Greenfield Care Center Of Fullerton, LLC
330 W. Bastanchury Road, Fullerton, CA 92835 · For profit - Limited Liability company · 99 certified beds · (714) 879-4511 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- 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
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (22% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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 (30) — 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 11.2% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.9% | 4.0% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.7% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 7.3% | 6.5% | check this* — see note marked star below the table |
| 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 | 1.9% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 8.6% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 1.7% | 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 | 1.3% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 4.1% | 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 | 100.0% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 29.1% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.1% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.47 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.77 | 1.57 | 1.80 | better |
* 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.
38.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 100 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.6% 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 76 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 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 31% 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 | 38.0%CMS range 29.0–47.1 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.3%CMS range 6.3–13.2 | 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 | 52.6% | 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 | 50.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 56.6% | 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 | 94.1% | 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 | 82.8% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 5.9% | 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 | 7.3%CMS range 4.1–12.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.31 | 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 81.4 residents a day — about 82% occupied, or roughly 18 beds typically open. It usually has some room. 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 4.21 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.77 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.62 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 3.95 hrs/resident/day on weekends vs 4.32 on weekdays — 9% thinner on weekends. RN hours go from 0.84 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 22% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · E2026-04-02 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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, medical record review, and facility P&P review, the facility failed to provide the necessary treatment and services to maintain the highest practicable well-being for three of three sampled residents (Residents 1, 2, and 3). * The facility failed to ensure Resident 1, 2, and 3's change of conditions was monitored every shift for at least 72 hours. These failures had the potential to negatively affect the residents' health and well-being and risk of not providing the residents with appropriate and individualized care.Findings: Review of the facility's P&P titled Change of Condition dated 4/2025 showed the following:- Licensed nurses will contact the primary physician (alternate physician or Medical Director) of resident status as soon as possible when there is a significant change of condition.- Licensed nurses will inform family members of change of condition and document notification.- All nursing actions, physician order/instructions, and resident assessment information will be documented…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was implemented for one of 21 final sampled residents (Resident 91). * The facility failed to implement the compressive care plan for Resident 91's right upper arm AV shunt (arteriovenous shunt is a direct connection between an artery and a vein that bypasses the normal network of small capillaries). The facility failed to ensure the facility staff did not obtain Resident 91's blood pressure on his right arm, the arm with his dialysis access site/ AV shunt). This failure had the potential to damage the AV shunt and/or increase the risk of blood clots for Resident 91.Findings: Review of the facility's P&P titled Care Plan revised 4/2024 showed a care plan is the summation of the resident concerns, goals, approaches, and interventions, in order to meet the goals and help minimize if not totally eradicate residents' problems. Medical record review for Resident 91 was initiated on 9/8/25.…
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 before2025-09-11 · 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, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services related to pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore to promote wound healing) were provided to one of two final sampled residents (Resident 2) reviewed for pressure injuries. * The facility failed to ensure LVN 3 administered the wound treatment as per the physician's orders to Resident 2's right heel pressure injury. This had the potential for Resident 2 not receiving the appropriate care and services to promote healing of the pressure injury.Findings: Review of the facility's P&P titled Wound Care revised 1/2025 showed it is the policy for the facility to provide guidelines for the care of wounds to promote healing. To review the resident's care plan to assess for any special needs of the resident. To use no -touch technique. Use sterile…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the environment remained free from accident hazards for one of one final sampled resident (Resident 43) reviewed for falls. * The facility failed to ensure Resident 43's post fall risk assessment was completed accurately to identify the resident's risk for fall and to prevent further falls and/or injuries. This failure posed the risk of not providing the necessary care to the resident to prevent further falls and/or injuries.Findings: Review of the facility's P&P titled Fall Management revised on 12/2024 showed the following:- the licensed nurses/designee will gather data from the resident, family of interested party about the resident's history of falling; and- the licensed nurse will