No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Wolf Creek Care Center

107 Catherine Ln., Grass Valley, CA 95945 · For profit - Limited Liability company · 59 certified beds · (530) 273-4447 Medicare & Medicaid certified

Call the home — (530) 273-4447 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Oct 2023Behavioral-health or dementia-care citation — no harm found (F0744)1 actual-harm citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2023
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
152 Catherine Ln Ste E · (888) 966-2398 · Call to confirm hours
Pharmacy
640 E Main St · (530) 274-0100 · Call to confirm hours
Grocery
290 Sierra College Dr · (530) 272-5333 · Call to confirm hours
Park
250 Sierra College Dr · Typically dawn to dusk
Place of worship
154 Hughes Rd · (530) 273-6425

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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.

Overall rating4★
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 increased6.2%10.2%15.4%better
Long-stay residents who lose too much weight0.8%4.0%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms5.1%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 injury2.8%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents whose ability to walk worsened11.4%9.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication6.1%13.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers4.7%4.3%4.7%typical
Long-stay residents with worsening bladder/bowel control9.1%10.2%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table13.8%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication1.6%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine97.0%93.2%79.4%better
Short-stay residents rehospitalized after admission19.6%23.0%22.6%better
Short-stay residents with an outpatient ER visit17.1%11.2%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.332.251.67better
Long-stay outpatient ER visits per 1,000 resident days0.591.571.80better

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.

61.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 186 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.5%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
73.3%U.S. median 56.6%
Met the expected recovery
0.55U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.28hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 73.3% 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 105 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 41% 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 SNF61.5%CMS range 54.7–67.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 7.1–14.310.7%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 discharge73.3%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 discharge74.3%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 discharge63.8%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 setting100.0%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 discharge100.0%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 stay0.7%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 worsened1.4%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 hospitalization8.6%CMS range 4.9–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 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

0.47
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.48
Aide hours/ resident / day
3.82
Total nurse hours/ resident / day
0.38
RN hoursweekends
53.7%
Total nursing turnover
62.5%
RN turnover

How full it usually is: this home is certified for 59 beds and averages 54.5 residents a day — about 92% occupied, or roughly 4 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 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 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 3.71 hrs/resident/day on weekends vs 3.86 on weekdays — 4% thinner on weekends. RN hours go from 0.50 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% 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

6
deficiencies at the latest standard inspection (2025-05-22)
8
at the previous standard inspection (2022-11-08)

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.

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · Gcited before2025-12-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident safety for two out of six sampled residents (Resident 1 and Resident 2) when:1. Resident 1 left the facility without staff knowledge and was found at a gas station without her Wander Guard (wearable monitoring device that alerts caregivers when a resident leaves a protected area); and2. Resident 2 had an avoidable fall (unintentional fall that happens because of identifiable and correctable factors) when she was not properly secured during transportation to an appointment.This failure resulted in Resident 1 leaving the facility unsupervised and increased her risk for harm and injury and in Resident 2 sustaining a left femur (lower end of thigh bone) fracture (crack, break, or chip in bone) that required surgery. Findings:1. During a review of Resident 1's admission Record, it indicated, Resident 1 was admitted to the facility November 2025, with multiple diagnoses which included dementia (impaired ability to remember, think, or make…

    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 · D2026-01-28 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to obtain consent for the administration of a Covid Vaccine (vaccine designed to induce immunity against SARS-Co-V-2, virus responsible for coronavirus disease 2019) for one of two sampled residents (Resident 1) when Resident 1 was administered the vaccine after Resident 1's RP's (Responsible Party) declined the vaccine. This failure resulted in Resident 1 to receive a covid vaccine without consent and violated the resident's RP's right to make health care decisions.Findings: Resident 1 was admitted to facility 4/10/13 with diagnoses that included, TBI (Traumatic Brain Injury, a complex injury by sudden external trauma that damages brain tissue), and cognitive deficit (impairment in mental processes including memory, attention, and executive function-that affect ability to learn, reason and make decisions). During an interview on 1/27/26 at 5 p.m. with Resident 1's daughter (RP), the RP stated on 1/27/26 that Resident 1 was not supposed to receive a Covid Vaccination, the chart was marked in big red letters not to vaccinate.…

