Citrus Nursing Center
9440 Citrus Ave, Fontana, CA 92335 · For profit - Corporation · 99 certified beds · (909) 823-3481 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $7,446 in federal fines (most recent 2023-08-30)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| 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 improved from 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.0% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.4% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 25.0% | 7.3% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.2% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 9.9% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 8.4% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.3% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 4.0% | 10.2% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.7% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.0% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.0% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.9% | 11.2% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 4.01 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.41 | 1.57 | 1.80 | worse |
* 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.
52.1% 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 124 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.2% 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 148 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 0.61 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 33% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 52.1%CMS range 42.9–62.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.8%CMS range 6.2–11.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 68.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 64.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 58.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.9% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 66.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.2%CMS range 4.6–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.32 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 99 beds and averages 90.5 residents a day — about 91% occupied, or roughly 8 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 4.02 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.73 hrs/resident/day on weekends vs 4.13 on weekdays — 10% thinner on weekends. RN hours go from 0.33 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below 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
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Immediate jeopardy · Jcited before2023-08-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide routine supervision and monitoring for one of 93 residents (Resident 1) and failed to implement interventions developed to help prevent an elopement (unauthorized and unsupervised exit from the facility) when: 1) On August 1, 2023, staff was unaware Resident 1 (a confused resident with cognitive deficit and required assistance with walking) had eloped from the facility. In addition, it was not identified Resident 1 was missing from the facility despite Resident 1 not being present during the evening meal (Resident 1 required direct 1:1 [one to one] staff assistance during mealtime). This failure resulted in Resident 1 subsequently being found (by non-facility staff) in a neighboring backyard unresponsive, on the ground, and covered with vomit. Resident 1 required hospitalization and intubation (a tube placed through the airway to help the resident breath when they are unable to breath on their own). This also had the potential to result in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-07-31 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 safe infection control practices and sanitary environment were followed when:a. Resident 101's oxygen nasal cannula tubing (device used to deliver oxygen into the nose via a tube) was found unlabeled and undated.b. Resident 84's oxygen tubing (is a small flexible plastic tube that connects to an oxygen source) [like machine or tank] was not labeled and dated per facility's policy and procedure (P&P). c. A facility's janitor ([DATE]) removed multiple pillows from several trash containers and placed them on a handrail at the facility's rear entrance/exit next to the laundry room.These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasite) to 85 medically compromised residents and staff in the facility.Findings: a. During a review of Resident 101's admission Record (contains medical and demographic information), the “admission Record” indicated Resident 101 was admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-31 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 maintain a clean and sanitary environment for residents who reside in the facility when on July 29, 2025, the North hallway shower room was found to have black substance on the shower stalls.This failure had the potential to exposed the residents using this shower room to increased risks of developing allergies, skin irritation, and serious respiratory issues.Findings:During an observation on July 29, 2025, at 2:30 PM in the residents' shower room in North hallway, the three shower stalls were found to have a black substance on the shower stalls floors, walls, and where the wall meets the floor and the ceiling. The substance was also present on the wall joints, and on and between the tiles. During an interview on July 29, 2025, at 2:40 PM, Certified Nursing Assistant 1 (CNA 1) confirmed and stated that this shower room is used by all residents in North hallway.During a concurrent observation and interview with the Environmental Services Director of Maintenance (ESD) on July 29, 2025, at 2:58 PM, the ESD…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff accurately and consistently monitored and documented fluid intake and output (intake refers to the total amount of fluids a person consumes, while output refers to the total amount of fluids the body eliminates) for one of one resident reviewed for urinary catheters (Resident 100), when Resident 100's intake and output record had blanks (no data recorded), documentation was not in the correct milliliter (ml - unit of measure) format, and there was no policy and procedure regarding monitoring and documenting intake and output as specified in Resident 100's care plan (an individualized plan for the medical care of a resident).These failures resulted in inconsistencies in the monitoring and documentation of Resident 100's intake and output which had the potential for Resident 100's medical record to inaccurately portray his fluid balance, and functional urinary status.Findings:During a review of Resident 100'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.
