Pacific Haven Subacute And Healthcare Center
12072 Trask Ave., Garden Grove, CA 92843 · For profit - Limited Liability company · 99 certified beds · (714) 534-1942 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 9.6% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.4% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.8% | 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 | 7.4% | 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 | 1.4% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 9.4% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 8.1% | 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 | 5.1% | 4.3% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 7.7% | 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 | 4.1% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.3% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 93.8% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.4% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 6.4% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.81 | 2.25 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.20 | 1.57 | 1.80 | better |
‡ 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.
52.4% 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 255 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 85.1% 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 87 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 0.45 therapist hours per resident per day in 2026Q1 — more than 76% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% 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 | 52.4%CMS range 45.0–58.6 | 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 | 11.5%CMS range 8.5–15.4 | 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 | 85.1% | 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 | 82.8% | 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 | 75.9% | 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 | 97.6% | 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 | 98.3% | 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 | 100.0% | 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 | 0.6% | 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 | 0.6% | 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 | 7.9%CMS range 5.1–10.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.37 | 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 93.2 residents a day — about 94% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.23 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.90 hrs/resident/day on weekends vs 5.37 on weekdays — 9% thinner on weekends. RN hours go from 0.94 to 0.77 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
34 citations, most serious first. The 12 most serious are shown; the remaining 22 are one tap away and print in full.
- Actual harm · G2025-11-04 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, closed medical record review, facility document review, and facility P&P review, the facility failed to ensure the RNs were properly trained on the administration and preparation of IV medications, as evidenced by: * The Nursing Skills Competency Skills Checklist for the RNs did not include the reconstitution (process of adding specific amount and type of sterile liquid to a powered medication to create a usable solution for IV administration) of an IV medication. * RN 3 did not receive training on the administration of medications containing amphotericin B (powerful antifungal medication used to treat serious, potentially life-threatening fungal infections). In addition, RN 3 did not research information about the amphotericin B liposomal or Amphotericin B medications, prior to administering the medication for the first time. This failure resulted in a medication error and contributed to the death of Resident 1.Findings: a. Review of the facility's P&P titled Intravenous Therapy dated 2/2020…
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.
- Actual harm · Gcited before2025-11-04 · 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 document review, the facility failed to provide the pharmaceutical services to ensure the accurate medication dispensing and administration for one of three sampled residents (Resident 1) as evidenced by: * Pharmacy 1 dispensed 350 mg of amphotericin B (powerful antifungal medication used to treat serious, potentially life-threatening fungal infections), instead of 350 mg of amphotericin B liposome (a different formulation of amphotericin B with different dosing requirements) as ordered by Resident 1's physician. * Pharmacy 1 dispensed a 250 ml bag of D5W (intravenous solution of 5% dextrose in water), which was intended for use with the amphotericin B liposomal (AmBisome). However, amphotericin B was dispensed in error and would have required 3500 ml for the medication to be reconstituted properly to the correct concentration. * Resident 1 received the amphotericin B 350 mg via IV infusion at a rate 2-3 times the recommended rate 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 · D2026-04-17 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 abuse allegations were thoroughly investigated for one of three sampled residents (Resident 6) reviewed for abuse. * The facility failed to conduct a thorough investigation into Resident 6's abuse allegation prior to allowing CNAs 5 and 6 to return to work. This failure had the potential to leave the vulnerable residents for further abuse, mistreatment, and injury.Findings: Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against revised 12/2023 showed it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. Under the Investigation section showed after receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. The facility will conduct…
