Glendale Healthcare Center
1208 S. Central Ave, Glendale, CA 91204 · For profit - Individual · 48 certified beds · (818) 246-5516 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
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (23) — 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) | 3 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 | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 8.8% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.5% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.0% | 7.3% | 6.5% | better |
| 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 | 5.4% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 8.3% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.1% | 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 | 8.8% | 4.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 18.8% | 10.2% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.9% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.1% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 34.3% | 23.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 1.0% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.57 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.24 | 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.
40.4% 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 152 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.5% 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 47 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.61 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 35% 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 | 40.4%CMS range 33.6–50.2 | 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 | 9.9%CMS range 6.6–13.0 | 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 | 42.5% | 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 | 42.5% | 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 | 53.2% | 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 | 100.0% | 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 | 100.0% | 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 | 95.1% | 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 | 0.8% | 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 | 0.0% | 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 | 9.2%CMS range 5.7–13.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.28 | 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 48 beds and averages 45.0 residents a day — about 94% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.77 hrs/resident/day on weekends vs 4.18 on weekdays — 10% thinner on weekends. RN hours go from 0.43 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · F2026-02-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to properly wash dishware when the water temperature was lower than manufacturer specifications. This deficient practice has the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in all medically compromised residents.Findings: During an observation on 2/18/2026 at 8:51 AM, Dietary Aide 1 (DA1) was operating a low-temperature dishwasher (commercial ware washers that clean at 120 -140 degrees Fahrenheit (F) water temperature and rely on chemical sanitizers) to wash plate ware from breakfast service where the water reservoir thermometer read 98 F. During a concurrent interview with Dietary Services Supervisor (DSS) she stated that water temperature varies during usage and should be 120 F at the beginning of dishwashing. During a concurrent record review, a poster issued by the manufacturer of the dishwashing machine placed on the wall facing where DA1 was working indicated It is recommended…
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 · E2026-02-20 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure annual skills competency assessments for four of seven sampled nursing staff (Licensed Vocational Nurse [LVN] 2, Certified Nursing Assistant [CNA] 2, CNA 3, and CNA 4) as required in their Facility Assessment (a yearly review that identifies the staff, equipment, and resources the facility needs to safely and effectively care of its residents). This deficient practice had the potential to place residents at risk for unmet care needs and care errors related to activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), hand hygiene (the practice of cleaning one's hands-either by washing with soap and water or using an alcohol-based hand sanitizer-to remove dirt, germs, and pathogens, thereby preventing the spread of infections), and measuring vital signs (VS) and intake / output (I/O). Findings: During a review of LVN 2's employee file, the file indicated LVN 2's last competency evaluation was done on 4/16/2024. During a 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 · D2026-02-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of seven residents sampled for pressure injury prevention (Resident 1), who had multiple pressure injuries, received necessary treatment and services consistent with professional standards of practice when Resident 1's low air loss mattress (LAL- a medical support surface that uses a constant flow of air to reduce pressure, heat, and moisture on the skin to help prevent or treat pressure injuries) was set to an incorrect setting. Based on Resident 1's weight of 161 pounds (lbs- a unit of weight), the LAL setting should have been at level 3. During the survey observation, Resident 1's LAL setting was found to be set at level 4. This failure had the potential to cause further worsening of Resident 1's pressure injuries. A misconfigured mattresses that is not aligned with the resident's weight may also compromise the resident's stability while in bed, increasing the