- Potential for harm · Dcited before2025-07-31 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Order Summary Diet Order (a list of provider orders) was followed for one of three residents (Resident 21) reviewed for dining observations when Resident 21 did not receive his physician ordered Boost VHC ( nutritional supplement, very high calories) with meals for lunch on July 29, 2025 and for breakfast on July 30, 2025.These failures had the potential to have contributed to Resident 21's weight loss.Findings:During a review of Resident 21's admission Record (contains medical and demographic information), it indicated Resident 21 was admitted to the facility on [DATE], with the diagnoses which included Myocardial infraction (heart attack), Dementia (a progressive state of decline in mental abilities) and immunodeficiency( a condition where the body's immune system is weakened, making it less able to fight off infections and diseases).During a review of Residents 21's Order Summary Diet Order, dated July 18, 2025, the Order…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-31 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for one of three sampled medication carts (South Cart ) with narcotics when Resident 100's Controlled Drug Receipt/Record/Disposition Form (CDR - document used to record the administration or destruction of a controlled drug for tracking purposes) was found to be inaccurate.This failure had the potential to place the facility at risk for drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff .Findings:During a review of Resident 100's clinical records, the admission Record, indicated Resident 100 was admitted on [DATE], with diagnoses which included, pressure ulcers stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), Type two diabetes mellitus (DM-a disorder characterized by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-31 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medical supplies were labeled and stored in accordance with currently accepted professional principles when an intravenous (giving medications through the vein) (IV) cart (a mobile cart used to store and transport medications and other supplies to patients) was found with expired supplies.These failures had the potential for the supplies to be less effective and compromised health and safety for the highly vulnerable population of 85 Residents in the facility.Findings:During a concurrent observation and interview on [DATE], at 12:23 PM, with the Director of Nursing (DON), the intravenous (IV) cart (a mobile storage unit designated to hold and transport medical supplies for intravenous medication and other treatment) was inspected. The following items were found expired and available for use:1. Six alcohol swabs (small, disposable pads or wipes that are saturated with isopropyl alcohol) were found with the following 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.
- Potential for harm · Dcited before2025-07-31 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to adequately protect and safeguard the healthcare identifiable information for two out of 25 sampled residents (Resident 7 and 89) when on July 30, 2025, the laptop screen of the Electronic Medical Record (EMR) (electronic form of record keeping) used by Licensed Vocational Nurse 3 (LVN 3) were:1. Left open, unsecured and unattended from 05:44 AM to 5:47 AM, for a total of 3 minutes in the North hallway for Resident 7.2. Left open, unsecured and unattended from 6:08 AM AM to 6:12 AM, for a total of 4 minutes in the North hallway for Resident 89. This failure resulted in the exposure of health-related identifiable information for Residents 7 and 89 when records were left unsecured and unattended in a location easily accessible to residents, visitors, and other unauthorized individuals, which led to a breach of resident confidentiality, violations of resident's privacy, potential loss of sensitive personal information.Findings:1. 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.