evaluate, and document falls that occur while the resident is in the facility; for example, when and where the fall occurs, observations of the events, injuries, treatments, etc. Review of the facility's P&P titled Documentations revised on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary dialysis care and services for two of two final sampled residents (Residents 10 and 91) reviewed for dialysis care. * The facility failed to follow up on Resident 10's laboratory results for the laboratory tests obtained at the dialysis center. * The facility failed to ensure the facility staff did not obtain Resident 91's blood pressure on six occasions on the arm with his AV shunt. These failures had the potential for the residents to experience medical complications and negatively affect Residents 10 and 91's physical well-being. Findings: Review of the facility's P&P titled Dialysis Services 1/2025 showed it is the policy of this facility to provide adequate and appropriate care to dialysis clients in coordination with the dialysis center. Coordination of care may include the following: information transmitted to the dialysis unit by the facility prior to dialysis through the phone and/or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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, medical record review, and facility P&P review, the facility failed to provide the appropriate treatment and services designed to help attain and maintain a resident's highest practical physical, mental, and psychosocial well-being for one of one final sampled resident (Resident 24) reviewed for dementia (group of conditions that cause a progressive decline in cognitive abilities, including memory, thinking and reasoning) care. * The facility failed to obtain the neurologist's progress notes and develop a dementia care plan for Resident 24. This failure had the potential for Resident 24 to not receive the appropriate treatment and services needed for her dementia.Findings: Review of the facility's P&P titled Dementia - Clinical Management revised 1/2025 showed the staff and physician will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes. The staff and physician will review the current…
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 before2025-09-11 · 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, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs for two of two final sampled residents (Residents 10 and 91) reviewed for dialysis care. * The facility failed to ensure accurate monitoring for the administration of Resident 10's blood pressure medications on the days Resident 10 had dialysis treatments. Resident 10's BP medications were sent with the resident to be administered by the dialysis nurse, however the facility's licensed nurses documented the administrations in Resident 10's MAR (Medication Administration Record). * The facility failed to ensure Resident 91's carvedilol (used to treat high blood pressure) and calcium acetate (supplement) medications were administered on time, in accordance with the facility's P&P. These failures had the potential to negatively affect Residents 10 and 91's health condition.Findings: Review of the facility's P&P titled Medication Administration…
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 before2025-09-11 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8%. Two of the three licensed nurses (LVN 1 and RN 1) observed were found to have made errors during the medication administration observation for two final sampled residents (Residents 33 and 54). * LVN 1 did not administer Resident 54's Creon (medication used to help digest food) medication with meals or food as ordered by the physician. * RN 1 did not administer Resident's 33's artificial tears ophthalmic solution (used for dry eye) as ordered by the physician. These failures had the potential to negatively impact the residents' health outcomes and posed the risk of possible complications.Findings: Review of the facility's P&P titled Policy and Procedure in Medication Administration revised 1/2025 showed the medications shall be administered in accordance with our established policies and procedures. The drugs must be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · 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, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage and disposal of medications. * The facility failed to ensure Resident 78's medication was stored properly and safely. * The facility failed to ensure the opened package of the [NAME] collagen powder (sterile, medical grade wound dressing, manage wounds by providing a moist healing environment) medication was stored properly in Medication Cart A. * The facility failed to dispose of the expired supply from the Medication Storage Room A. These failures had the potential to alter the efficacy of the stored medications, infection risk to the residents, and result in inappropriate administration of the prescription medications.Findings: Review of the facility's P&P titled Labeling and Storing Medications revised 1/2025 showed it is the policy of this facility that resident's medication will be properly labeled and stored in the locked medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-11 · 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, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed in the kitchen. * The facility failed to ensure the blender used for meal was air dried prior to storing. * The facility failed to ensure the food preparation utensil was not clean and in good working condition. These failures had the potential for cross contamination and foodborne illnesses for the residents consuming the food prepared in the facility's kitchen.Findings: Review of the facility's Order List dated 9/8/25, showed 85 of 88 residents consumed the food prepared in the kitchen. 1. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining…
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 20 citations
