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Grass Valley Healthcare Center

355 Joerschke Dr, Grass Valley, CA 95945 · For profit - Limited Liability company · 86 certified beds · (530) 273-7247 Medicare & Medicaid certified

Call the home — (530) 273-7247 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609) — most recent Oct 2019Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • 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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
670 Sutton Way · (530) 273-6000 · Call to confirm hours
Pharmacy
Rite Aid0.4 mi
720 Sutton Way · (530) 273-7399 · Call to confirm hours
Grocery
616 Sutton Way · (530) 477-6961 · Call to confirm hours
Park
110 Spring Hill Dr · (530) 272-3735 · Typically dawn to dusk

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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 fell from 5 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.6%10.2%15.4%better
Long-stay residents who lose too much weight3.6%4.0%5.4%better
Long-stay residents with a catheter left in their bladder1.1%0.8%0.9%worse
Long-stay residents with a urinary tract infection1.7%1.2%2.0%better
Long-stay residents with depressive symptoms2.7%7.3%6.5%better
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.3%1.6%3.3%better than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened10.0%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.5%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers4.6%4.3%4.7%typical
Long-stay residents with worsening bladder/bowel control13.4%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 table11.3%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.1%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine97.3%93.2%79.4%better
Short-stay residents rehospitalized after admission24.1%23.0%22.6%typical
Short-stay residents with an outpatient ER visit20.8%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.272.251.67better
Long-stay outpatient ER visits per 1,000 resident days1.931.571.80typical

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.

53.3% 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 205 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.3%U.S. median 51.5%
Got home and stayed home
9.3%U.S. median 10.7%
Went back to hospital
60.5%U.S. median 56.6%
Met the expected recovery
0.69U.S. median 0.31
Therapy hours / resident / day
0.37hours / resident / day
Physical therapy
0.27hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 60.5% 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 147 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 0.69 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF53.3%CMS range 48.9–61.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.3%CMS range 6.9–12.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge60.5%56.6%Oct 2024–Sep 2025CMS 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 discharge75.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge54.4%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting97.1%100.0%Oct 2024–Sep 2025CMS 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 discharge90.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.2%CMS range 3.3–10.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.671.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.42
RN hours/ resident / day
1.26
LPN hours/ resident / day
2.70
Aide hours/ resident / day
4.37
Total nurse hours/ resident / day
0.28
RN hoursweekends
40.9%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 86 beds and averages 83.3 residents a day — about 97% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. 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 4.37 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 2.70 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.89 hrs/resident/day on weekends vs 4.56 on weekdays — 15% thinner on weekends. RN hours go from 0.47 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.

