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Fallbrook Skilled Nursing

325 Potter Street, Fallbrook, CA 92028 · For profit - Limited Liability company · 93 certified beds · (760) 728-2330 Medicare & Medicaid certified

Call the home — (760) 728-2330 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Jul 2023
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — 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 (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
577 E Elder St · (760) 728-8999 · Call to confirm hours
Pharmacy
587 E Elder St · (760) 645-3021 · Call to confirm hours
Grocery
311 N Main Ave · (760) 451-1231 · Call to confirm hours
Park
831 E Fallbrook St · (442) 444-0824 · Typically dawn to dusk
Place of worship
911 E Elder St · (760) 728-2667

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 held steady at 4 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 rating4★
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 increased12.7%10.2%15.4%better
Long-stay residents who lose too much weight9.2%4.0%5.4%worse
Long-stay residents with a catheter left in their bladder1.2%0.8%0.9%worse
Long-stay residents with a urinary tract infection2.1%1.2%2.0%typical
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
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 injury1.2%1.6%3.3%better than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened12.0%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication8.4%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers4.1%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control16.3%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 table7.9%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.4%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine98.2%93.2%79.4%better
Short-stay residents rehospitalized after admission23.2%23.0%22.6%typical
Short-stay residents with an outpatient ER visit6.8%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days2.292.251.67worse
Long-stay outpatient ER visits per 1,000 resident days2.951.571.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

59.6% 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 78 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.6%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
0.16U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 34% 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 SNF59.6%CMS range 50.3–68.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 6.9–15.110.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified92.5%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge95.0%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 hospitalization6.7%CMS range 3.6–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.971.02Oct 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

0.31
RN hours/ resident / day
1.13
LPN hours/ resident / day
2.40
Aide hours/ resident / day
3.84
Total nurse hours/ resident / day
0.19
RN hoursweekends
40.9%
Total nursing turnover
57.1%
RN turnover

How full it usually is: this home is certified for 93 beds and averages 80.8 residents a day — about 87% occupied, or roughly 12 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 3.84 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 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 3.38 hrs/resident/day on weekends vs 4.03 on weekdays — 16% thinner on weekends. RN hours go from 0.36 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

5
deficiencies at the latest standard inspection (2025-05-01)
8
at the previous standard inspection (2023-07-20)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

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

  • Potential for harm · D2025-09-18 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 22 CCR S 72313S 72313. Nursing Service--Administration of Medications and Treatments(a) Medications and treatments shall be administered as follows:(1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order.(2) Medications and treatments shall be administered as prescribed.(3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded.(4) Preparation of doses for more than one scheduled administration time shall not be permitted.Based on interview and record review, the facility failed to ensure 3 of 4 residents reviewed for omitted medication doses, (Residents 1, 3, and 4) and this failure placed the residents at risk of harm due to uncontrolled high blood presure. Findings:Resident 1 was admitted to the facility on [DATE], with diagnosis (health problems) that included Type 2 diabetes (a disorder of hormone secretion, that causes high blood sugar…

    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 · No revisit needed
  • Potential for harm · D2025-09-18 · tag F0842 — failed to keep accurate, complete medical records — isolated
    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 22 CCR S 72543S 72543. Patients' Health Recordsa) Records shall be permanent, either typewritten or legibly written in ink, be capable of being photocopied and shall be kept on all patients admitted or accepted for care. All health records of discharged patients shall be completed and filed within 30 days after discharge date and such records shall be kept for a minimum of 7 years, except for minors whose records shall be kept at least until 1 year after the minor has reached the age of 18 years, but in no case less than 7 years. All exposed X-ray film shall be retained for seven years. All required records, either originals or accurate reproductions thereof, shall be maintained in such form as to be legible and readily available upon the request of the attending licensed healthcare practitioner acting within the scope of his or her professional licensure, the facility staff or any authorized officer, agent, or employee of either, or any other person authorized by law to make such request.(b) Information…