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 · D2025-06-12 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 one of six sampled residents reviewed for dining (Resident 1) received food prepared in a form to meet the resident's individual dietary needs. * The facility failed to ensure Resident 1 was provided with the chopped vegetables as per the physician's diet order. This failure had the potential for Resident 1 not liking the food based on the dietary modification and could affect the resident's quality of life. Findings: Review of the facility's P&P titled Nutrition Management of Dysphagia dated 2023 showed in the section for dysphagia mechanical diet, all cooked vegetables should be chopped approximately half inch and cooked, soft to a mashable texture. Medical record review for Resident 1 was initiated on 6/12/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/25/25, showed Resident 1 had the capacity to understand and make decisions. 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 · E2025-05-05 · tag F0761 — failed to label and store drugs safely — patternEnsure 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, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications. * The facility failed to ensure the expired supply was removed from the medication cart, the medication was labeled, and the supplies were clean and sanitary for Medication Cart A. * The facility failed to ensure the supplies in the cart were kept in clean and sanitary manner and the expired supplies were removed from the current supplies from Medication Cart B. * The facility failed to ensure the internal medications were not mixed with external medications for Medication Cart C. In addition, the facility failed to ensure the non-controlled medication was not stored with the controlled medication inside Medication Cart C. * The facility failed to ensure the expired supplies were removed from the medication and the supplies were kept in clean and sanitary manner for 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 · Ecited before2025-05-05 · 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 4.a. On 4/29/25 at 1100 hours, Room A's resident closet contained a disposable brief stored on the floor, exposed, unwrapped, and touching the shoe box and splint. The resident's diaper was disorganized. Linen was placed underneath the chair leg, and the diaper was exposed and lying on the floor of the closet. On 4/29/25 at 1400 hours, an observation and concurrent interview was conducted with LVN 11. LVN 11 verified the above findings and stated the staff should have organized and cleaned the residents' closet. LVN 11 acknowledged the potential for contamination as the diaper, gown, and linen were touching the floor and chair legs. b. On 4/29/25 at 1055 hours, Room C's resident closet had a wheelchair cushion stored on the floor of the closet. The cushion was dusty and had small pieces of wood debris. On 4/29/25 at 1130 hours, Room C's resident closet for Resident 63 contained an exposed diaper and the belt gait and clothing were disorganized On 4/29/25 at 1135 hours, Room C's resident closet for Resident 58…
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 · D2025-05-05 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 one of 19 final sampled residents (Resident 30) was safe to self-administer a medication. * There was no assessment or care plan to address Resident 30's self-administration of medications when the resident had two bottles of Alphagan eye drops (medication used to lower high eye pressure) at the bedside and had been self-administered this medication. This failure had the potential to negatively impact the residents' well-being and administer the medications inaccurately. Findings: Review of the facility's P&P titled Self-Administration of Medications (undated) showed each resident will be informed of his/her right to self-administer medication. The residents will be informed that they have a right to self-administer drugs upon admission. Medical record review for Resident 30 was initiated on 4/29/25. Resident 30 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 30'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 · D2025-05-05 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
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 one of 19 final sampled residents (Resident 78) was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 78's prescription for lorazepam (antianxiety medication) had documentation of the physician's clinical rationale to show when the PRN order was extended beyond 14 days. This failure had the potential to negatively impact the Resident 78's well-being from the continued use of the lorazepam medication. Findings: Review of the facility's P&P titled Psychotropic Medications revised 12/2023 showed the following: - Based on comprehensive assessment, the facility will ensure PRN orders for psychotropic drugs are limited to 14 days. Except for PRN orders for antipsychotic medications, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN psychotropic medication order to be extended beyond 14 days, he or she should document their rationale 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 · D2025-05-05 · 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 observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of 19 final sampled residents (Residents 14 and 78) and one of three residents reviewed for closed records (Resident 8). * The facility failed to develop a care plan to address Resident 78's use of padded side rails. In addition, the facility failed to develop a care plan to address Resident 78's use of IV device. * The facility failed to develop a care plan to address Resident 14's use of the sequential compression device. * The facility failed to develop a care plan for Resident 8's DM. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents. Findings: 1. On 4/29/25 at 1056 and 1454 hours, 4/30/25 at 1118 and 1609 hours, 5/1/25 at 0845, 1333, and 1601 hours, and 5/2/25 at 0837 and 0858 hours, Resident 78 was observed in bed with 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 · D2025-05-05 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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 provide the individualized and ongoing activity program to meet the needs and interests for one of two final sampled residents (Resident 78) reviewed for activities. * The facility failed to provide the activities for Resident 78 which met the resident's identified interests such as watching TV. This failure had the potential for Resident 78 to negatively impact the resident's well-being. Findings: On 4/29/25 at 1056 hours, during the initial tour of the facility, Resident 78 was observed awake in bed. The TV was turned off, and there was no other sensory stimulation provided for Resident 78. Medical record review for Resident 78 was initiated on 4/29/25. Resident 78 was readmitted to the facility on [DATE]. Review of Resident 78's Activity Assessment - V2 dated 3/13/25, showed Resident 78's current activity interests included watching TV/movies, keeping up with the news, and listening to music. Review of Resident 78's Care Plan…
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 before2025-05-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to the reported injury was addressed and reported to the resident's responsible party and the physician for one of 19 final sampled residents (Resident 6). This failure posed the risk of Resident 6's injury to worsen. Findings: Medical record review for Resident 6 was initiated on 5/1/25. Resident 6 was readmitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 3/24/25 showed Resident 6's diagnoses included sepsis, Parkinson's Disease, schizophrenia, and dementia. Resident 6 had no capacity to understand and make decisions. On 5/1/25 at 1046 hours, a concurrent observation and interview for Resident 6 was conducted with CNA 1. CNA 1 verbalized Resident 6 was alert but confused and was able to propel himself in his wheelchair. When asked about the skin conditions for Resident 6, CNA 1 verbalized Resident 6 did not have any skin conditions. However, Resident 6 was observed with a red colored circular 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 · D2025-05-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure the necessary treatment and services were provided to maintain or improve their ROM functions and prevent further declining of the ROM functions for two of two final sampled residents (Residents 38 and 44) reviewed for ROM functions. * Residents 38 and 44 did not receive the restorative nursing treatment daily as ordered by the physician. This failure posed the risk for the residents to develop complications from immobility and not achieve their highest practicable level of independence. Findings: 1. Medical record review for Resident 38 was initiated on 4/29/25. Resident 38 was readmitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 38's H&P examination dated 12/4/24, showed Resident 38 had functional quadraplegia (paralysis). Resident 38 had the capacity to understand and make decisions. Review of Resident 38's care plan dated 4/30/25, showed Resident 38 was at high risk for decline 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.
Show the remaining 22 citations
- Potential for harm · Dcited before2025-05-05 · 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 interview, medical record review, and facility P&P review, the facility failed to monitor the onset of weight loss for one of three final sampled residents (Resident 25) reviewed for nutrition. * The facility failed to ensure the RD's recommendations were followed up with the physician and addressed in the IDT Nutrition when Resident 25 had a significant weight loss of 11 lbs/11.1% in three months. This failure posed the risk of nutritional interventions not being implemented in a timely manner and potentially could cause the residents to have further weight loss. Finding: Review of the facility's P&P titled Weight Change Protocol dated 2023 showed early identification of a weight problem and possible cause(s) can minimize complications. Assessment of residents experiencing weight changes should be completed in a timely manner. The following Criteria define significant weight or insidious weight changes: - slow and progressive weight change trending away from weight goal. This can refer to weekly 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 · D2025-05-05 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 19 final sampled residents reviewed for enteral services received the appropriate treatment and services. Additionally, the enteral feedings were not properly stored or monitored. * The expired enteral feeding bottles were stored in the subacute storage unit. * The facility failed to ensure Residents 14 and 32's HOB were elevated at a 30 degree angle or above when the residents were receiving the enteral feeding via the GT. These failures posed the risk for complications related to the use of the enteral feeding for the residents. Findings: 1. On 5/1/25 at 1014 hours, a concurrent observation of the subacute storage unit and interview was conducted with Central Supply 1. Central Supply 1 verified four bottles of the enteral feeding formula bottles with a best before date of 4/1/25, and one bottle of enteral feeding with a best before date of March 2025. Central Supply 1 verified the enteral…