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

10
deficiencies at the latest standard inspection (2025-09-25)
5
at the previous standard inspection (2023-06-09)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · G2025-11-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to provide appropriate and adequate supervision to prevent an avoidable accident when one of three sampled residents (Resident 1) left the facility without the facility's knowledge and supervision.This failure resulted in Resident 1 experiencing falls outside the facility, leading to multiple abrasions on the hands and knee and increased the risk of cold exposure and potential injury from passing motor vehicles. Findings: Resident 1 was admitted to the facility in the fall of 2025 with diagnoses which included traumatic brain injury (an injury to the brain caused by a sudden bump, or jolt to the head, which can disrupt its normal function), muscle weakness, and difficulty walking. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/6/25, the MDS indicated Resident 1 had moderate impairment of his memory and was independent with most activities of daily living (ADLs). During a review of Resident 1's document titled FALL RISK EVAL [FRE, fall risk evaluation], dated 10/30/25, the FRE indicated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to store items in a sanitary manner for two of six sampled residents (Resident 1 and Resident 2) when used urinals were stored uncovered in a drawer that contained the residents' personal items.This failure increased the risk of contamination and infection for the residents.Findings:Resident 1 admitted to the facility in late 2025 with diagnoses which included urinary tract infection and weakness.Resident 2 admitted to the facility in mid 2024 with diagnoses which included urinary tract infection and bacteria in the bloodstream.During an interview on 12/30/25 at 12:53 p.m. with Certified Nursing Assistant (CNA1), CNA 1 stated urinals should be stored in a drawer without other items.During a concurrent observation and interview on 12/30/25 at 1:28 p.m. with the Infection Preventionist (IP) of Resident 1's closet, Resident 1's bottom drawer of the closet contained an uncovered urinal, a clear drinking cup which held an uncovered toothbrush, and a bottle of cologne. The IP confirmed the findings and stated 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-25 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    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 one out of 24 sampled resident (Resident 17) was provided with an ongoing activity program that meets psychosocial needs (a combination of mental health, emotional, spiritual, or behavioral needs that are important to a person) when Resident 17's frequency of ongoing activity program visit was followed.These failures had the potential for Resident 17 to not achieve her highest mental, emotional, spiritual, and psychosocial well-being.Findings:A review of Resident 17's clinical record indicated Resident 17 was admitted February of 2018 and had diagnoses that included dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), skin cancer, and muscle weakness.A review of Resident 17's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 9/16/25, indicated Resident 17…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-25 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure the menu was followed for therapeutic diets (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during the lunch meals on 9/22/25 and 9/23/25 when:1. Two residents (Resident 19 and 77) with CCHO (controlled carbohydrate) diets (a therapeutic diet to manage diabetic disease and/or to stabilize blood sugar level) received one slice of garlic bread instead of one half (1/2) slice.2. 22 residents (Resident 3, 5, 16, 22, 28, 32, 37, 38, 40, 47, 50, 62, 63, 65, 66, 67, 70, 74, 77, 81, and 96) with fortified diets (a dietary pattern that includes foods that have been enriched with additional nutrients, such as calories and protein) did not get the fortified foods.3. Two residents (Resident 26 and 44) with puree (a very smooth, crushed or blended food usually for people with swallowing and/or chewing difficulties) diet received mashed potatoes and did not get the pureed red beans…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service safety when:1. The ice machine was not clean; and2. The arrangement of the food stored in the freezer was not in a food safety manner; and3. Items found in the clean and ready-to-use storage areas: A few metal sheet pans were stored and stacked wet; and The metal sheet pans, food processor and metal strainers were found with brown substances; and4. Three dietary staff did not wear hair restraint and beard restraint appropriately; and5. Three dietary staff did not practice hand hygiene between soiled and clean dishes during the dishwashing process; and6. The metal coating of the can opener blade was worn off These failures had the potential to result in food contamination which could cause illness for 80 residents who received food prepared from the facility kitchen. Finding: 1. During an concurrent observation and interview on 9/22/25 at 11:06 a.m. with Dietary Supervisor (DS) 1, DS 1 stated 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-25 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 80 residents when:1. Enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use) was not implemented to Resident 5 and Resident 63;2. A facility staff did not wear required personal protective equipment (PPE) when performing resident care on Resident 56 who was on EBP; and,3. Facility staff entered a contact precaution room (an infection control measure used in healthcare settings to prevent the spread of infectious agents that can be transmitted by direct or indirect contact with a patient or their environment) without using all the required PPE.These failures resulted in an increased risk for cross-contamination (movement…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure physician orders were followed in accordance with professional standards of care for one out of 24 sampled residents (Resident 3), when Resident 3 did not receive treatments as ordered by the physician. This failure had the potential for Resident 3's wounds to not heal, put them at risk for further skin breakdown and not achieve their highest practicable well-being. Resident 3 was originally