    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 · No revisit needed
  • Potential for harm · Fcited before2025-05-01 · 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 policy review, the facility failed to ensure leftover and opened food items were labeled and dated when placed in the refrigerator. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: 1. An undated facility policy titled, Leftover Foods indicated, Policy: Leftover foods will be stored and served in a safe manner. Procedure: Leftover foods are those that have been prepared for a meal and not served. 1. Storage of leftovers b. Label and date. During an observation of the reach-in refrigerator on 04/29/2025 at 11:14, there were two plates that contained a hamburger and French fries and one place that contained a pureed hamburger and pureed French fries that were not labeled or dated. The Dietary Manager stated the plates should be labeled and dated and that he would discard them now. 2. An undated facility policy titled, Foods Brought by Family /Visitors indicated, 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator.…

    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 · D2025-05-01 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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 ensure a resident's call light was placed within reach for 1 (Resident #1) of 19 sampled residents. Findings included: A facility policy titled, Strategies for Reducing the Risk of Falls revised 03/2018, indicated Call light within resident's reach. An admission Record indicated the facility readmitted Resident #1 on 11/21/2022. According to the admission Record, the resident had a medical history that included a diagnosis of personal history of traumatic brain injury. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. During an observation on 04/29/2025 at 2:42 PM, Resident #1 was observed in bed and their call light was noted on the floor behind the resident's bed. During an interview on 04/29/2025 at 3:29 PM, Licensed Vocational Nurse #5 stated Resident #1's call light should be close to them. During a concurrent…

    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 · D2025-05-01 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a Level I preadmission screening and resident review (PASARR) was completed prior to admission for 1 (Resident #8) of 5 sampled residents reviewed for PASARR. Findings included: An admission Record indicated the facility admitted Resident #8 on 01/07/2021. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2025, revealed Resident # 8 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated that the resident had active diagnoses to include depression and schizophrenia. Resident #8's Care Plan Report included a focus area initiated 03/03/2025, that indicated the resident had a nutritional problem or the potential for a nutritional problem related to diagnoses to include dementia, schizophrenia, and major depressive disorder. Resident #8's medical record revealed no evidence…

    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 · D2025-05-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    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

    Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's fingernails and toenails were kept cleaned and trimmed for 3 (Residents #1, #23, and #40) of 4 sampled residents reviewed for activities of daily living (ADL). Findings included: A facility policy titled, Activities of Daily Living (ADLs), Supporting revised 03/2018, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1. An admission Record indicated the facility readmitted Resident #1 on 11/21/2022. According to the admission Record, the resident had a medical history that included a diagnosis of personal history of traumatic brain injury. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for ADLs.…

    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 before2025-05-01 · 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 ensure a resident's catheter tubing and privacy bag were kept off the floor for 1 (Resident #14) of 3 sampled residents reviewed for urinary catheters. Findings included: A facility policy titled, Catheter Care, Urinary revised 09/2014, indicated, 3b. Be sure the catheter tubing and drainage bag are kept off the floor. An admission Record indicated the facility admitted Resident #14 on 11/14/2012. According to the admission Record, the resident had a medical history that included a diagnosis of epilepsy. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/24/2025, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident had an indwelling catheter. Resident #14's Care Plan Report included a focus area revised 01/10/2025, that indicated the resident had a potential for actual impairment due to skin integrity related to fragile skin,…

    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 · D2024-10-29 · tag F0555 — isolated
    Honor the resident's right to choose his or her attending physician.
    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 honor a resident ' s preference for their personal physician for one of three residents (Resident 1) when reviewed. This failure ignored the resident ' s right to choose a physician and caused Resident 1 to feel ignored and depressed. Findings: Resident 1 was admitted to the facility on [DATE] with diagnosis that included: recurrent enterocolitis (stomach inflammation, causing pain or diarrhea or constipation); heart disease; major depressive disorder; anxiety. Resident 1 has the capacity (ability) to make her own health care decisions. On 9/17/24 at 11:35 A.M. Resident 1 was interviewed. Resident 1 stated she had made an appointment to see her regular doctor outside of the facility. Resident 1 said when her daughter called the facility to ask about transportation arrangements related to the doctor appointment, her daughter was told the facility staff cancelled the appointment and explained (Res 1) must see our doctor. Resident 1 said she was upset…