    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 · D2025-12-08 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 Policy and Procedures (P&P) and ensure professional standards of practice were met for one of six sampled residents (Resident 3) when, Resident 3 was administered medications with possible drug interactions without clarification from the doctor.This failure had the potential to have caused adverse outcomes and worsen Resident 3's condition and decreased the potential to provide safe administration of medication.During a review of Resident 3's clinical record, Resident 3 was admitted [DATE] with diagnosis that included Nontraumatic Intracerebral Hemorrhage (ICH) (bleeding directly into the brain tissue from causes other than injury), Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), Transient Ischemic Attack (temporary blockage of blood flow to the brain), Cerebral Infarction (blood clot blocks an artery supplying the brain, leading to a lack of oxygen and nutrients, causing brain tissue death).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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-05-22 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for a census of 53 residents when the Registered Dietician (RD) and Dietetic Services Supervisor (DSS) were both hired as part time (an employee who is scheduled to work and who does work a schedule of anything under 32 hours per week) employees. This failure had the potential for unsafe food handling and spread of food borne illnesses in a highly susceptible population. Findings: During an interview on 5/19/25 at 9:40 a.m. with the DSS, the DSS stated she was working as a part time employee for the facility and was also working at another facility. The DSS further stated that their RD was also working as part time employee and the Dietetic Services Supervisor in Training (DSSIT) who was not yet licensed, was working as full-time employee. A review of the DSS's employment document titled, New Hire Input Form, dated 9/7/24, indicated the DSS was hired as a part time employee of the facility…

    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 · Fcited before2025-05-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 storage and preparation, and maintenance of food contact surfaces were in accordance with professional standards for food safety for the 53 residents who ate facility prepared meals when: 1. Three out of three small cutting boards had stains, and two out of six large cutting boards had deep scratches; and, 2. A box of garlic bread, a box of fried eggs, and a box of bacon were found with ice crystals built-up, opened and were exposed to air in the freezer. These failures had the potential to put residents at risk for foodborne illnesses. Findings: 1. During a concurrent observation and interview on 5/19/25, within the initial kitchen tour beginning at 8:23 a.m., with the Dietetic Services Supervisor in Training (DSSIT), three out of three small cutting boards were found stained with brownish substance, and two out of six large cutting boards were found with deep scratches. The DSSIT confirmed the observation and stated cutting boards with stains and deep scratches could potentially harbor 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-22 · 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

    Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for one out of 16 sampled residents (Resident 17) when: 1. Resident 17's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) face mask was not changed every seven days and was left uncovered when not in use; and, 2. Resident 17's oxygen nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not changed every seven days. These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure to germs, and may cause infection to Resident 17. Findings: 1. A review of Resident 17's clinical record indicated Resident 17 was admitted April of 2025 and had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems),…

    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 · D2025-05-22 · 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 the facility's policy and procedures as well as professional standards of care for one out of 16 sampled residents (Resident 20), when Resident 20 did not receive insulin (hormone that controls the amount of sugar in the blood) medication within the parameters as ordered by the physician. This failure had the potential for Resident 20 to experience hypoglycemia (condition where the level of sugar in the blood drops below a healthy range) and for the resident to not achieve their highest practicable well-being. Findings: Resident 20 was originally admitted to the facility in September 2022 with multiple diagnoses which included type 2 diabetes mellitus (condition where the body either doesn't produce enough insulin or doesn't respond properly to the insulin). A review of Resident 20's Minimum Data Set (MDS, an assessment tool) dated 3/18/25, indicated, Resident 20 was cognitively intact. During a review of Resident 20's Order Summary Report, dated 5/21/25, Resident 20…

    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 · D2025-05-22 · 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 16 sampled residents (Resident 2) received treatment and care in accordance with professional standards of practice, and facility's policy, procedure (P&P), and care plan when Resident 2's suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen) drainage bag was not positioned below Resident 2's bladder during a wound care treatment. This failure had the potential for Resident 2 to develop infection and possible suprapubic catheter complications. Findings: A review of Resident 2's clinical record indicated Resident 2 was initially admitted September of 2024 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body), urinary tract infection (UTI- an infection in the bladder/urinary tract), and obstructive and reflux uropathy (blockage in the urinary tract that prevents urine from flowing properly causing backflow of urine from the bladder into 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-22 · 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 16 sampled residents (Resident 43) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 43's pain medication orders were not consistently followed. This failure had the potential for Resident 43 to experience over medication, not achieve pain relief, and not attain her highest practicable well-being. Findings: A review of Resident 43's clinical record indicated Resident 43 was admitted April of 2025 and had diagnoses that included infection following a surgical procedure, fracture (a break in the continuity of a bone) of left lower leg, osteomyelitis (a serious infection of the bone), neuropathy (a nerve condition that can cause pain, numbness, tingling, or weakness in the body), and opioid dependence (reliance on a substance found in certain prescription pain medications). A review of Resident 43's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns,…