admitted to the facility in September 2024 with multiple diagnosis which included type 2 diabetes mellitus (condition where the body either doesn't produce enough insulin or doesn't respond properly to the insulin) with foot ulcer (open sore on the foot) and cellulitis (bacterial infection of the deeper layers of the skin) of right lower limb. A review of Resident 3's Minimum Data Set (MDS, an assessment tool) signed 8/21/25, indicated, Resident 3 was cognitively intact. A review of Resident 3's Order Summary Report, with start date 9/11/25, indicated, Tx [treatment]: Left medial [middle] ankle wound: cleanse with NS [normal…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure one out of 24 sampled residents (Resident 56) received treatment and care in accordance with professional standards of practice, and facility's policy, procedure (P&P), and care plan when Resident 56's foley catheter (a thin, flexible tube inserted into the bladder to drain urine) care and butterfly strap (a small, adhesive device designed to secure the catheter tubing to the skin, preventing accidental removal and reducing patient discomfort) monitoring was not done consistently.This failure had the potential for Resident 56 to develop infection and possible foley catheter dislodgement (removal) and/or other complications.Findings:A review of Resident 56's clinical record indicated Resident 56 was admitted June of 2025 and had diagnoses that included neuromuscular dysfunction of the bladder (a condition where the nerves or muscles that control bladder function are impaired, leading to abnormal bladder control), and left thigh fracture (a break in the continuity of a bone).A review of Resident 56's Minimum Data Set…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure safe and proper delivery of respiratory care consistent with the facility's policy and procedures (P&P) for one out of 24 sampled residents (Resident 11) when Resident 11's oxygen saturation (percentage of oxygen carried in the blood) was not consistently monitored.This failure had the potential to result in Resident 11 developing respiratory issues without staff knowledge and for Resident 11 to not achieve her highest practicable well-being.Findings:A review of Resident 11's clinical record indicated Resident 11 was admitted January of 2024 and had diagnoses that included chronic obstructive pulmonary disease (a group of diseases that causes airflow blockage and breathing-related problems), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently).A review of Resident 11's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 7/7/25, indicated Resident 11 had a Brief Interview for Mental Status (BIMS- a tool…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-25 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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 one out of 24 sampled residents (Resident 56) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 56's pain medication order was not consistently followed.This failure had the potential for Resident 56 to experience unrelieved pain and not attain her highest practicable well-being.Findings:A review of Resident 56's clinical record indicated Resident 56 was admitted June of 2025 and had diagnoses that included left thigh fracture (a break in the continuity of a bone), and cardiomyopathy (a group of heart muscle diseases that weaken or thicken the heart muscle, making it difficult for the heart to pump blood effectively).A review of Resident 56's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 9/9/25, indicated Resident 56 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 9 out of 15 which indicated Resident 56 had a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-25 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for each 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 ensure dental services were provided in accordance with professional standards of care for one out of 24 sampled residents (Resident 7), when facility staff did not assist Resident 7 in obtaining a dental appointment as physician ordered. This failure had the potential for Resident 7 to experience unnecessary pain and an increased risk for infection. Resident 7 was originally admitted to the facility in August 2024 with multiple diagnosis which included bacteremia (bacteria in the blood), depression (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities) and anemia (low levels of healthy red blood cells). A review of Resident 7's Minimum Data Set (MDS, an assessment tool) signed 6/27/25, indicated, Resident 7 had severe cognitive impairment. A review of Resident 7's Order Summary Report, with start date 7/30/25, indicated, Dental referral for dental pain.During a concurrent interview and record review on 9/24/25, at 3:21 p.m., with the Social Services…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2025-09-25 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 special dietary requirements were met for two of 80 residents (Resident 22 and 42) during lunch meal observation on 9/22/25. This deficient practice had the potential to result in meal dissatisfaction and decreasing meal intake that may lead to further compromising medical and nutrition status and/or weight loss of residents. Finding:During an observation of the lunch meal in the dining room on 9/22/25 at 11:57 a.m. with a concurrent review of Resident 22's and Resident 42's meal tickets (a ticket including resident's diet, date, allergies, specific food and beverage items, dislikes, and likes) the following was noted:1. Resident 22's meal ticket indicated, .8 ounces (oz., a unit of fluid volume) of vegetable juice. was one of Resident 22's food preferences but did not receive the vegetable juice with his meal.2. Resident 42's meal ticket indicated, no pepper, no non-salt seasoning but Resident 42 received the pepper and non-salt seasoning packets with her meal.During an interview on 9/22/25 at 12:07…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-07-30 · tag F0697 — failed to manage pain — pattern