    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 · E2023-07-20 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    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 provide a registered nurse (RN) on duty 8 consecutive hours per day, seven days per week. This failure had the potential for more advanced assessments and care activities provided by an RN to be unavailable to residents. Findings: During the initial tour of the facility on 7/17/23 at 10 A.M., there were no RN's observed to be on duty. During a resident council meeting on 7/18/23 at 9:56 A.M., Resident (4) stated, The staffing schedule was messed up; weekends are especially hard, staff call off and it makes it hard on residents. During a resident council meeting on 7/18/23 at 9:10 A.M., seven of seven residents (4,13,25,33,37,51,125) stated there were lots of registry staff, some are rude and ignore residents, and there are no RN's, only LVN's. A review of the facility's document, titled Staffing Assignments, for July 17, July 18 and July 19 2023, indicated a blank space for the column RN. A review of the PBJ (payroll based journal) Staffing Data Report, CASPER report 1705D, FY (fiscal year) Quarter 2,…

    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 · Ecited before2023-07-20 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 ensure that all food items were labeled and dated. In addition, the facility did not ensure that there were no expired food items. This failure had the potential for all residents who eat at the facility to become ill due to increased bacteria growth in the food, and/or have decreased food intake leading to weight loss due to poor food palatability. Findings: An initial tour/observation of the facility's kitchen was conducted on 7/17/23 at 9:50 A.M., with the facility's Dietary Services Manager (DSM). In the walk in refrigerator, there was a bakers rack with two trays of cappuccino mousse, two trays of fruit salad, and two trays of lettuce salad with no made-on date nor an expiration date. In the dry storage area, there were the following items with no expiration date: Four 6-pound cans of black beans; Two 6-pound cans of pinto beans; Two 6-pound cans of sweet potatoes; Nine 6-pound cans of beef stew. An interview was conducted with the DSM on 7/17/23 at 10:00 A.M. The DSM stated, The cans have no expiration…

    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
Show the remaining 10 citations
  • Potential for harm · D2023-07-20 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident (Resident 1) was free from a physical restraint when a lap tray was used to keep Resident 1 from falling out of the wheelchair. This deficient practice had the potential to increase Resident 1's risk for injury and potentially a further decline in mobility. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnoses that included traumatic brain injury (TBI). On 7/18/23 at 8:51 A.M., a review of Resident 1's MDS (a health status screening and assessment tool), dated 11/21/22, indicated a BIMS (Brief Interview for Mental Status-test for cognitive function) was 14 out of 15, indicating cognition is intact. On 7/17/23 at 3:14 P.M., an observation of Resident 1 in his room was conducted. Resident 1 was observed sitting in a high back wheelchair leaning forward with his arms supported by a black padded board. The black padded board was laying across the resident and attached with two Velcro straps to the left…