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 before2025-05-05 · 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 two of sampled residents (final sampled resident, Resident 32 and nonsample resident, Resident 63) reviewed for respiratory care received the appropriate treatment. * The facility did not ensure the nebulizer mask, tubing, and bag were changed weekly or properly labeled for Resident 63. * The facility failed to ensure Resident 32 was provided with the correct type of tracheostomy set for emergency use. Resident 32 was provided with an uncuffed tracheostomy set instead of a cuffed tracheostomy set. In addition, the facility failed to ensure the suction device was changed weekly as per the physician's order. These failures had the potential to negatively impact the respiratory health and overall well-being of the residents in the facility. Findings: 1. Medical record review for Resident 63 was initiated on 4/29/25. Resident 63 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-05 · 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, facility document review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided for two of 19 final sampled residents (Residents 32 and 72) and two nonsampled residents (Residents 26 and 296) when: * The facility failed to ensure the administration of controlled medication for Resident 296 was documented in the narcotic record. * The facility failed to ensure a record of controlled medications for Residents 26 was completed * The facility failed to ensure Resident 72's old lidocaine external patch (patch used for pain relief) was removed as ordered by the physician. * The facility failed to adhere to Resident 32's blood pressure and blood glucose parameters as prescribed by the physician for two medications: midodrine (blood pressure medication) and insulin (medication to lower blood sugar levels). These failures posed the risk for diversion of the controlled medications and medication errors, and may have negative…
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 before2025-05-05 · 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 requirements were met. * A red bucket solution was stored next to the food items. * There was a staff portable radio stored on the beverage preparation area. * Two soft, wrinkled, and blackened bell peppers were stored inside the refrigerator. * A bag of croissants opened 4/3/25, was stored inside the refrigerator. * There was a staff water bottle stored inside walk in refrigerator. * There was an unlabeled package of mushrooms in the refrigerator. * There was an unlabeled frozen pizza and unlabeled bag of tamales. These failures posed the risk of unsanitary and possible food-borne illness. Findings: Review of the Diet Type Report dated 4/30/25, showed 59 of 95 residents food were prepared in the kitchen. Review of the facility's P&P titled Storage of Food and Supplies dated 2023 showed the food storage areas should be used only for food. The cleaning supplies should be stored in entirely separate and specific areas. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-05 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
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 resident care equipment and refrigerator were maintained in the safe operation condition when: * The record of quality control for one glucometer from Medication Cart C was not accurate. * The facility staff used whiteout to correct documentation entries in the Quality Control Record for Glucometers A and B. The facility was not able to refer to the previous entries made as a result of completely erasing the original documentation requiring corrections. * The refrigerator inside Medication Room A containing medications was not kept within the acceptable temperature parameters. * The walk-in freezer inside the kitchen remained free of ice buildup. These failures had the potential to affect care and services provided to the residents in the facility. Findings: 1. Review of the facility's document titled Policy: Quality Control Testing on Assure Platinum Meter showed quality control testing using the Assure Dose Control Solution will be performed to examine 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 · Ecited before2024-04-11 · 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, interviews, and facility policy review, the facility failed to ensure staff used appropriate hand hygiene and glove use when they handled ready-to-eat food. This failure affected 59 residents who received meals from the kitchen, out of the 95 residents who currently reside in the facility. Findings included: A review of the facility policy titled, Glove Use Policy, dated 2020, revealed, The appropriate use of gloves is essential in preventing food borne illness. Wearing disposable gloves is one of the acceptable ways that any food, ready-to-eat food, or otherwise, may be prepared and served. Gloved hands are considered a food contact surface that can get contaminated or soiled. During an observation on 04/09/2024 at 12:13 PM, the surveyor noted [NAME] #1 did not wash his hands or change his gloves after he was noted to scratch the side of their face with a gloved hand, then continued to pick up meat and cilantro with the same gloved hand. In an interview on 04/09/2024 at 2:08 PM, [NAME] #1 stated he wore gloves for sanitation. [NAME] #2 stated if he touched…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-11 · 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