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their pain management policies and procedures (P&P) for three out of three residents (Residents 1, 2, and 3) when: 1. Resident 1 had high PRN (as needed and must be asked for) pain medication usage for eight months prior to evaluating the need to change the current pain medication regimen. 2.The facility failed to determine if Resident 1's behavior of screaming was caused by pain, anxiety, or related to a diagnosis of dementia. 3a. Non-pharmacological interventions (any health intervention that was used to assist with managing chronic pain and did not involve the use of medication. Examples included but were not limited to distraction, music, re-positioning, stretching, or activities) were not implemented or monitored for effectiveness for Resident 1. 3b. Non-pharmacological interventions were not implemented or monitored for effectiveness for Resident 2. 3c. Non-pharmacological interventions were not implemented or monitored for effectiveness…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-30 · tag F0551 — isolated
    Give the resident's representative the ability to exercise the resident's rights.
    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 that Resident 1's rights were protected when:1. Licensed Nurse (LN) B administered a PPD test (purified protein derivative, injected under the skin to determine if a person had tuberculosis, a contagious bacterium that had the potential to cause death) after Resident 1's responsible party (RP, decision maker) had declined administration of the PPD test. 2. The facility provided medication to Resident 1 based on the RP's decisions rather than assessment data and concerns regarding Resident 1's appearance of being sedated. These failures violated Resident 1's rights. Findings: 1. A review of the Resident [NAME] of Rights, dated 12/1/12, indicated, residents had the right to refuse any treatment or procedure. A review of the facility's policies and procedures (P&P) titled, Requesting, Refusing, and/or Discontinuing Care or Treatment, revised 2/1/21, indicated, the resident and or the residents RP had the right to refuse treatment. A 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-30 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policies and procedures (P&P) regarding medication administration documentation for one out of three sampled residents (Resident 1) when Licensed Nurse (LN) B initialed the medication administration record (MAR) for a medication that LN A prepared and administered to Resident 1. This caused inaccurate documentation and had the potential to negatively impact resident safety.Findings: A review of the facility's P&P titled, Administering Medications, revised 4/1/19, indicated, The individual administering the medication initials the residents MAR on the appropriate line after giving each medication and before administering the next dose. A review of the Client Resident Profile, dated 8/5/24, indicated, Resident 1 was admitted to the facility on [DATE] and Resident 1 was not her own responsible party (RP, decision maker). A review of the Medical Diagnosis, dated 8/5/24, indicated, Resident 1 was admitted to the facility with the diagnoses 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices when facility staff disinfected the Hoyer lift (mechanical device used to safely transfer residents from one place to another) in the hallway, did not wear gloves, or perform hand hygiene (washing hands or using alcohol-based hand sanitizer) afterwards. This failure had the potential to spread infections to other residents, facility staff, and visitors.Findings: A review of the facility's policies and procedures, (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 9/1/22, indicated, facility staff would clean and disinfect medical equipment in-between resident use. A review of the facility's P&P titled, Personal Protective Equipment (PPE, items worn to prevent the spread of infection such as gowns or gloves), revised 10/1/18, indicated, PPE requirements were specific to job requirements and facility staff would wear the appropriate PPE for specific tasks. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-06-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to: 1. Label/date and dispose of specific food in accordance with the professional standards for food service safety 2. Have dietary staff follow hygienic practices in the facility's kitchen 3. Have accurate values and documentation for the dish machine chemical solutions. These failures resulted in the potential to result in putting residents at risk for food borne illnesses (illness caused by consuming contaminated foods or beverages). Findings: 1. During a concurrent observation and interview on 06/06/2023 at 10:03 AM, with Dietary Aide C (DA C) and the Dietary Manager (DM), it was observed in the refrigerator in the facility kitchen that there was a clear, plastic container with a green lid labeled, Egg, with a date of 06/01/2023, with approximately six eggs inside of the container. Another clear, plastic container with a green lid labeled, Turkey, with a date of 06/01/2023 was identified in the facility kitchen refrigerator, and was acknowledged as a turkey sandwich by DA C. It was confirmed by DA C and DM…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-09 · tag F0940 — failed to train staff — pattern
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    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 develop, implement, and maintain an effective training program for all new and existing staff with documentation that dietary staff had been provided appropriate competencies and trainings. This failure had the potential to result in dietary staff providing inadequate and potentially harmful services that could result in foodborne illnesses (illness caused by consuming contaminated foods or beverages). Findings: During concurrent observation and record review of a document titled, Dish Machine Temperature Log, dated June 2023, on 06/06/2023 at 9:46 AM, the test strip values for chlorine (a chemical used to sanitize the dishware) were 200 ppm (parts per million, a unit of concentration) for each breakfast with the dates 06/01/2023 to 06/06/2023. The test strip values for chlorine were 200 ppm on 06/01/2023 and 150 ppm on 06/02/2023 for lunch. The test strip values for chlorine were 150 ppm on 06/01/2023 and 200 ppm on 06/02/2023 and 06/03/2023. During a review of the facility's document titled, Dish Machine…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 one of four sampled residents (Resident 43) was free of unnecessary psychotropic medication (drug prescribed to affect the mind, emotions or behavior) when Resident received clonazepam (a type of medication used to treat anxiety, seizures and panic disorders) on an