- Potential for harm · Dcited before2025-09-11 · 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 interview and medical record review, the facility failed to ensure the medical record was accurately maintained for one of 21 final sampled residents (Resident 91). * The facility documented (on three separate days) having obtained Resident 91's blood sugar, however, Resident 91 was out of the facility for his dialysis appointment, during the times the facility documented having obtained Resident 91's blood sugar. This failure resulted in Resident 91's medical record containing inaccurate information.Findings: Medical record review for Resident 91 was initiated on 9/8/25. Resident 91 was admitted to the facility on [DATE]. Review of Resident 91's Order Summary Report showed the following physician's orders:- dated 8/29/25, for Resident 91 to receive hemodialysis twice a week on Monday and Friday at 0430 hours.- dated 8/26/25, to obtain Resident 91's blood sugar once daily and to contact the physician if Resident 91's blood sugar was less than 60 mg/dL or greater than 250 mg/dL. a. Review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-11 · 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, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment, and help prevent the development and transmission of diseases and infections. * The facility failed to ensure Kitchen Aide 1 performed proper hand hygiene after picking up trash off the floor. * The facility failed to ensure LVN 3 followed the infection control practices during the wound observation for Resident 2. LVN 3 placed Resident 2's right heel on the pillow after cleaning the wound. * The facility failed to ensure the facility staff performed hand hygiene after handling soiled linen. These failures posed the risk of the transmission of communicable diseases to the residents and employees throughout the facility.Findings: 1. Review of the facility's P&P titled Sanitation and Infection Control – Handwashing dated 2018 showed the Food Service workers will keep their hands and exposed portion of their arms…
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 before2024-09-06 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility document review, the facility failed to ensure the ice machine was cleaned and sanitized according to the manufacturer's instructions. This failure posed the risk of the residents contracting the illnesses from the ice served to them. Findings: Review of the facility matrix showed 93 of 93 residents residing in the facility received food prepared in the kitchen. On 9/3/24 at 0951 hours, a concurrent observation, interview, and facility document review was conducted with the Maintenance Director. The facility was equipped with one ice machine. When asked about cleaning and sanitizing the ice machine, the Maintenance Director showed an inner panel on the ice machine containing the instructions on how to clean and sanitize. Review of the instructions on the panel included the descaling and sanitizing solutions were to be mixed with water. On 9/4/24 at 1544 hours, a concurrent interview and facility document review was conducted with the Maintenance Director. The Maintenance Director verified he was not mixing the descaling and sanitizing…
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 before2024-09-06 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections. * The facility failed to plan and implement the control measures to prevent the growth of the Legionella (a bacteria that can cause a serious type of lung infection) in the facility's water system. * The facility failed to ensure LVN 2 performed hand hygiene in between glove change while providing wound care to Resident 486. These failures had the potential for the spread of infection in the facility. Findings: According to the CMS QSO 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease revised 7/6/2018, the facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-06 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 medical record review, the facility failed to facilitate the residents' preferences and choices for food for three of 19 final sampled residents (Residents 22, 61, and 70). * Residents 22, 61, and 70 were not offered Korean breakfast. In addition, the Korean menu was posted in English. These failures posed the risk of the residents not being able to choose food items according to their ethnic preferences. Findings: Review of the facility's P&P for Nutrition Care - Resident Food Preferences revised 2018 showed the resident food preferences should be reviewed with the resident by the DSS and ethnic food preferences should be taken into consideration. 1.a. On 9/3/24 at 0951 hours, an interview was conducted with the DSS. When asked about breakfast served to residents, the DSS stated all residents were served breakfast from the American menu. On 9/4/24 at 0851 hours, Resident 22 was observed with her breakfast tray of scrambled eggs, toast, oatmeal, orange slice, and milk. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-06 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to implement the P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report an abuse allegation to the local law enforcement for one of one final sampled resident investigated for abuse (Resident 47). This failure had the potential for a delay in law enforcement response to the allegation. Findings: Review of the facility's Abuse and Neglect Prevention Management revised August 2018 showed all allegation of abuse or mistreatment will be reported per state law including the local law enforcement. Medical record review for Resident 47 was initiated on 9/3/26. Resident 47 was admitted to the facility on [DATE]. On 9/3/24 at 1455 hours, an interview was conducted with Resident 47 at their bedside. Resident 47 made an abuse allegation that three staff members were mean to her and rough. On 9/3/24 at 1523 hours, the Administrator was informed of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-06 · 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the low air loss mattress (pressure redistributing support surface) was set appropriately according to the resident's weight for one of two final sampled residents (Resident 486) reviewed for pressure ulcer (skin injury caused by prolonged pressure on an area of the body). This failure had the potential of Residents 486 not receiving the appropriate care and services to promote healing or prevent the development of the pressure ulcers. Findings: Review of the facility's P&P titled Pressure Reducing Mattresses revised 1/2024 showed specialized mattress/beds are to be utilized according to suppliers' direction for use. Review of the facility's document titled Operating Instruction Comfy Aire Series, undated, showed the Comfy Aire system is designed for patient weighting between 35- 145 pounds, using the comfort control. Depending on the desired resident comfort level 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 · D2024-09-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the physician order for oxygen therapy was followed for one of one final sampled resident reviewed for oxygen therapy (Resident 17). This failure had the potential for Resident 17 to not to receive appropriate respiratory care and posed the risk to negatively affect Resident 17's medical condition. Findings: Review of the facility's P&P titled Oxygen Therapy revised 1/2024, showed it is the policy of the facility that oxygen to be administered as ordered by the physician or as an emergency measure until the order could be obtained. Under the section Procedure showed to adjust oxygen flow as ordered by the physician. On 9/3/24 at 0940 hours, an observation was conducted for Resident 17. Resident 17 was observed lying in bed and receiving oxygen at six liters per minute via nasal cannula. Medical record review for Resident 17 was initiated on 9/3/24. Resident 17 was admitted to the facility on [DATE].…