Based on observations, interviews, and facility document and policy review, the facility failed to ensure staff properly cleaned glucometers according to a manufacturer's labeled specifications for use as a disinfectant to help prevent the spread of bloodborne pathogens during use, for 2 of 13 glucometers observed in use during medication pass. Findings included: A review of a facility infection control policy titled Cleaning and Disinfecting Glucose Monitoring Devices, revised in June 2022, revealed, It is the policy of the facility to disinfect equipment used to reduce the potential for disease transmission. The policy revealed, The Director of Nursing (DON) and/or its designee shall be responsible for implementation and enforcement of this policy. The policy revealed, If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. The policy further revealed, Refer to manufacturer's guidance of blood glucose meters to determine what products, meeting 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 before2024-04-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident who had not been assessed as safe to self-administer medications did not self-administer an inhaler, failed to follow physician's orders for administration of an inhaler, and failed to follow facility policy for medication administration for 1 (Resident #299) of 4 residents observed during a medication pass. Findings included: A review of an undated facility policy titled Self-Administration of Medications revealed, Each resident will be informed of his/her right to self-administer medications. The Interdisciplinary Team will assess and determine if the practice is safe. Medications to be self-administered are specifically ordered, and monitored by the facility nursing staff. Such orders will be periodically reassessed to assure that they may still be given safely. The policy further revealed the procedure included, 5. The Physician's Orders for such drugs will be clarified to include: MAY KEEP…
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 before2024-04-11 · 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
Based on observation, interviews, record review, and facility policy review, the facility failed to licensed staff only documented medications they administered during medication administration for 1 (Resident #299) of 4 residents observed for medication administration. Findings included: A review of an undated facility policy titled Oral Medication Administration revealed 6. The medication nurse is responsible for noting any changes on the Medication Administration Record (MAR). Per the policy, 31. Return to the Medication Cart and document medication administration with initials in appropriate spaces on the MAR. During medication administration observation on 04/10/2024 at 8:22 AM, Licensed Vocational Nurse (LVN) #5 was noted to administer medication to Resident #299 to include cholecalciferol 125 micrograms. However, a review of Resident #299's Medication Administration Record, for 04/01/2024 to 04/30/2023, revealed LVN #9's initials on the MAR to indicate she administered the medication to the resident. On 04/10/2024 at 4:37 PM, the Director of Nursing (DON) brought LVN #5 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 · Ecited before2023-12-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 supplemental oxygen was administered as ordered by the physician and by the competent staff for four of five sampled residents (Residents 1, 2, 3, and 5). * Supplemental oxygen was not administered as ordered for Residents 1, 2, and 3. * Resident 5's supplemental oxygen was administered and removed by a CNA. These failures had the potential to put the residentsat risk of respiratory complications. Findings: Review of the facility's P&P titled Oxygen Administration revised October 2020 showed to verify and review the physician's order before administering the oxygen and after the oxygen set up or adjustment. 1. Closed medical record review for Resident 1 was initiated on 12/20/23. Resident 1 was admitted to the facility on [DATE], and discharged on 12/4/23. On 12/20/23 at 0913 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated one day when they arrived around 0900…
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 before2022-11-23 · 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 as evidenced by the following: * The facility failed to ensure the can openers were in sanitary condition and free of food particles; the kitchen utensils had a smooth cleanable surface and were not worn out; the kitchen equipment was air dried and free of food particles; and the kitchen utensils were clean and free of food particles. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. 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 titled Resident Census and Conditions of Residents completed by the facility dated 11/15/22, showed 49 out of 95 residents residing in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in 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 before2022-11-23 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