    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 · D2023-07-20 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide alternative language accommodations for 3 of 18 sampled residents; (Residents 1, 49, and 45), who had been identified to need alternative communication. This deficient practice had the potential to affect Residents (1, 49, and 45) care and accomedations not being met. Findings: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury (TBI), and epilepsy (a seizure disorder) per the facility facesheet. On 7/17/23 at 11:17 A.M. an observation and interview with Resident 1 was conducted in Resident 1's room. Resident 1 was observed making sounds with his mouth but was unable to verbalize clear sentences when responding to a question. No communication tools were observed in Resident 1's room or bedside. Resident 1's speech was incomprehensible and unclear. On 7/18/23 at 8:51 A.M., a review of Resident 1's MDS (a health status screening and assessment tool), dated 11/21/22, indicated 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
  • Potential for harm · Dcited before2023-07-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    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 ensure a resident (Resident 12) safely consumed administered medications when medications were found in Resident 12's bedside drawer. This deficient practice had the potential to put the health and safety of all residents at risk. Findings: Resident 12 was admitted to the facility on [DATE] with diagnoses that included heart failure and atrial fibrillation (a chronic progressive condition that affects the heart) per the facility facesheet. On 7/17/23 at 12 P.M., an observation and concurrent interview were conducted with Resident 12 in her room. Resident 12 opened the bedside table drawer and removed two clear plastic medication cups which contained 5 pills: 1. Two small round peach-colored tablets 2. One small round reddish/brown colored tablet 3. One medium round white colored tablet 4. One medium oblong purple color tablet Resident 12 stated, four of the pills were from the morning medication administration (7/17/23 A.M.) and one of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a physicians' order for oxygen therapy was followed for 1 of 18 sampled residents, Resident 10. As a result, Resident 10 did not receive oxygen therapy as ordered. Findings: Resident 10 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure (a progressive lung disease that makes it difficult to breathe), per the facility's Face Sheet. On 7/18/23 at 8:51 A.M., a review of Resident 10's MDS (a health status screening and assessment tool), dated 6/11/23, indicated a BIMS (Brief Interview for Mental Status-test for cognitive function) was 12 out of 15, indicating mild impairment of cognition. On 7/18/23 at 9:01 A.M., Resident 10 was observed sitting in her wheelchair in front of her room with oxygen on at 1 1/2 liters per minute (LPM) via nasal cannula (NC) (a plastice tubing connected from the oxygen tank to the resident's nostrils). On 7/18/23 at 9:15 A.M., an interview with Resident 10 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-20 · tag F0761 — failed to label and store drugs safely — isolated
    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 discard a residents' medication from the medication storage room when the resident was discharged from the facility. This had the potential risk for other residents to be given the wrong medication. Findings: On 7/19/23 at 10:16 A.M., an observation, interview and record review was conducted with LN 24. An observation of a clear plastic bag containing several small bottles of a liquid Lidocaine (a numbing medication to reduce discomfort) was found on the counter of the medication storage room. The clear plastic bag had a pharmacy label that indicated a resident name, a date (10/14/2022) and the resident room number. LN 24 stated, the medication should not be in the medication storage room. LN 24 stated, the resident was no longer in the facility per the census. LN 24 further stated, the medication should have been discarded when the resident was discharged . On 7/19/23 at 11:33 A.M., an interview with the DON was conducted. The DON stated, it is the expectation of staff to discard unused medications of any…

    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 · Dcited before2023-07-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure infection control practices within the facility when: 1. The facility did not ensure a residents oxygen tubing was labeled and dated when last changed. In additon, 2. The facility did not implement a water management system program. This lack of infection control practices had the potential to expose a vulnerable population of residents to harmful organisms. Findings: 1. Resident 10 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure (a progressive lung disease that makes it difficult to breathe), per the facility's Face Sheet. On 7/18/23 at 8:51 A.M., a review of Resident 10's MDS (a health status screening and assessment tool), dated 6/11/23, indicated a BIMS (Brief Interview for Mental Status-test for cognitive function) was 12 out of 15, indicating mild impairment of cognition. On 7/18/23 at 9:01 A.M., Resident 10 was observed sitting in her wheelchair in front of her room with oxygen…

    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 before2019-09-18 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 ensure food was prepared and stored in accordance with professional standards of food service safety when: 1. Proper food cool down procedures were not followed. 2. Two resident unit refrigerator temperatures were not consistently monitored. Food in one refrigerator was unlabeled and undated, and one refrigerator was not clean. These failures had the potential for bacterial growth in resident's food and placed residents at risk for food borne illness. Findings: 1. During an initial tour of the kitchen on 9/15/19 at 9:36 A.M., cook 1 stated the book where the cool down log was kept had been updated, therefore there was no current cool down log. [NAME] 1 stated she cooked a beef roast this morning, which was removed from the oven at approximately 7 A.M., and placed in the freezer for cool down. [NAME] 1 stated the roast was moved from the freezer just before 9 A.M. and placed in the refrigerator. On 9/15/19 at 9:40 A.M., a pan of roast beef was observed on the middle shelf of the walk-in refrigerator covered…

    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 · D2019-09-18 · 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 ensure bruising was evaluated and communicated to the wound treatment nurse for monitoring for one of two residents (45) sampled for anticoagulation (blood thinner) medication side effects. This failure had the potential for bruising to increase in size without monitoring and lead to a delay in treatment for Resident 45. Findings: Resident 45 was admitted to the facility on [DATE] with diagnoses, which included end stage heart failure (weakened heart muscle is unable to pump enough blood) and palliative care (comfort care to treat symptoms and side effects of serious illnesses), per the facility's Face Sheet. According to Resident 45's physician orders, dated 7/26/19, the resident received clopidogrel (a blood thinner that affects blood clotting) daily for blood clot prevention. According to Resident 45's physician orders, dated 9/5/19, the resident received warfarin (a blood thinner that counteracts the clotting actions of Vitamin K in the blood).…