risk of accidents or injury. During a review of Resident 1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-20 · 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, and record review, the facility failed to provide appropriate treatment and services to prevent complications (unexpected problems that may arise during treatment) of enteral feedings (liquid nutrition through a flexible tube that goes in directly into the stomach) for two of three sampled residents ( Residents 36 and 25) who was observed receiving enteral feeding continuously with head of bed (HOB) less than 30 degrees in accordance with the facility's policy and procedure titled Enteral Feedings - Safety Precautions This deficient practice had the potential to result in vomiting and/or aspiration pneumonia (severe lung infection) that could negatively affect Resident 36 and 25 qualities of life. Findings: 1. During review of Resident 36's admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included attention to gastrostomy (G-tube-a surgically placed device used to give direct access to the stomach for supplemental feeding),…
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 before2026-02-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 don (put on) an isolation gown (designed to protect healthcare workers from blood, bodily fluids, and contaminants by covering the torso, arms, and back) when providing care for one of one sampled residents (Resident 7) who was placed on Enhanced Barrier Precautions (EBP-an infection prevention and control intervention to reduce the spread multidrug resistant organisms [MDRO- disease causing organism resistant to medication used to treat infection]) due to the resident having a Sacro coccyx (near the lower back and spine) wound. This deficient practice had the potential to result in Resident 7 acquiring MDROs and/or spreading MDROs to other residents in the facility which could result in wide spread infection in the facility affecting their health and quality of life. Findings: During review of Resident 7's admission Record indicated Resident 7 was originally 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 before2025-09-17 · 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 and record review the facility failed to develop a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for one of two sampled residents (Resident 1) reviewed for anticoagulant (a medicine that prevented blood clots from forming in the bloodstream) and antiplatelet (a type of medicine that prevented platelets [a type of blood cell] from sticking together and forming a blood clot) medication by failing to implement a care plan for apixaban (also known as Eliquis, a type of medicine known as a blood thinner) and clopidogrel bisulfate (also known as Plavix, a medicine that prevented blood clots by making your blood cells [platelets] less sticky). These deficient practices had the potential for a lack of individualized care and to affect the quality of services provided to Resident 1.During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included…
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 before2025-01-24 · 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
Based on observation, interview, and record review, the facility failed to assess, monitor, intervene and evaluate care of two out of three sampled residents (Residents 28 and 31) by failing to: 1.Ensure Resident 28's wound on the left eye was identified and assessed by facility to ensure resident received timely and appropriate care for behavior of self -inflicted wound and scratching under the left eye. 2. Ensure Resident 31's daily episodes of emesis (vomit) where documented, assessed for the root cause, monitored and reported to the primary physician. As a result of these deficient practices, Resident 28 could develop worsened skin and wound infection and severe pain. For Resident 31 frequent vomiting could result in dehydration (significant fluid loss in the body) and electrolytes (essential minerals in the body for the cells to function) loss that leads to and organ failures. Findings: 1. A review of Resident 31's admission Record indicated the facility admitted the resident on 8/27/2021, with diagnoses that included gastro- esophageal reflux disease (Acid reflux, a condition…
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 · D2025-01-24 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 19) had an informed consent (the voluntary agreement of a resident or a resident's representative to accept a treatment or procedure after receiving information regarding risks and benefits of the treatment) prior to treatment of Amitriptyline (a medication used to treat depression [severe feeling of sadness and hopelessness] and neuropathic [damaged nerves] pain in adults). This failure violated the residents rights of Resident 19 or representative to make an informed decision about the treatments of Amitriptyline and its side effects such as increased agitation, irritability and worsened depression of the medication and any alternative treatments available. Findings: During a review of Resident 19's admission Record (Face Sheet), dated 1/23/2025, the face sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including polyneuropathy (damage to many…