    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 before2023-12-28 · 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 provide a sanitary environment when one out of three sampled residents, (Resident 1), had oxygen tubing, suctioning tubing and yankhauer (hard tube-like plastic tool which is placed into a person ' s mouth to suction secretions) laying on Resident 1 ' s bedroom floor. This failure had the potential to transmit communicable diseases and infections to Resident 1. Findings: During a review of Resident 1 ' s record titled, admission Record, dated 11/28/2023 indicated Resident 1 was admitted on [DATE]. Resident 1 was admitted with cancer of the major salivary glands (glands located in and around the mouth area), trouble swallowing, muscle weakness and a gastrostomy tube, (tube inserted directly into the stomach used for nutrition when a person cannot eat using their mouth). During a review of Resident 1 ' s record titled, Order Summary Report, indicated Resident 1 had an order for: 1. Oxygen 2 liters via nasal cannula (tube that is connected 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 protect Resident 1 from abuse when Resident 1 was scratched on the face and her hair was pulled by Resident 2. This failure caused a scratch to the left cheek and mild scalp pain for Resident 1, potentially leading to adverse clinical outcomes. Findings: A review of Resident 1's (R1) admission Record, indicated R1 was admitted to the facility on [DATE] with diagnoses including stroke, difficulty speaking and lack of coordination. A test for mental function referred to as a Brief Interview for Mental Status (BIMS) was scored as a12 on 8/03/23, indicating moderate cognitive (ability to think and reason) impairment. A review of Resident 2's (R2) admission Record, indicated R2 was admitted on [DATE] with diagnoses including psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and anxiety disorder. R2 had a BIMS score of 2 on 7/26/23, indicating severe cognitive impairment. A review of R1'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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · E2022-11-08 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to reflect the care needs for four of 14 Residents (Residents 8, 14, 33, and 45) when: 1. A care plan problem and intervention for Hoyer lift (a mechanical lift used to safely transfer residents) use was not listed for Resident 45. This failure resulted in a dislocated right shoulder and pain. 2. A comprehensive care plan was not developed for antipsychotic (medication use to treat behaviors) use for Resident 33. This had the potential for staff to be unaware of potential adverse events, side effects or therapeutic effect. 3. Resident 8's skin assessment intervention was not implemented. This had the potential to result in skin injury going unnoticed and untreated. 4. Resident 14's weekly weight interventions were not implemented. This had the potential to result in delayed nutritional care for weight fluctuations. Findings: 1. A review of a facility policy titled, Care Plans, Comprehensive revised…