as needed (PRN) schedule for longer than the 14 day limit without clinical justification. This failure had the potential for adverse effects such as sedation, falls, headaches weight gain, dizziness, nausea and abnormal involuntary movements. Findings: Review of Resident 43's record indicated they were admitted to the facility with diagnosis including anxiety disorder, encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition) ,Type 2 diabetes mellitus and syncope (fainting or passing out and falling down). Resident 43's Physician Orders dated 08/07/22, included an order for clonazepam 1 mg by mouth as needed for anxiety manifested by verbally expressed every evening. Clonazepam was discontinued on 09/13/2022…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-09 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure safe medication storage practices in one of four medication carts (Med Cart, a locked mobile cart used to store medications and supplies) when undated multidose prescription medication was stored and available for use. These failed practices could contribute to unsafe medication storage and administration of outdated and ineffective medications. Findings: Record review indicated Resident 43 was admitted to the facility on [DATE], with diagnoses included Type 2 diabetes mellitus ( a disease in which the body is unable to regulate the blood sugar levels) and anxiety disorder. During a concurrent observation and interview on 6/7/23 at 10:58 AM, Licensed Vocational Nurse (LVN B) removed an insulin pen, Tresiba Flextouch 100 (a device resembling a pen used to administer insulin used to treat diabetes), for Resident 43 from med cart on Hall 4. The insulin pen did not have a date written on the date opened label on the medication. LVN B…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-09 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 the physician ordered diet for one of eighteen sampled residents, (Resident 24) when the Fortified Regular, finger foods, small portions diet was not followed. This failure had the potential to cause negative clinical outcomes including weight loss, and the inability to eat independently due to a severe cognitive impairment. Findings: A policy revised October 2017, titled Therapeutic Diets, indicated therapeutic diets are prescribed by the attending physicians to support the residents' treatment and plan of care and in accordance with his or her goals and preferences. This policy indicated the diet order should match the terminology used by the food and nutrition services department. The dietician, nursing staff, and attending physician will regularly review the need for, and resident acceptance of prescribed therapeutic diets. A review of medical records indicated Resident 24 was admitted to the facility on [DATE] with diagnoses…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-11 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 interviews, record reviews, and review of the facility's policy, the facility failed to implement their policy and identify an allegation of resident to resident abuse for six residents (Resident (R) 43, R61, R44, R47, R20 and R63) out of a survey sample of 17 residents. Specifically, the facility failed to report allegations of resident to resident physical abuse, within 24 hours, to the State Agency (SA) as federally mandated. The failure to recognize abuse and immediately implement the facility's abuse prohibition policy had the potential to adversely affect all 69 resident's residing in the facility at the time of the survey. Findings include: 1. A review of R43's admission Record revealed the resident was admitted to the facility on [DATE], with a diagnosis of cerebral vascular disease. A review of R43's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 09/01/19, revealed the resident had a Brief Interview for Mental Status (BIMS) of 12 out of 15, which…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-11 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, the facility failed to ensure all allegations of suspected abuse were reported immediately, but not later than 24 hours after the allegation was made, for resident to resident altercations which involved six residents (Resident (R) 43, R61, R44, R47, R20 and R63). This failure had the potential to impede the safety and protection of the facility's residents. Findings include: Review of the facility policy titled, Abuse Investigation and Reporting dated as revised 07/17, revealed, .All alleged violations involving abuse.will be reported by the facility Administrator, or-his/her designee immediately, and to the following persons or agencies as required by law or regulation.The State licensing/certification agency responsible for surveying/licensing the facility. Record reviews during the survey process revealed six Residents were involved in incidents of potential resident to resident abuse that were not reported to the state survey agency as required. Please refer to F607 for…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CYPRESS HEALTHCARE GROUP — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.8-0.8 vs chain
Health inspection 3 of 52.9+0.1 vs chain
Staffing 4 of 54.0≈ chain avg
Quality measures 4 of 54.8-0.8 vs chain
The other 12 homes this chain runs (chain average 3.8★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
JACKSON, MATTHEWIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 06/24/2026
JACKSON, ROBERTIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024
SANOFSKY, JACKIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 06/24/2026
GILL, KULDIPIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024
WEBSTER, MATTHEWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/30/2024

CMS files one row per role, so the 11 rows in the source record cover these 5 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.

$7.7M
Net patient revenuemost recent cost report
-8.2%
Operating marginrevenue minus expenses
$736K
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 77%Medicare 14%Other / private 10%

About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $736K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$443per resident / day
operating cost
$13,472per month
≈ monthly operating cost
$409per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 055640. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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