectively fight infections and diseases, leading to frequent, severe infections and potentially cancer), Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing).A review of Resident 61's clinical record indicated Resident 61 was admitted [DATE] with diagnosis that included Immunodeficiency,…

    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 · D2026-01-09 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent 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

    Based on interview and record review, the facility failed to ensure one of 24 sampled residents (Resident 9) was free of unnecessary psychotropic medications (any drug that affects behavior, mood, thoughts or perception) when Resident 9 did not receive a psychiatric evaluation to determine if their psychotropic medication should be continued.This failure had the potential to result in the use of an unnecessary psychotropic medication that could cause adverse consequences.During a review of Resident 9's admission record (AR), the AR indicated Resident 9 was admitted to the facility in November 2025 with multiple diagnosis including dementia (a progressive state of decline in mental abilities). Resident 9's AR did not indicate a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 9's physician's orders dated 11/7/25, the physician's orders indicated Resident 9…

    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 before2025-12-24 · 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 interview and record review, the facility failed to perform the weekly weights for one of the four sampled residents (Resident 1) per order and care plan. This failure exacerbated Resident 1's weight loss significantly.Findings:During a review of Resident 1's admission Record (AR), AR indicated, Resident 1 was admitted on [DATE] with diagnoses which included Metabolic encephalopathy (when the brain does not work because of chemical imbalance or problem in the body's metabolism), Burn of Second Degree of Left Thigh due to heatstroke (heatstroke- when the body overheats dangerously from too much sun, leading to symptoms like confusion, dizziness, high fever, requiring immediate medical help.)During a review of Nutritional Risk Assessment (NRA), dated and signed by Registered Dietician (RD) on 7/8/25, the NRA indicated, .Goals: Maintain weight within +/- 5 pounds of current body weight (CBW). Resident 1's admission weight was 198 lbs. (pounds- a unit of weight measurement).During a review of order summary…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide respiratory care services according to professional standards of quality for one resident (Resident 1), when Resident 1 arrived to the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) center with an empty oxygen tank. This failure decreased the facility's potential to safely provide Resident 1's oxygen therapy. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in May 2024 with diagnoses including respiratory failure (a condition where there's not enough oxygen in the body) and pneumonitis (inflammation of the lung tissue). A review of Resident 1's Care plan report, dated 5/22/24, indicated Resident 1 required continuous oxygen every shift. A review of Resident 1's physician orders, dated 5/21/24, indicated Resident 1 was scheduled for dialysis on Monday, Wednesday, and Friday with pick up time from facility at 12:45 p.m. and chair time for dialysis at 1:15 p.m. The order further indicated…

    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
Show the remaining 17 citations
  • Potential for harm · Fcited before2024-09-13 · 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 facility failed to store and prepare food in a sanitary environment when: 1. Ice packs for resident pain relief were stored in a refrigerator for food, 2. A dietary aide did not correctly test the sanitizer bucket, and 3. A cook did not correctly describe the cool down process. This failure could potentially lead to food-borne illness in vulnerable residents. Findings: 1. During an observation and concurrent interview on 9/12/24 at 2:33 p.m. with Dietary Manager, the Station 1 refrigerator for residents' food had a sign taped to the front that indicated For Resident Food Only. The refrigerator contained a six-pack of Ensure labeled with a resident's name and a bottle of Snapple with a resident name on it. The freezer compartment contained multiple white ice packs with the words Cold Pack in blue print on them. When queried, Dietary Manager stated the ice packs were for if a resident had a headache or something. When asked if ice packs should be in the refrigerator for resident food, Dietary Manager stated her department 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-13 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    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 keep the trash area clean. This failure could potentially result in an infestation of rodents or other vermin. Finding: During an observation and concurrent interview on 9/12/24 at 2:30 p.m., when asked where the kitchen trash was disposed, Dietary Manager went out to the trash area outside the kitchen back door. The trash area had two dumpsters. Dietary Manager stated one dumpster was for garbage and one for recycling. Behind the dumpster for garbage was a large [NAME] that was full of many pieces of garbage such as drink cups, napkins, and plastic bags. When asked about the [NAME] full of garbage, Dietary Manager stated the garbage was coming from the building next door. The dumpster for garbage was low to the ground with approximately two inches of clearance under it. Shoved underneath the dumpster were plastic bags with napkins, straw wrappers, and plastic utensils in them, such as would be used to eat take-out food. When asked 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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 maintain safe water temperatures at resident sinks when 6 of 22 resident bathroom sinks had water that was too hot to touch. This failure caused two residents to feel afraid of getting burns and one resident to yell out in pain when a hot wash cloth touched her hands. Findings: During an observation on 9/9/24 at 10:49 a.m., the hot water from the sink in the room [ROOM NUMBER] bathroom felt very hot to the touch. The water was too hot for this surveyor to keep a finger under the stream of water for more than one second. The temperature of the hot water using the surveyor's thermometer was 118 degrees Fahrenheit (F) after 20 to 30 seconds. During an observation on 9/9/24 at 12:29 p.m., a staff brought a lunch tray to Resident 6, who was in her bed, and set it on the overbed table. The staff got a washcloth and turned on the faucet in the bathroom, then brought the washcloth to Resident 6 and began to wash her hands. Resident 6 yelled, It'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 · E2024-09-13 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 they were adequately staff when: 1.five out of five residents (Residents 64, 47, 295, 10 and Anonymous 1) complained of short staffing and were left sitting on their urine or feces for over an hour, 2. staff complaints of short staffing and difficulty completing their task timely. These failures resulted in residents feeling sorry for themselves, feeling frustrated, humiliated, embarrassed and worried about their safety and Resident 295 fearful she might get a wound infection. Findings: During an interview on 9/9/24 at 10:40 a.m., Resident 64 stated the facility was short staffed, and it did not matter what shift, weekdays or weekends, the facility was still short staffed. Resident 64 stated he had talked to the Director of Staff Development (DSD) about the short staffing, but the DSD had no answer. Resident 64 stated due to lack of staff, Certified Nursing assistant (CNA) left him sitting on his feces for over an hour. Resident 64 stated he…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-13 · 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