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 before2024-09-06 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.41% (for two medication errors out of 27 total opportunities). * The facility failed to ensure LVN 1 administered Resident 63's medication as ordered. This failure had the potential to cause the negative outcomes to Resident 63. Findings: Review of the facility's P&P titled Policy and Procedure In Medication Administration revised January 2024 showed medications must be administered in accordance with the physicians' orders. On 9/4/24 at 0838 hours, a medication administration observation was conducted with LVN 1 for Resident 63. LVN 1 administered the following medications: - one tablet of Extra Strength Glucosamine Hcl (hydrochloride) with MSM (methylsulfonylmethane). - one softgel of Vision Formula 50+ dietary supplement with Lutein, Zeaxanthin, and Omega 3. LVN 1 stated Resident 63's family member brought 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 · D2024-09-06 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents obseved for the medication administration (Residents 28 and 62) were free from significant medication errors. * Residents 28 and 62's blood pressure medications were not held as ordered by the physician. These failures had the potential for the adverse outcomes to the residents. Findings: Review of the facility's P&P titled Policy and Procedure In Medication Administration revised 1/2024 showed medications must be administered in accordance with the physicians' orders 1. Medical record review for Resident 28 was initiated on 9/3/24. Resident 28 was admitted to the facility on [DATE]. a. Review of Resident 28's Order Summary Report dated 9/6/24, showed an order dated 9/20/22, for amlodipine besylate (a medication to treat high blood pressure) 5 mg daily, hold for a SBP less than 110 mmHg. Review of Resident 28's MAR for July 2024 showed on 7/19/24, amlodipine besylate…
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 before2024-09-06 · 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, medical record review, and facility P&P review, the facility failed to document the medication as refused for one nonsampled resident observed for the medication adminstration (Resident 83). This failure resulted in inaccurate medication administration records, which had the potential for the resident's well-being. Findings: Review of the facility's P&P titled Policy and Procedure In Medication Administration revised 1/2024 showed the medications must be documented immediately after administering. Medical record review for Resident 83 was initiated on 8/4/24. Resident 83 was admitted to the facility on [DATE]. On 9/4/24 at 0848 hours, an observation was conducted of Resident 83's medication administration by LVN 1. During the observation, LVN 1 poured polyethylene glycol (laxative medication) 17 gm and mixed it with water. LVN 1 brought the medication to Resident 83's bedside for administration. Resident 83 refused it because he was leaving for an appointment. LVN 1 administrated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-06 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, medical record review, and facility P&P review, the facility failed to monitor and address the use of antibiotics when the resident's condition did not meet McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for one of 19 final sample residents (Resident 24) and one nonsampled resident (Resident 73); and failed to identify if the residents' condition met the McGeer's criteria for infection for one nonsampled resident (Resident 29). These failures had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria. Findings: Review of the facility's P&P titled Antibiotic Stewardship- Order for Antibiotics dated 12/2016 showed appropriate use of antibiotic included criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). Review of the facility's P&P titled Antibiotic Stewardship-Review and Surveillance of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2021-10-29 · 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, medical record review, facility P&P review, and facility document review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections. * The facility failed to show documentation of the Legionella (a bacteria that can cause a serious type of lung infection) facility risk assessment and Legionella testing protocols. * The facility failed to ensure the trash bin and laundry hamper were available for used gloves and used washable gowns in Resident 39's room, who was on isolation precautions. * LVN 3 failed to perform hand hygiene while providing wound care to Resident 26. * LVN s 5 and 6 failed to perform hand hygiene during medication administration. These failures had the potential to result in the transmission of infection to a vulnerable population of residents in the facility. Findings: 1. According to the CMS QSO 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water…
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 before2021-10-29 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure labeling and dating of foods in the refrigerator and open storage area used for resident food. * The facility failed to air dry equipment. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the form CMS-672 Resident Census and Conditions of Residents completed by the facility dated 11/2/21, showed 90 of 92 residents residing in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Receiving and Storage of Cold Foods dated 2018, showed all the perishable food items purchased by the department of food and dining services will be stored properly. All open food items will have an open date and use-by-date per manufacturer's guidelines. On 10/26/21 at…