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 before2025-01-24 · 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 record review, the facility failed to ensure two of eight sampled residents (Residents 15 and 195) had a call light device (a device used to call for assistance) within reach. This failure had the potential to result in Residents 15 and 195 being unable to call for assistance when needed and not receive immediate care in the an emergency that could lead to falls, accidents and injury. Findings: a. During a review of Resident 15 ' s admission Record (Face Sheet) dated 1/23/2025 , the face sheet indicated the facility admitted Resident 15 on 11/20/2019 with diagnoses including rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of left knee, and tear of meniscus (crescent shaped bands of thick, rubbery cartilage attached to the shinbone that act as shock absorbers and stabilize the knee) of the left…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-24 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to notify the primary physician of the signitficant change of condition for 1 of 3 sampled residents (Resident 31) who had daily episodes of vomiting for unknown period of time. This deficient practice resulted in the resident's delay in treatment and monitoring to prevent fluid loss, discomfort and weight loss. Findings: A review of Resident 31's admission Record indicated the facility admitted the resident on 8/27/2021, with diagnoses that included Gastro- esophageal reflux disease (Acid reflux, a condition where stomach acid flows back up into the esophagus), intervertebral disc degeneration (spine loses ability to cushion the vertebrae) and kidney disease. A review of Resident 31's Minimum Data Set (MDS- A comprehensive assessment and screening tool) Dated 12/1/2024, indicated Resident 31 had severely impaired cognition (a mental process that take place in in the brain, including thinking, attention, language, learning, memory, and perception) and required maximal assistance with activities of daily living. During a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · Dcited before2025-01-24 · 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 and record review, the facility failed to develop a resident specific comprehensive care plan that reflected the resident's current needs and health status for two out of eight sampled residents (Residents 6 and 39) by failing to ensure: 1. Resident 6's care plan for her weight loss had no measurable objectives and time frames such as the target weights for the resident. 2. Resident 39 did not have a care plan to address the care and monitoring of the resident ' s intravenous (IV- a thin, flexible tube that is inserted into a vein) insertion site. This deficient practice placed Resident 6 at risk for further weight loss. For Resident 39, the resident had the potential to be at risk of complications associated with IV insertion such as bleeding, infiltration (leakage of fluid from the vein to the surrounding tissue causing pain and swollenness) and infection. Findings: 1. A review of Resident 6's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that…
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 before2025-01-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to ensure 1 of 3 sampled residents (Resident 28) was provided care and services to maintain good grooming and personal hygiene by ensuring the resident's nail was free of dirt. This deficient practice had potential to lead to skin infection and poor body image from having dirt underneath nails. Findings: A review of Resident 28's admission record indicated the facility admitted the resident on 9/8/2020, with diagnosis that included malignant neoplasm of brain (fast growing Brain Tumor), acute respiratory failure (sudden condition that makes it difficult to breathe on your own), paralysis of vocal cords and larynx (unable to speak, swallow, or breath on own). A review of Resident 28's History and Physical (H&P), undated, indicated the resident was alert and oriented to person, place, time. A review of Resident 28's Minimum Data Sheet ( MDS, a standard assessment tool that measures health status), dated 12/14/2024, indicated the resident ' s cognition ( a mental process related to thinking, attention, language,…
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 · D2025-01-24 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the intravenous (IV- a thin, flexible tube that is inserted into a vein) catheter dressing was labeled with the date and time on when the IV dressing was changed, and the name or initial of the staff who changed the dressing. This deficient practice placed Resident 39 at risk of complications associated with IV insertion such as infection that can travel to the blood and result in sepsis (a severe life-threatening infection in the blood). Findings: A review of Resident 39 ' s admission Record indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included surgical amputation (surgical removal of a body part), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). A review of Resident 39 ' s History and Physical (H&P), dated 12/29/2024, indicated 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 · D2024-09-09 · 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 record review, the facility did not ensure medical records are accurately documented for one of three sampled residents (Resident 1), the time of incident and vital signs recorded on Resident 1 ' s progress note (a type of documentation that is used to track and document patient's progress throughout treatment) and vital signs sheet (reflect essential body functions, including your heartbeat, breathing rate, temperature, and blood pressure) were not accurately documented per facility ' s policy. This deficient practice had the potential in miscommunication, provided inaccurate information affect to delivery of care and possible leading to the cause of death. Findings: A review of Resident 1 ' s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to respiratory failure (a condition in which the lungs have a hard time loading the blood with oxygen and result in difficulty breathing),…