    Based on observation, interview, and record review, the facility failed to initiate a care plan for falls when one of two residents sampled (Resident 48) fell which resulted in a hematoma (collection of blood beneath the skin) on her forehead and a laceration on her right foot. This failure had the potential to place Resident 48 at risk for insufficient provision of care and services when her care givers may be unaware of the plan of care for her wounds. Finding: Review of Resident 48's face sheet revealed an admit date of 5/31/24. Review of Resident 48's Interdisciplinary Team note dated 9/3/24 revealed Resident 48 had fallen on 9/2/24 trying to get out of bed which resulted in a hematoma on the side of her face and a laceration on her right foot. Review of Resident 48's care plan revealed no focus area regarding the injuries that resulted from the fall. Review of Resident 48's physician orders revealed orders dated 9/2/24 to monitor the forehead hematoma and right foot laceration daily for signs of infection, but no orders for treatment for the head and foot injuries. Review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement all care measures specified in one resident's (Resident 345) Comprehensive Care Plan, when there was no documented evidence Resident 345 was turned and repositioned every two hours. This failure had the potential to delay wound healing. Findings: Record review of a document titled, admission Record indicated Resident 345 was admitted to the facility on [DATE] with diagnoses of Aftercare Following Joint Replacement Surgery, Presence of Left Artificial Knee Joint, Iron deficiency Anemia (a condition in which blood lacks adequate healthy red blood cells, which are necessary to carry oxygen to the body's tissues), and Down Syndrome (a genetic disorder causing developmental and intellectual delays). Record review of Resident 345's care plan, initiated on 11/29/23, which focused on Resident 345's potential for pressure ulcer development indicated the following nursing intervention, Needs monitoring/reminding/assistance to turn/reposition. Record…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-14 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident bedrooms provided at least 80 square feet of living space per resident in 29 multiple resident bedrooms. This failure had the potential for residents not to have enough personal space to live comfortably. Findings: During an observation on 6/27/24, at 2:50 p.m., the facility's Administrative Staff A measured resident bedrooms [ROOM NUMBER]. Each bedroom had three beds and were occupied by three residents. Administrative Staff A's measurements indicated resident bedrooms 6, 7 and 8 measured 12 feet and 5 inches by 18 feet and 3 inches each excluding the space occupied by the movable warbrobe. This resulted in a total living space area of 226.6 square feet or 75.5 square feet per resident. During a concurrent interview, Administrative Staff A stated all facility multiple resident bedrooms with three beds had the same measurements. A review of the facility census for 6/27/24 indicated 29 multiple resident bedrooms with three…

    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.