- Potential for harm · Dcited before2024-12-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 proper care was provided to prevent a blister (a painful swelling on the surface of the skin), for one of three sampled residents (Resident 1). This failure placed a clinically compromised Residents (Resident 1) health and safety at risk, when a facility acquired blister to the right heel (back of the human foot below the ankle) developed while in the facility. Findings: During a review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (a disease in which there is too much sugar in the blood and the body is not able to control the sugar ), muscle wasting and atrophy (a condition with shrinking and loss of muscle), and depression (a condition with feeling of sadness and hopelessness). During an interview on November 19, 2024, at 8::55 AM, with Resident 1, Resident stated, They told me, I got a blister on my…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-06-10 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutrition status for 2 out of 40 residents (Residents 13 and 62) reviewed for nutrition when: 1. Resident 62 lost 18% of his body weight in the last 6 months. Since September 5, 2021, he had poor food intake. Three different registered dietitians recommended an appetite stimulant on September 28, 2021, October 7, 2021, and March 14, 2022. The appetite stimulant was ordered on April 10, 2022. Consequently, Resident 62 lost 26 pounds during that time. 2. Residents 13 and 62, who were on a fortified diet (diet to increase calories for residents who need to maintain or gain weight) were given fortified cereal for breakfast and fortified mashed potatoes for lunch and dinner daily. These foods were in addition to the foods that were already on the menu. Multiple observations indicated Residents 13 and 62 were not consuming the extra fortified foods provided. This intervention was intended to add additional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 wound care dressings were labeled in accordance with the facility's policy and procedure for four of five residents (Residents 61, 693, 53, 490) reviewed for pressure injury (or pressure ulcers- wounds that happen on areas of the skin that are under pressure). This failure had the potential for inconsistent care coordination, and for Resident's 61, 693, 53, 490, not to receive the optimal care they need, which would hinder the healing of their pressure injuries. Findings: 1. During a review of Resident 61's admission Record (clinical record with demographic information), on June 7, 2022, at 10:00 AM, the admission Record indicated Resident 61 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (elevated sugar levels in the blood), hypertensive heart disease with heart failure (elevated blood pressure), pressure ulcer of sacral (tail bone) region stage three (the sore gets worse and extends…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 11 citations
- Potential for harm · D2022-06-10 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure 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 a process to routinely evaluate staff skill levels (range of tasks and duties to be performed) and develop individualized competency-based training (a process to acquire skills and knowledge to be able to perform a task to a specified standard) was implemented for three of four licensed nurses (Registered Nurse 1, Licensed Vocational Nurse 4, and Licensed Vocational Nurse 5). This failure had the potential to compromise the services and types of care necessary to safely meet the resident's needs. Findings: During an interview on June 10, 2022, at 9:35 AM, with the Director for Staff Development (DSD), the DSD stated he has not done a performance evaluation and skills competencies on any of the staff since he started on this role February 2022. He also stated he has no process of tracking staff competencies and performance evaluations. During an interview on June 10, 2022, at 2:20 PM, with the Administrator and the DSD, the Administrator stated they do not have the following polices: Performance Evaluation and Staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-10 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for four of four medication carts (South, South-Center, North, and North-Center carts). These failures placed the facility at potential for diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 92 residents. Findings: 1. During a concurrent observation and interview on June 9, 2022, at 12:50 PM, with a License Vocational Nurse (LVN 3), the North-Center medication cart's Controlled Drug Inventory (CDI- narcotic records, a form used by the facility to verify counting of controlled drugs at the change of shift by oncoming and off going licensed nurses), dated May 19, 2022, to June 8, 2022, was reviewed. The CDI indicated the following: a. On May 22, 2022, missing signature from the night shift (11:00 PM - 7:00 AM) oncoming nurse and a missing discrepancy count (counting the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-10 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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 follow the menu, and serve the correct size of roast beef for the regular texture diets (food with no modifications) for lunch on June 7, 2022. This failure had the potential to impair the nutritional status of 58 out of 92 residents who receive food from the kitchen. Findings: During a concurrent observation and interview, on June 7, 2022, at 11:45 AM, in the kitchen, during lunch tray line (when the cook puts food on the plates for the residents), a [NAME] served two ounces of roast beef for the regular textured diets. [NAME] verified the roast beef should have measured at three ounces per the menu. During a review of the facility's Cooks Spreadsheet - Summer Menus dated June 7, 2022, the spreadsheet menu indicated for lunch as serving size of three ounces of Herb and Spice Roast Beef, the roast beef should have been served for the regular, 2 gm (gram-unit of measurement) Na (sodium), CCHO (consistent carbohydrate diet), Renal diets (special diet for residents with kidney problems), and low fat/cholesterol…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-10 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. There were two open style rodent bait traps which had the potential to contaminate the area if a rodent was trapped. 