    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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-11-08 · 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 safe and sanitary food preparation and storage practices in the kitchen when: 1. The blue plastic holder for the can opener and the base was unsanitary. 2. The chipped paint on white shelves in both three-door reach in refrigerators were not easily cleanable. 3. The rusting area of the shelf on the table had stored mixing bowls which had the potential to contaminate the clean metal bowls and containers. 4. A visible amount of water was observed in a kitchen drawer. 5. Four of the kitchen drawers had yellowish sticky food particles on the inside of the drawers which stored cooking utensils. 6. The ventilator fans had black debris in both three-door reach in refrigerators. 7. The cooking utensils had dried food particles. 8. The metal dividers used for separating the food during tray line preparation had food particles. 9. The pipes under the cook preparation (prep) sink next to the stove were covered with black debris and cumulative dust. 10. There were sausage patties in a box unwrapped found exposed 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-08 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that a care plan for one of fourteen sampled residents (Residents 8) was revised and updated to reflect current fall risk interventions. This failure had the potential for resident's individual care needs to go unrecognized, and a risk for a decline in residents physical, mental, and psychological status. Findings: A review of a facility policy titled, Care Plan Revision, no date, indicated, Care plans shall be reviewed and revised to incorporate goals and objectives that lead to the resident's highest obtainable level of independence . These goals and objectives are revised when the desired outcome has not been achieved . A review of Resident 8's admission record indicated he was admitted to the facility on [DATE], and re-admitted to the facility on [DATE], with diagnoses that included cervical vertebra fracture, abnormal posture, and Parkinson's disease (neurological involuntary movement which includes tremors) 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transfer one of fourteen sampled residents, (Resident 45) safely using a Hoyer lift (a mechanical lift used to transfer residents safely) per resident's care plan when two Certified Nursing Assistants (CNA)transferred Resident 45 from the bed to the wheelchair without a lift. This failure resulted in an avoidable accident when Resident 45 sustained a dislocated right shoulder that caused pain. Findings: A review of a facility policy titled, Safety and Supervision of Residents, dated (January 2011), indicated Our facility strives to make the environment as free from accident hazards as possible. The policy instructed that The staff shall use various sources to identify risk factors for residents. It indicated Implementing interventions to reduce accident risks and hazards shall include the following: Communicate specific interventions to all relevant staff, assign responsibilities for carrying out interventions, provide training as necessary and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-08 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide individualized dementia (the loss of cognitive functioning - thinking, remembering, and reasoning) care plan for two of fourteen sampled residents (Resident 28 and Resident 34). This failure resulted in Resident 28 feeling cold and startled and had the potential to adversely affect the psychosocial well-being of all dementia residents. Findings: 1) During a record review Resident 28 was admitted to the facility on [DATE] with diagnoses of dementia (a cognitive disorder when a person can no longer be independent), dysphagia, (difficulty swallowing), and history of falls. A review of the Minimum Data Set (MDS, an assessment tool), dated 9/15/22, indicated functional status for bed mobility is extensive assistance with two assistants needed, indicated resident is totally dependent on staff for activities of daily living. Resident 1 had severe cognitive impairment (unable to think and reason). A review of Resident 28's care plans, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-08 · 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 observation, interview, and record review, the facility failed to ensure safe standards of medication administration for three of four sampled residents (Residents 164, 39, 33) when: 1. Resident 164 was instructed to take one puff on an inhaler instead of two puffs, resulting in receiving half of the ordered dose, and, 2. Resident 39's identification was not verified at the time of medication administration which placed him at risk of receiving the wrong medication, and, 3. Resident 33 was given a topical antibiotic ointment and the nurse failed to check the expiration date which placed the resident at risk of receiving expired and/or ineffective medication. Findings: 1. Resident 164 who was admitted to the facility on [DATE] with diagnosis of lung disease. A review of Resident 164 physician's order summary dated, [DATE], indicated Spiriva (a medication that relaxes muscles around airways to treat lung disorders) Handihaler Capsule 18 microgram, 2 puffs inhaled orally daily. During a medication pass…

    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 · D2022-11-08 · 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 medications were stored, labeled and disposed of correctly for two of 14 residents (Residents 19 and 34) when: 1. a.Two tubs of triamcinolone cream (a medicated cream to treat certain skin conditions) were found in the treatment cart when they should have been disposed of as the orders for use had expired, and b. An opened bottle of latanoprost (a medicated solution to treat a condition that leads to vision loss) that had not been dated when it was first opened was found in medication cart 2, and, c. An opened bottle of risperidone (a medication to treat certain mood/mental disorders) was found unlabeled in medication cart 2. These failures had the potential for medication misuse and ineffectiveness. Findings: 1. a. During a concurrent observation and interview on [DATE] at 10:25 am with Licensed Nurse (LN) E, two tubs of triamcinolone 0.1% cream labeled for the use of Resident 19 were found. On the labels were the orders as…

    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 · D2022-11-08 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based observation, interview, and record review, the facility failed to maintain complete documentation of controlled drugs for two of 14 residents (Residents 35 and 22) when a licensed nurse (LN) did not document doses given at the time of administration. This failure resulted in the incorrect accounting of federally controlled drugs. Findings: A concurrent observation, interview and record review was made on 11/3/22 at 11:03 am, during an inspection of Medication Cart 2. When LN D was instructed to show documentation for the administration of controlled drugs (medications that can potentially be abused or lead to dependence) she requested to complete the documentation first. When asked when she had administered the medications she stated, a couple hours ago. A review of residents' Controlled Drug Records and electronic Medication Administration Records and an observation of the controlled drugs resulted in the finding that two residents (Residents 35 and 22) had been administered controlled drugs (respectively, lacosamide, an anticonvulsant, at 8:15 am, and lorazepam, a sedative,…