    Environmental Deficiencies · Waiver has been granted
  • Potential for harm · F2022-04-12 · 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

    Based on observation, and interview, and record review the facility failed to ensure dietary staff had appropriate competencies and skill sets to carry out the function of the food and nutritional services when a cook did not follow a recipe for preparing pureed vegetables. This failure had the potential for a population of 71 residents, who received food from the kitchen, to be at risk for receiving meals that did not meet their nutritional needs. Findings: During a kitchen observation and concurrent interview on 4/4/22 at 11:15 a.m., the Dietary Manager (DM) was asked about her responsibilities in the kitchen. The DM stated she oversees all the dietary staff, orders food, conducts in-services (trainings) and goes around to the residents to collect food preferences. During a food production observation on 4/6/22 starting at 10:15 a.m., [NAME] V was observed preparing pureed vegetables and turkey. [NAME] V placed cooked sweet potatoes in a blender and added chicken broth, blended, and then added a 1/2 ladle (10 oz ladle was used) of thickener. [NAME] V was observed not following 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-04-12 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure 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 food production observations, resident and dietary staff interviews, and test tray evaluation the facility failed to prepare and serve meals that were palatable, and flavorful when: 1) mechanical soft (any foods that can be blended, mashed, pureed, or chopped using a kitchen tool such as a knife, a grinder, a blender, or a food processor and requires less chewing) and pureed meals ( is an eating plan where all the foods have a soft, pudding-like consistency) were prepared in a manner that diluted the flavor and/or nutrient composition of food and 2) preparation of meals that were not flavorful or palatable which resulted in residents ordering food from outside sources. Failure to ensure food palatability and nutritive value may result in decreased dietary intake and unplanned weight loss and/or unplanned weight gain from eating food ordered from the outside which 1) is not suitable for therapeutic diets and further compromise residents' medical status and 2) resulted in 2 of 11 Residents (Resident 4 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-04-12 · tag F0880 — failed to prevent and control infections — widespread
    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 facility failed to implement infection prevention control practices when: 1. Staff did not perform proper hand hygiene during wound care for two sampled residents (Resident 27 and Resident 117), which included one resident (Resident 27) placed on Isolation for possible Clostridium difficile (a germ that causes severe diarrhea and stomach pain) infection. 2. High touch areas such as doorknobs and handrails were not frequently cleaned, disinfected, and sanitized. 3. Laundry barrels were not sanitized in between use. 4. Laundry staff did not remove PPE (Personal Protective Equipment) when moving from a dirty room to a clean room. 5. Nursing staff entered the laundry room from the dirty area to the clean area to get a clean clothing item for the resident. 6. Emergency water supplies were stored in unsanitary condition. These failures had the potential to result in the spread of communicable diseases (diseases infection transferrable from one person to another) such as C. diff (Clostridium difficile a type of bacteria causing…

    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 · Ecited before2022-04-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide 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 follow respiratory care practices for four of four sampled residents (Resident 168, Resident 27, Resident 3, and Resident 117) when: 1. Two residents (Resident 168 and Resident 3) did not have Physician Order for oxygen therapy, and 2. Four residents (Residents 168, 27, 3 and 117) did not have documentation for nasal cannula (device used to deliver oxygen) changes. These failures had the potential to result in wrong administration of oxygen therapy, and the potentioal to promote infection in nasal cannulas that were not being changed. Findings: 1. A review of Resident 168's medical record indicated diagnoses for COPD (Chronic Obstructive Pulmonary Disease-group of diseases that cause airflow blockage and breathing-related problems), Pneumonia (infection that inflames the air sacs in the lungs) and Heart Failure. Resident 168 was admitted [DATE]. During a concurrent observation and interview on 4/4/22 at 3:31 p.m., Resident 168 was observed…

    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 · E2022-04-12 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure annual competency and skills check were conducted for licensed nurses and C.N.A.s (Certified Nursing Assistant). This failure had the potential to affect the quality of care provided to the residents in the facility. Findings: During a concurrent interview and record review on 4/6/22, at 11:15 a.m., competency and skills check records for Licensed Staff L, Licensed Staff M, Unlicensed Staff N and Unlicensed Staff O were reviewed with Management Staff J. Licensed Staff L's competency and skills check were back in 12/24/20. Unlicensed Staff N's SKILLS COMPETENCY was back in 7/30/19. Unlicensed Staff O's skills competency was back in 8/21/19. Management Staff J stated that competency and skills check were conducted within 90 days upon hire, annually and as needed for both licensed nurses and C.N.A.s. Management Staff J stated that the Director of Nursing (DON) was responsible for the licensed nurses' competency and the Director of Staff Development (DSD) was responsible for the C.N.A.s skills check. Management Staff J…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-04-12 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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 snacks were served at times in accordance with residents' needs, preferences, and requests when snacks were not provided or available to residents after the kitchen closed. Failure to meet resident food needs and requests could possibly lead to a decline in nutritional status. Findings: During a Resident Council meeting on 4/5/22 at 10:00 a.m., Residents were asked if snacks are offered in-between meals. Residents stated snacks are delivered at 10 a.m., 3 p.m., and 8 p.m. Resident 12 stated we get the same snacks every time --Jell-O, fruit cocktail, and pudding--and occasionally we get fresh fruit. Resident 2 stated she has requested a snack after the kitchen closes and did not get one because the kitchen was closed. Residents 20 also stated you can request a snack or if you want something they will tell you sorry we do not have that. Resident 4 stated, she has requested a snack after the kitchen closed and did not get it. Resident 4 stated she buys her own fruit and keeps it in her room. During an…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-12 · tag F0732 — isolated
    Post nurse staffing information every day.
    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 nurse staffing was posted daily and in a prominent place that is readily accessible to residents and visitors. This failure resulted in out-of-date posting of nurse staffing and in a place where it was not readily accessible to residents and visitors. Findings: During a concurrent observation and interview on 4/6/22, at 12:28 p.m., Management Staff J was asked for the nurse staffing posting in the facility. Management Staff J went to look for the nurse staffing posting in the glass-covered bulletin board and there was no posting. Management Staff J stated that nurse staffing posting might be in the receptionist area and went to look for it. Management Staff J found the nurse staffing posting and it was in the corner of the receptionist's countertop next to a door of an office. Management Staff J showed the posting and did not notice the date on the nurse staffing posting. The nurse staffing posting was dated 4/4/22. During an interview on 4/6/22, at 12:28 p.m., the nurse staffing posting was showed 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-12 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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