    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 before2019-09-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    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 ensure one of five residents (3) investigated for falls, had an interdisciplinary team (IDT) meeting (to discuss and implement an updated care plan) following a fall. This had the potential to contribute to additional falls with injury for Resident 3, and miscommunication among health care providers. Findings: Resident 3 was admitted to the facility on [DATE] with diagnoses, which included non-traumatic subdural hemorrhage (bleeding into the brain not caused by external injury) and dementia (a loss of mental abilities that leads to impairments in memory, reasoning, planning, and behavior), per the facility's Face Sheet. According to a review of Resident 3's physicians order, dated 5/31/19, the resident was admitted to the facility following a fall. According to a review of Resident 3's Fall Risk Assessments, dated 5/31 and 9/6/19, the resident was at high risk for falls. On 9/15/19 at 12:36 P.M., Resident 3 was observed lying in bed under…

    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 · D2019-09-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure LNs followed their policy and procedure for checking the medication label for the expiration date prior to administering for one randomly sampled resident (276). As a result, Resident 276 received two doses of an expired medication. Findings: Resident 276 was admitted to the facility on [DATE], with diagnoses to include anemia (decreased amount of red blood cells in the body), per the facility's Face Sheet. Resident 276's admission physician orders included folic acid (vitamin important to red blood cell production) 1 mg daily. On 9/17/19 at 8:45 A.M., during a medication observation, LN 5 prepared and administered 11 medications to Resident 276, including folic acid 1 mg. On 9/17/19 at 9:25 A.M., LN 5 was interviewed. LN 5 inspected Resident 276's folic acid bubble pack (method of packing medications, where each dose was placed in a small plastic bubble and backed by a sheet of foil and cardboard) and pharmacy label. LN 5 stated…

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

    Pharmacy Service 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 PROGRESSIVE HEALTH CARE CENTERS — 5 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 53.8+0.2 vs chain
Health inspection 4 of 53.2+0.8 vs chain
Staffing 3 of 52.6+0.4 vs chain
Quality measures 4 of 54.6-0.6 vs chain
The other 4 homes this chain runs (chain average 3.8★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
GOINGS FAMILY TRUST DATED FEBRUARY 18, 2005Organization5% OR GREATER DIRECT OWNERSHIP INTEREST33%since 01/23/2015
HELEN LOUISE LARSON REVOCABLE TRUST CREATED UNDER THAT CERTAIN DECLARAOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST8%since 01/23/2015
THE HERMAN J TANSKE TRUST DATED MAY 28, 1987, AS AMENDEDOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST17%since 01/23/2015
THE LARSON FAMILY TRUST OF 2010 AS AMENDEDOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST8%since 01/23/2015
VICTOR AVILA FAMILY TRUST DATED JANUARY 26, 1990Organization5% OR GREATER DIRECT OWNERSHIP INTEREST33%since 01/23/2015
AVILA, STEPHANIEIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST17%since 01/23/2015
AVILA, VICTORIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST17%since 01/23/2015
GOINGS, VERNAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST17%since 01/23/2015
LARSON, MARIAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST8%since 01/23/2015
MCDONALD, JASONIndividualW-2 MANAGING EMPLOYEEsince 07/20/2015
PISCO, MARY JEANIndividualW-2 MANAGING EMPLOYEEsince 07/20/2015
GOINGS, GREGORYIndividualCORPORATE OFFICERsince 01/23/2015
KILIAN, JAMESIndividualCORPORATE OFFICERsince 01/23/2015
GOINGS & GOINGS INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/23/2015

6 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.

$9.1M
Net patient revenuemost recent cost report
-4.9%
Operating marginrevenue minus expenses
$952K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 7%Medicare 8%Other / private 84%

This home reported $952K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$376per resident / day
operating cost
$11,438per month
≈ monthly operating cost
$359per 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 055298. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-01, 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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