    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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-11-07 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity for two of three residents (Residents 16 and 46) when they were not informed of, nor provided with the opportunity to exercise the right to refuse a room change. This resulted in avoidable psychosocial distress and could have a negative impact on the resident's health and well-being. Findings: Resident 16's medical records were reviewed. 1. Resident 16 was admitted to the facility on [DATE] with diagnoses that included a stroke, depression, and anxiety disorder. Resident 16 was alert and oriented. Resident 16's speech was impaired (due to the stroke), but his communication ability was effective to make his needs and wishes known. The record included guidelines to contact Resident 16's Family Member (FM) 1 by text only and if no response, call FM 2. On 11/04/19 at 12:04 pm, during an observation and interview, Resident 16 stated he was not happy with his new room. Resident 16 stated he…

    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 · Ecited before2019-11-07 · 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

    Based on observation, interview and record review the facility failed to develop and/or implement infection control policies and procedures when: 1. No policy and procedure was found for use of the residential style washing machine in the laundry room (used for small loads). 2. Restorative Nurse Assistant (RNA) touched the lid of a trash can, then proceeded to assist residents with eating without performing hand hygiene. This failure resulted in the potential for cross-contamination of germs and viruses to residents, which could negatively impact their health and well-being. Findings: 1. On 11/06/19 at 3:40 pm, during an observation of the laundry room and a concurrent interview, the Laundry Supervisor (LS) explained a residential style washing machine was used for small loads that included clothing protectors (bib style, used to protect resident clothing during meals), kitchen rags, and other miscellaneous items. LS stated laundry detergent and one ounce of bleach was added to wash loads (unless the material was not appropriate for the use of bleach). When asked about a written…

    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 · D2019-11-07 · tag F0559 — isolated
    Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based interview, and record review, the facility failed to provide written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for three of three residents review for recent room changes (Residents 8, 16, and 46). This failure resulted in a process that did not take into account the Resident's preferences before making room changes for Residents are made. Findings: On 11/05/19 12:35 pm during an interview, the Social Service Director (SSD) indicated the facility's room change process did not include giving written notice, of any kind, before the resident's room or roommate in the facility was changed. The SSD confirmed no written notice was provided, prior to recent facility initiated room changes, for Residents 8, 16, and 46. On 11/05/19 at 4:20 pm, during an interview and concurrent record review, the Medical Records Director confirmed the following: a. Resident 8 was moved to a new room, on 10/31/19, from the room where he had resided since 6/20/17 (over two years). b. Resident 16 was moved to a new room, on 10/31/19,…

    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 · D2019-11-07 · tag F0560 — isolated
    Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
    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 resident right to refuse a room transfer, for one of three residents (Resident 16). This resulted in Resident 16, being moved to a new room without consent, solely for the convenience of the facility. Findings: Resident 16's medical records were reviewed. Resident 16 was admitted to the facility on [DATE] with diagnoses that included a stroke. Resident 16 was alert and oriented. Resident 16's speech was impaired (due to the stroke), but his communication ability was effective to make his needs and wishes known. The record included guidelines to contact Resident 16's Family Member (FM) 1 by text only and if no response, call FM 2 by phone. On 11/04/19 at 12:04 pm, during an interview, Resident 16 stated he was not happy with his new room. Resident 16 stated he was moved to his current room three days ago, and doesn't know why. Resident 16 stated he liked the room he was in and wants to move back to his room. On 11/05/19 at 4:40…