    Based on observation, interview and record review, the facility failed to ensure that all Licensed Nurses follow the written direction for medication administration written by a Pharmacist to one of five residents, Resident 14. The medication called Viibryd (antidepressant) had a written directions on the label to be given with food. A Licensed Nurse administered the medication to Resident 14 on an empty stomach. This failure had the potential to result in poor absorption and poor effectiveness of the medication when taken on an empty stomach. Findings: During an observation of medication administration on 4/6/2022 at 9:03 a.m., Licensed Staff U administered a medication, Viibryd, 40 milligram (mg) one tablet by mouth on an empty stomach to Resident 14. Licensed Staff U asked Resident 14 if she had eaten her breakfast. Resident 14 stated to Licensed Staff U that she never liked to eat breakfast or eat anything in the morning even milk or cracker. Resident 14 stated to Licensed Staff U that she only took her medication on an empty stomach. Licensed Staff U administered the medication…

    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 · D2022-04-12 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Physician/Nurse Practitioner's medication order and medication administration was adequately monitored for one of five residents, Resident 14, when: 1. The Assistant Director of Nursing (ADON), Management Staff G, did not put a date and time on the Physician's order after she reviewed the medication order for Metolazone (Metolazone is a diuretic medication (water pill)). 2. Management Staff G did not clarify with the ordering Physician or Nurse Practitioner when to initiate the first dose of the medication. 3. The initial dose of Metolazone was administered by a licensed nurse two days after it was ordered by the Physician/Nurse Practitioner. These failures had the potential to result in Resident 14's condition of Chronic Heart Failure (CHF) to worsen, which could lead to unnecessary illness and complications. Findings: 1. Record review of a document titled Physician Order dated 2/9/2022 for Resident 14 revealed, a medication written by NP…

    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
  • No harm found · Bcited before2026-01-09 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 28 multiple-resident rooms (rooms 1-9, 11-13, 15-21, 28-35, 37) met the required 80 square feet (sq. ft.) per resident when the following rooms were measured as:room [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER]…

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

    Environmental 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.2+0.8 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 4 of 52.7+1.3 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare And Rehabilitation - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Northgate PlazaIrving, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA

Showing 40 of 341; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
WILLITS, BRADLEYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2023
WILLITS, ADAMIndividualCORPORATE DIRECTORsince 02/01/2023
BURNAM, SOONIndividualCORPORATE OFFICERsince 11/08/2022
KEETCH, CHADIndividualCORPORATE OFFICERsince 03/01/2011
MONETTE, CORYIndividualCORPORATE OFFICERsince 02/01/2023
SATO, AMIIndividualCORPORATE OFFICERsince 09/09/2024
STAR REHAB SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 02/01/2023
DHUGGA, GURPREETIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2024
PORT, BARRYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/28/2025
ENSIGN SERVICES INCOrganizationADP OF THE SNFsince 10/31/2022

CMS files one row per role, so the 13 rows in the source record cover these 10 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.

2 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.

$15.5M
Net patient revenuemost recent cost report
+12.2%
Operating marginrevenue minus expenses
$1.4M
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 55%Medicare 21%Other / private 24%

This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$496per resident / day
operating cost
$15,074per month
≈ monthly operating cost
$565per 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 055014. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-09, 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.

What to do next