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 maintain a copy of one of 19 final sampled residents' (Resident 12) advance directive in the medical record to ensure it was readily available to the facility staff. This had the potential for the resident's decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives revised 2/2022 showed if a resident has executed an advance directive, the facility must obtain a copy from the resident or legal representative. The facility's copy of the advance directive must be filed in the resident's clinical record. Medical record review for Resident 12 was initiated on 11/15/22. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Physician Orders for Life-Sustaining Treatment (POLST) dated 6/9/22, showed Resident 12 had formulated an advance directive. Review of Resident 12's Social Service Assessment admission 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 · Dcited before2022-11-23 · 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 medical record review, the facility failed to ensure one of 19 final sampled residents (Resident 14) was administered the prescribed enteral formula (liquid nourishment administered through a GT) as ordered by the physician. This failure posed the risk for Resident 14 to have unplanned weight loss. Findings: During the tour of the facility on 11/17/22 at 0758 hours, Resident 14 was observed lying in bed with a continuous feeding pump infusing at 70 ml per hour from a 1500 ml bottle of Jevity (fiber-fortified tube-feeding formula) 1.5 Cal Medical record review for Resident 14 was initiated on 11/17/22. Resident 14 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the physician's order dated 11/14/22, showed to administer Jevity 1.5 Cal at 80 ml per hour via GT for 20 hours to provide 1600 ml/2400 calories. On 11/17/22 at 0813 hours, an observation and concurrent interview was conducted with the ADON and DON. The ADON and DON verified the rate of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-23 · 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, and facility P&P review, the facility failed to provide the respiratory care to meet the needs for one of 19 final sampled residents (Resident 64). The facility failed to ensure the mechanical ventilator low pressure alarm for Resident 64 was set within the safe parameters as per the facility's P&P. This posed the risk for delayed care and interventions if the resident's ventilator alarm was not trigerred when it should have, to alert the staff the resident was in distress or disconnected from their ventilator. Findings: Review of the facility's P&P titled Mechanical Ventilation (undated) showed to set the ventilator low pressure alarm 5 to 10 cmH2O below the PIP. According to the Clinical Application of Mechanical Ventilation 2014, Fourth Edition, the low-pressure alarm is triggered if the PIP is less than the alarm setting. Conditions that may trigger the low-pressure alarm may include circuit disconnection, exhalation valve driveline disconnection, endotracheal tube cuff leak,…
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 · D2022-11-23 · 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, and clinical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was at 6.67% when the metoprolol (antihypertensive) medication for one of 19 final sampled residents (Resident 89) and one of one nonsampled resident (Resident 29) were not administered with food as per the manufacturer's specifications. This failure created the risk for complications and ineffective therapeutic effects of the medications. Findings: According to Lexicomp.com (a professional resource or a nationally recognized drug information site for healthcare professionals), metoprolol tartrate medication should be taken with or immediately after food intake. a. During the medication administration observation on 11/17/22 at 0840 hours, the GT was clamped during the medication pass. LVN 1 administered metoprolol 10 mg to Resident 89 via GT. LVN 1 was asked when Resident 89 finished her breakfast. LVN 1 stated the GT feeding was turned off 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 · Dcited before2022-11-23 · 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, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 19 final sampled residents (Resident 64) was complete and systematically organized. The facility failed to ensure Resident 64's respiratory rate and PIP were documented on the flow sheet after each ventilator check as per the facility's P&P. This had the potential for the resident's care needs not being met as their medical information was incomplete. Findings: Review of the facility's P&P titled Mechanical Ventilation Flowsheet (undated) showed services provided by the respiratory care provider must be documented properly in the resident's medical record. Each ventilator check will be recorded on the flow sheet with the following information as indicated, including the measured (respiratory) rate and PIP. On 11/15/22 at 0848 hours, Resident 64 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. Medical record review for 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.