2. There was a meatball, crumbs and loose trash under the food prep table and black grime and crumbs at the side of the stove which had the potential for microorganism (small organism like bacteria, virus, or fungus) growth and attract pests. 3. The underside of the dishwasher counter had a patch and repair area with foam installation and a T-shaped piece of wood supporting the counter. This area was not smooth and easily cleanable, which could lead to microorganism growth that could inadvertently be transferred to food. These failures had the potential to cause foodborne illness in a highly susceptible population of 92 residents who received food from the kitchen. Findings: 1. During an observation and concurrent interview with the Dietary Services Supervisor (DSS), on June 7,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-10 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 maintain infection control practices when a Registered Nurse (RN 1) did not wear gloves when disconnecting the IV (a thin bendable tube that slides into one of your veins) tubing on June 10, 2022, for one of six residents (Resident 53) reviewed for intravenous therapy in accordance with the facility's policy and procedure. This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasites) to Resident 53. Findings: 1. During a review of Resident 53's admission Record (clinical record with demographic information), the admission Record indicated, Resident 53 was admitted to the facility on [DATE], with diagnoses which included acute pancreatitis (a condition where the pancreas becomes inflamed (swollen) over a short period of time), gastrostomy (is a tube inserted through the belly that brings nutrition directly to the stomach) status, Stage 4 pressure ulcer of sacral region (wound…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-08-23 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 safe and sanitary food preparation and storage practices for dietary services when: 1. Plastic tray bins were found stacked and stored wet. 2. Ice machine Cooling Compartment (where the ice is made) had a build-up of yellowish orange residue, that was removable with a white paper towel. These failures had the potential to lead to harmful bacteria and cross contamination that could lead to foodborne illness for a medically compromised population of 91 residents who receive food and water from dietary services. Findings: 1. During an observation and interview on August 19, 2019, at 9:00 AM, with Dietary Supervisor (DS). Nine out of Nine plastic tray bins were found clean and stacked wet for use. The DS stated these plastic bins are used for the residents drinks to be kept on ice on the tray line and verified they were found stacked clean and wet. The DS stated stacking them wet had the potential for bacterial growth. During a record review and interview on August 19, 2019, at 2:56 PM, of the Policy and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-08-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure two Licensed Vocational Nurses (LVN 1 and LVN 3) followed the facility policy and procedure for obtaining a fingerstick blood glucose level (blood sugar level) for four of seven residents sampled for blood sugar levels (Residents 66, 40, 78, and 50) when the staff tested the first drop of blood after using alcohol to clean the residents' finger, instead of discarding that drop and using the second drop for an accurate blood glucose reading. This failure had the potential to result in inaccurate blood sugar levels which may lead to alterations in treatment provided to the residents. Findings: During a medication pass observation with Licensed Vocational Nurse 1 (LVN 1), on August 21, 2019, at 5:19 AM, LVN 1 wiped Resident 66's finger with alcohol, used a lancet (a tool used to prick a finger) to create a blood drop, then used a glucometer (device used to test blood sugar) to test the first drop of blood from the residents' finger. A review of the physician's order for Resident 66, dated July 15, 2019,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-08-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During an observation on August 19, 2019, at 9:10 AM, an oxygen concentrator (A device that provides concentrated oxygen by taking in air, purifying it, then delivering the oxygen) and oxygen tubing in a dated plastic bag was noted at Resident 87's bedside. During review of the clinical record for Resident 87, the admitting physician orders dated July 15, 2019, is written for Oxygen at 2 liters (liter-a unit of measurement) per minute via nasal cannula PRN (as needed) for SOB (shortness of breath). During an observation on August 19, 2019, at 9:32 AM, a Certified Nursing Assistant (CNA 4) observed placing a Oxygen in use/No