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 · E2024-01-25 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure one of one outdoor refuse container (a waste container that a person controls that includes dumpsters, trash cans, garbage pails, and plastic trash bags) was closed with a tight-fitting lid and kept covered in accordance with the facility's policy and procedure titled, Food Related Garbage and Refuse Disposal. This failure had the potential to attract insects and harborage of pests in the refuse area that can cause a wide spread of diseases and affect the residents, staff, and visitors. Findings: During an observation on January 23, 2024, at 9:00 a.m., in the presence of the Dietary Supervisor (DS) at the facilities parking lot, the outdoor refuse container was observed with no tight fitting/secured lid. During an interview on January 23, 2024, at 9:20 a.m. with the DS, she stated the dumpster container is supposed to be covered. During a review of the facility's policy and procedure titled, Food- Related Garbage and Refuse Disposal dated 2021 (revised October 2017), indicated, all garbage and refuse…
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 before2024-01-25 · 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 interview, and record review, the facility failed implement the facility's policy and procedure on infection control to prevent spread of infection by failing to: 1. Ensure the facility monitors the water system for Legionella (bacteria most found in water, including groundwater, fresh and marine surface waters that causes severe pneumonia [severe infection in the lungs]. Legionella is transmitted through breathing in Legionella-contaminated, aerosolized [the form of a fine spray] water and is also possible from breathing in Legionella contaminated soil or while drinking water) as evidenced by not conducting water testing for Legionella. 2. Ensure the staff was wearing the correct personal protective equipment (PPE- gown, mask and gloves) before entering a contact isolation (diseases spread by direct or indirect contact) precaution room for one of one sampled resident (Resident 34). This deficient practice had the potential to result in the infection (a process when a microorganism, such as bacteria,…
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 before2024-01-25 · 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
Based on observation, interview, and record review, the facility failed to ensure a resident's call light device (an alerting device for nurses or other nursing personnel to assist a patient when in need) was maintained within easy reach for one of one sampled resident (Resident 344), in accordance with the resident's care plan. This failure resulted in Resident 344 not being able to ask for staff assistance on 1/22/2024. A potential for further decline in the resident's activities for daily living, self-esteem, and self-worth. Findings: A review of Resident 344's admission Record indicated Resident 344 was admitted to the facility on 1/10/ 2024, with diagnoses that included history of fall, fracture of sacrum (occurs when a bone called the sacrum breaks), anxiety disorder (persistent and excessive worry that interferes with daily activities), and Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) During a review of Resident 344's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated…
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 · D2024-01-25 · 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
Based on observation, interview and record review, the facility failed to ensure one of three sampled resident (Resident 28) or his/her representative was assisted to formulate an Advance Healthcare Directives (AD-a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) upon admission to the facility, and the AD was maintained in the resident's clinical records at all times. This deficient practice had the potential to cause conflict with Resident 28's wishes regarding health care treatment especially in an event of emergency. Findings: During a review of Resident 28's admission Record indicated the facility admitted Resident 28 on 8/27/21 with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and hypertension (high blood pressure). During a review of Resident 28's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/2/23,…
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 before2024-01-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary services in activities of daily living (ADL) to maintain good personal hygiene by ensuring the toenails were not thick and discolored and the fingernails were trimmed for one of two sampled residents (Resident 21) who had long untrimmed fingernails and toenails. This deficient practice had the potential for Resident 21 not to receive necessary services to maintain and achieve their highest potential and wellbeing. Findings: 1. A review of Resident 21's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses frailty (the condition of being weak and delicate), diabetes mellitus (high blood sugar) and chronic obstructive pulmonary disease (COPD-an inflammatory lung disease that causes obstructed airflow from the lungs and difficulty breathing). A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), date 10/23/2023,…