- No harm found · Bcited before2025-05-05 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
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 obtain a copy of the advance healthcare directive for one of six final sampled residents (Resident 32) reviewed for advance directives. This failure had the potential for the resident's decisions regarding their healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advance Directives and Associated Documentation revised 12/2023 showed the following: - It is the policy of the facility that a resident's choice about advance directives will be recognized and respected. Further, it is the policy of the facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. The facility recognizes and respects the resident's right to choose their treatment and make decisions about care to be received at the end of their life; - Obtain copy of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-05-05 · tag F0803 — failed to meet residents' dietary needs — patternEnsure 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 — the official record, unedited, may be distressing
Based on observation, interview, and facility document review, the facility failed to follow the menu for nine residents who were on pureed diets. * The facility failed to ensure the pureed potato recipe was followed during the pureed food preparation. This failure had the potential of not following the menu and not meeting the residents' nutritional needs which could lead to nutritional-related health complications. Findings: Review of the April 2025 Diet Type Report for the residents on puree diets showed a total of nine residents received the puree meals prepared in the facility's kitchen. Further review of this document showed two residents were on no added salt puree diets. On 4/30/25 at 1040 hours, a puree food preparation observation was conducted with [NAME] 1. [NAME] 1 was observed adding low sodium broth to the puree potatoes being prepared for the residents on puree diets. However, review of the facility's recipe for puree potatoes showed to gradually add warm milk to the pureed potatoes. The finding was verified with [NAME] 1.
- No harm found · B2025-05-05 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility document review, the facility failed to ensure the food prepared in the facility's kitchen was attractive in appearance and at an appetizing temperature. This failure had the potential for the residents to not eat the food served and could affect their nutritional status. Findings: According to the IDDSI.org website, puree food items have a smooth texture with no lumps. Review of the April 2025 Diet Type Report for the residents on puree diets showed a total of nine residents received the pureed meals prepared in the facility's kitchen. On 4/30/25 at 1040 hours, a puree preparation observation was conducted with [NAME] 1. [NAME] 1 was observed preparing the puree salad. The prepared puree salad had lumps and with water surrounding the puree salad. When asked what consistency the puree salad should be, [NAME] 1 stated it should be apple sauce consistency. When asked about the lumps and water surrounding the puree salad, [NAME] 1 stated when the salad cooled down, the consistency would look more like apple sauce consistency. On 4/30/25 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.
- No harm found · Bcited before2025-05-05 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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, medical record review, and facility document review, the facility failed to ensure the medical record for one of three final sampled residents (Resident 8) reviewed for closed records was complete. * There was inconsistent documentation of Resident 8's monitoring for the indwelling urinary catheter care and checking of Quinton catheter (a type of central venous catheter inserted on the chest wall used for hemodialysis access when the conventional vascular access is difficult to establish) to the right upper chest wall. This failure had the potential for Resident 8's care needs to not be met as there were missing documentation in the medical record. Findings: Review of the facility's document titled Documentation Content of the Record Set (undated) showed under Federal Regulations Pertaining to Clinical Records: Federal regulation requires that the facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete,…
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 · Bcited before2023-12-22 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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, observation, and medical record review, the facility failed to ensure the medical records were accurate and complete for four of five sampled residents (Residents 1, 2, 3, and 4). This failure had the potential to not effectively evaluate the care and services provided and residents' health conditions. Findings: Review of the facility's P&P titled Oxygen Administration revised October 2020 showed to verify and review the physician's order before administering oxygen and after oxygen set up or adjustment, the following should be recorded in the resident's medical record: the date and time, rate of oxygen flow, route and rational, frequency and duration of the treatment, reason for PRN administration, and how the resident tolerated the procedure. 1. Medical record review of Resident 2 was initiated on 12/20/23. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's Order Summary Report dated 12/20/23, showed a physician's order dated 10/6/23, for oxygen to be administered…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| CRUZ, MELODY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/19/2025 |
| LE, CHINH | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 03/19/2025 |
| WILLITS, ADAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 09/11/2024 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | since 09/11/2024 |
| LOOPER, WILLIAM | Individual | CORPORATE OFFICER | since 09/11/2024 |
| SATO, AMI | Individual | CORPORATE OFFICER | since 09/11/2024 |
CMS files one row per role, so the 10 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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 $963K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 055575. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-05, 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.