smoking sign out outside of Resident 87's room (35 days after the oxygen use was initiated). During review of the clinical record for Resident 87, the admission assessment dated [DATE], indicated Resident 87's current room and bed assignment was unchanged since admission. During an interview with CNA 4 on August 20, 2019, at 10:10 AM, he stated that he was told that the Resident 87's room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-08-23 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to safely store medications for one of one sampled residents (Resident 445) when two medications were stored beyond the expiration date. This failure had the potential to result in decreased efficacy of the medications for Resident 445. Findings: During observation of medication storage on August 21, 2019, at 7:10 AM, the south station medication cart was noted to contain the following prescriptions for Resident 445: a. Sertraline (an antidepressant) 25 mg (milligram a unit of measurement) with an expiration date of February 12, 2019 b. Atorvastatin (cholesterol lowering medication) (40 mg) with an expiration date of April 22, 2019 During an interview with a Licensed Vocational Nurse (LVN 6) on August 21, 2109, at 7:15 AM, she stated that the medications for Resident 445 were expired. She stated that the nurses are supposed to look at dates every day and that she was going to discard the medications. During a review of the facility's policy and procedure titled Storage of Medications revised June 2016, under the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-08-23 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a Licensed Vocational Nurse (LVN 1) followed the facility policy and procedure for medication administration when the LVN did not document the administration of one medication in the Medication Administration Record (MAR-a record used to document the administration of medications) for one of 16 Residents sampled for medication pass (Resident 340). This failure lead to the facility not having complete nor accurate medication administration records for Resident 340 which may put the residents' health and safety at risk. Findings: During a review of Resident 340's clinical record, the Record of admission (contains demographic and medical information), indicated Resident 340 was admitted to the facility on [DATE]. A review of the Physicians admission Orders/Medication Record, dated August 17, 2019, indicated the resident had diagnoses which included acute ischemic stroke (the sudden loss of blood circulation to an area of the brain),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-08-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based observation, interview, and record review, the facility failed to ensure infection control prevention was implemented when: 1. For one of one residents (Resident 18) a urinary catheter (a hollow, flexible tube that collects urine from the bladder and leads to a drainage bag) tubing was dragging on the floor while the resident self-propelled in the wheelchair across the hallway. 2. For Resident 15 a Certified Nursing Assistant (CNA 4) was observed touching the sitting stool he sat on and then touching the straw multiple times of a resident's beverage. These failures had the potential for cross contamination and the spread of infection. FINDINGS: 1. During an observation on August 20, 2019, at 11:30 AM, in the hallway on the north side of the facility, Resident 18 was sitting in a wheelchair. He was observed wheeling himself down the hallway with tubing from a urinary catheter dragging on the floor. During an interview with Licensed Vocational Nurse (LVN 4), on August 20, 2019, at 11:30 AM, she was asked if the resident's catheter was positioned correctly. LVN stated What? 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$7,446 in federal fines across 1 penalty.
- $7,446 — penalty dated 2023-08-30
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to DAVID JOHNSON — 48 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.2 | +1.8 vs chain |
| Health inspection | 4 of 5 | 2.7 | +1.3 vs chain |
| Staffing | 2 of 5 | 3.3 | -1.3 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 47 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 47; 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CITRUS NURSING CENTER | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/06/1991 |
| MARMUR, ELI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/24/1990 |
| JOHNSON, FRANK | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/24/1990 |
| DEHGHANMANESH, ADRIAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2021 |
| OXFORD, MICHEAL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/03/2022 |
| BERNARD-BUTLER, ESTHER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2024 |
| DE JESUS, WALTER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/18/2020 |
| GOLBOO, SEPEHR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2022 |
| KOCHEK, JOSHUA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2022 |
| CIBC BANK USA | Organization | ADP OF THE SNF | — | since 09/01/2021 |
| K-REGENCY, LLC | Organization | ADP OF THE SNF | — | since 12/15/2024 |
| SUN MAR MANAGEMENT SERVICES | Organization | ADP OF THE SNF | — | since 10/12/1989 |
| FARRALES, MARY | Individual | ADP OF THE SNF | — | since 01/01/2023 |
CMS files one row per role, so the 23 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.4M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055872. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-31, 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.