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 before2024-01-25 · 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 record review, the facility failed to coordinate and communicate the care services of one of two sampled residents (Resident 6) with the hospice (an end-of-life care with focus on the resident's quality of life) staff as indicated in the facility's policy and procedure for hospice care titled, Hospice and Nursing Facility Services Agreement, This deficient practice had the potential to negatively affect the resident's psychosocial and physical well-being and/or delay the delivery of hospice care services to Resident 6. Findings: During a review of Resident 6's admission record indicated, Resident 6 was initially admitted to the facility on [DATE], and admitted to the hospice care and services on 8/15/2023, with diagnoses that included hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild loss of strength in a leg, arm, or face) following unspecified cerebrovascular disease (a group of conditions that affect blood flow…
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 before2024-01-25 · 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 and record review, the facility failed to ensure one of three sampled residents (Resident 24) receiving gastrostomy tube feeding (nutrition through gastrostomy tube feeding tube [GT-a flexible tube surgical inserted through abdomen into the stomach for feeding, fluid, and medication administration] was being fed continuously in accordance with the resident's physician's orders. This deficient practice had the potential to result in altered nutritional status resulting from inconsistent caloric intake and loss of weight to the resident. Findings: A review of Resident 24's face sheet (admission Record) indication the resident was admitted to the facility on [DATE], with diagnoses that included but not limited to dysphagia (difficulty swallowing), oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). A review of Resident 24's Minimum Data Set (MDS - an assessment and care screening tool) dated November 16, 2023, indicated the resident's cognitive ability…
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 · D2024-01-25 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide medically related social services to one of 2 sampled residents (Resident 21) by failing to follow the physician's order to provide podiatrist service (a physician specialized in foot care and foot diseases) for the foot care with long, thick discolored nails to Resident 21. This deficient practice resulted for Resident 21 not to have the toenails trimmed to prevent accidental injury and infection. Findings: A review of Resident 21's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses frailty (weak and delicate), diabetes mellitus (high blood sugar) and chronic obstructive pulmonary disease (COPD-an inflammatory lung disease that causes obstructed airflow from the lungs and difficulty breathing). A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), date 10/23/2023, indicated Resident 21's cognitive skills (ability to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate dispensing, and administering of all drugs and biologicals) to meet the needs of each resident by failing to destroy expired Lorazepam ( a medication used to treat anxiety [the fear of the unknown]) for one of one sampled resident (Resident 6). The deficient practice had the potential for medication diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) and unauthorized release of residents' personal information. Findings: During a review of Resident 6's admission record, it indicated Resident 6 was initially admitted on [DATE], she then admitted to the hospice on 8/15/2023 with diagnoses of, but not limited to, hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild loss of strength in a leg, arm, or face) following unspecified…
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 CAMBRIDGE HEALTHCARE SERVICES — 32 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 | 2.5 | +1.5 vs chain |
| Health inspection | 4 of 5 | 2.4 | +1.6 vs chain |
| Staffing | 3 of 5 | 3.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 4.0 | ≈ chain avg |
The other 31 homes this chain runs (chain average 2.5★, 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 |
|---|---|---|---|---|
| WIN WIN ENTERPRISES, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 45% | since 03/25/2003 |
| ANDERSON, TIFFANY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/09/2020 |
| MOORE, AMANDA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/08/2023 |
| SMEDRA, IRA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/05/2003 |
| WINTNER, JACOB | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/25/2003 |
| CAMBRIDGE HEALTHCARE SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/27/2025 |
| PROFESSIONAL DIRECTIONS FOR HEALTH CARE | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/23/2013 |
| BUTENKO, JULIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/24/2023 |
| CAPELA, HEIDI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/03/2023 |
| HANNA, LAILA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/13/2014 |
| HASSELL, LANCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | — | since 04/25/2022 |
| LUTZ, LINDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2012 |
| MARQUEZ, FE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/11/2023 |
| SALAZAR, PAULINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/14/2020 |
| 1208 SOUTH CENTRAL AVE., LLC | Organization | ADP OF THE SNF | — | since 04/01/2003 |
| BH ALLIANCE | Organization | ADP OF THE SNF | — | since 04/01/2003 |
CMS files one row per role, so the 35 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $606K 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 555609. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-20, 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.