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 · D2021-10-29 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the bed remote control and call light were kept within reach for one of 19 final sampled residents (Resident 4). This failure resulted in Resident 4 not being able to use the bed remote control to lower the head of the bed and the call light for assistance when she was in pain, which had the potential to negatively impact the resident's well-being. Findings: On 10/26/21 at 1243 hours, Resident 4 was observed lying in bed with the head of bed elevated. Resident 4 was calling on staff asking to put her bed down, and stating her right shoulder was painful. Resident 4 was observed rubbing her right shoulder. The bed remote control was observed at the foot of the bed and the call light was observed on the floor, out of Resident 4's reach. On 10/26/21 at 1250 hours, a concurrent observation and interview was conducted with LVN 3. LVN 3 verified the bed remote control was at the foot of the bed and the call light was on the floor,…
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 · D2021-10-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable care for the protection of the resident's personal property from loss or theft for one of 19 sampled residents (Resident 39). Resident 39's cabinet was locked with a chain and a padlock; however, when she was transferred to another room, the facility failed to ensure the chain and padlock were placed in the resident's cabinet in the new room. This resulted in Resident 39 feeling upset and stressed about her personal belongings, which had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Personal Property revised 9/12 showed upon request, the facility shall provide or allow the resident to place a lock, chain or other security device on his/ her night stand, bed side table, and/or closet door as appropriate. On 10/26/21 at 1000 hours, during the initial tour of the facility, an interview was conducted with Resident 39. Resident 39…
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 before2021-10-29 · 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, medical record review, and facility P&P review, the facility failed to ensure the medications were administered in accordance with the standards of practice for one of the nonsampled resident (Resident 48). * Resident 48's polyethylene glycol (laxative medication) was not administered in a timely manner. This failure had the potential for medication errors. Findings: Review of facility's P&P titled Medication Administration, revised 07/13, under the section Procedures, showed Medication must not be prepared in advance and must be administered within one hour before and after administration time per the physician's order. On 10/28/21 at 0749 hours, a medication administration observation was conducted for Resident 48 with LVN 2. LVN 2 withheld Resident 48's polyethylene glycol 3350 powder 17 grams, 1 scoop by mouth one time a day for bowel management. LVN 2 was stated she had to check the medications later. Review of the Order Summary Report for October 2021, showed a physician's order dated 10/28/21 to administer polyethylene glycol 3350 powder 17…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-09-11 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of 21 final sampled residents (Resident 43) was revised to reflect the resident's current care needs and interventions. * The facility failed to revise Resident 43's long-term care plan addressing the resident's high risk for fall when Resident 43 sustained a fall on 8/7/25. This posed the risk of not providing Resident 43 with an individualized and person-centered care.Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Plans revised on 4/2025 showed the assessments of the residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility's P&P titled Care Plan revised on 1/2025 showed the following:- Long term care plan: this is a problem or concern of the residents that has been ongoing for longer periods of time;- A short-term problem that has been noted twice should…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-09-06 · tag F0847 — patternInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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, medical record review and facility P&P review, the facility failed to ensure the arbitration agreement was explained to one nonsampled resident (Resident 12). This failure posed the risk for the resident to not have the right to file an appeal if there was any issue of medical malpractice. Findings: Review of the facility's admission Agreement P&P - Binding Arbitration Agreements revised 4/2024 showed the facility will explain the agreement in a form, manner and language the resident and representative understand. Medical record review for Resident 12 was initated on 9/5/24. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's MDS showed her BIMS score was 9, indicating the resident had moderate cognitive impairment. Review of Resident 12's Facesheet showed the resident had one son and three daughters listed as responsible parties. Review of Resident 12's Arbitration Agreement, undated, showed Resident 12 signed the statement agreeing to have any issue of medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2021-10-29 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure the garbage and refuse were properly stored in two of two garbage dumpsters. The lid of the facility's garbage dumpsters were left open. This failure had the potential to harbor pests or rodents which carry diseases. Findings: According to the US Food Code 2013, 5-501.113, Covering Receptacles, receptacle units for refuse shall be kept covered with tight fitting lids after they are filled. Review of the facility's P&P titled Food-Related Garbage and Rubbish Disposal revised 12/2014, showed outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter. On 10/28/21 at 0740 hours, an observation and concurrent interview was conducted with the DSS. The two garbage dumpsters located outside of the facility adjacent to the kitchen were observed with the lids propped open. The DSS verified the findings.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to EVA CARE GROUP — 9 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 | 3.4 | +1.6 vs chain |
| Health inspection | 4 of 5 | 2.6 | +1.4 vs chain |
| Staffing | 5 of 5 | 4.4 | +0.6 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 8 homes this chain runs (chain average 3.4★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CHEN, JENQ | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 50% | since 06/01/2003 |
| CHEN, TZE-YUN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 02/20/2017 |
| PADAMA, JOHN | Individual | CORPORATE DIRECTOR | — | since 08/02/2017 |
| PADAMA, ANTHONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/11/2024 |
| SONG, CHAEWON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/14/2010 |
CMS files one row per role, so the 8 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $471K 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 056151. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.