    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 · Dcited before2019-11-07 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 prevent physical abuse when Resident 21 was the aggressor in an altercation with Resident 47. This failure resulted in Resident 47 sustaining bruises from being pinched on the arm by Resident 21. Findings: Resident 21's medical record was reviewed. Resident 21 was admitted to the facility on [DATE] with a diagnosis that included unspecified intellectual disabilities, obsessive-compulsive disorder and bipolar disorder. On 10/03/19 Resident 21 had an assessment of his mental status using a test called a Brief Interview for Mental Status (BIMS) in which he scored a zero (0), indicating he could not mentally perform the assessment exam. Resident 47's medical record was reviewed. Resident 47 was admitted to the facility on [DATE] with a diagnosis that included dementia. On 7/04/19 Resident 47 had a BIMS score of 5 indicating severe cognitive dysfunction; with a BIMS score of 5 memory and recall of events would be minimal. On 11/04/19 at 3:33 PM 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-11-07 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 store and prepare food in a safe and sanitary manner when a container filled with leftover chicken noodle soup was found unlabelled and areas on the clean side of the kitchen were found to contain areas of grime and food splatter, potentially exposing the residents to food borne illnesses associated with out-dated foods and unclean surfaces. Findings: During the initial tour of the kitchen on 11/4/19 at 10:05 am, a plastic pitcher containing chicken noodle soup was found in refrigerator 2, the cook acknowledged there was no date on the container. Dietary Aide (DA) 1 stated he had put it in the refrigerator the day before and on the cook's instruction, added a label to the container. Review of the facility's policy Food Receiving and Storage, revised October 2017, indicated all foods stored in the refrigerator or freezer will be covered, labeled and dated. During an observation on 11/5/19 at 12:30 pm, dark colored grime was noticed on the lower wall in the corner on the clean side of the kitchen, next to the…

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

    Nutrition and Dietary 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 PACS GROUP — 274 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 4 of 52.9+1.1 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 273 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Anchor Post AcuteAiken, SC 1 of 5Arbor Post AcuteChico, CA 1 of 5Artesia Palms Care CenterArtesia, CA 1 of 5Arvin Post AcuteArvin, CA 1 of 5Ashland Post AcuteAshland, OR 1 of 5Bakersfield Post AcuteBakersfield, CA 1 of 5Beachwood Post-Acute & RehabSanta Monica, CA 1 of 5Brookshire Post AcuteDenver, CO 1 of 5Brushy Creek Post AcuteGreer, SC 1 of 5Buckeye Care And RehabilitationLancaster, OH 1 of 5Carnegie Park Post AcutePittsburgh, PA 1 of 5Cascade Terrace Post AcutePortland, OR 1 of 5Centennial Post AcuteAnchorage, AK 1 of 5Chandler Creek Post AcuteGreer, SC 1 of 5Chehalem Post AcuteNewberg, OR 1 of 5Country Hills Post AcuteEl Cajon, CA 1 of 5Delhi Post-AcuteCincinnati, OH 1 of 5Dublin Post AcuteDublin, OH 1 of 5Edisto Post AcuteOrangeburg, SC 1 of 5Evan Terrace Post AcuteMcMinnville, OR 1 of 5Forest Acres Post AcuteColumbia, SC 1 of 5Grandview Post AcuteCookeville, TN 1 of 5Great Plains Post AcuteWichita, KS 1 of 5Hemet Hills Post AcuteHemet, CA 1 of 5Highland Hills Post AcutePittsburgh, PA 1 of 5Highline Post AcuteDenver, CO 1 of 5Johns Island Post AcuteJohns Island, SC 1 of 5Karcher Post AcuteNampa, ID 1 of 5Kennedy Care CenterLos Angeles, CA 1 of 5Kern River Transitional CareBakersfield, CA 1 of 5Lakeview Post AcuteFlorissant, MO 1 of 5Marion Valley Post AcuteMarion, OH 1 of 5Mirage Post AcuteLancaster, CA 1 of 5Monroeville Post AcuteMonroeville, PA 1 of 5Napa Post AcuteNapa, CA 1 of 5North Royalton Post AcuteParma, OH 1 of 5Northstar Post AcuteCarson City, NV 1 of 5Overland Park Post AcuteOverland Park, KS 1 of 5Pikes Peak Post AcuteColorado Springs, CO 1 of 5Ridgeway Post AcutePetaluma, CA

Showing 40 of 273; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleSince
PRITCHETT, JONIndividualCONTRACTED MANAGING EMPLOYEEsince 03/17/2017
MERRILL, DAENENIndividualW-2 MANAGING EMPLOYEEsince 06/19/2023
APT, FREDERICKIndividualCORPORATE OFFICERsince 01/01/2024
HANCOCK, MARKIndividualCORPORATE OFFICERsince 01/01/2024
JERGENSEN, JOSHUAIndividualCORPORATE OFFICERsince 01/01/2024
MITCHELL, JOHNIndividualCORPORATE OFFICERsince 01/01/2024

The source lists no ownership percentage for any party here — 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.

$9.0M
Net patient revenuemost recent cost report
-0.7%
Operating marginrevenue minus expenses
$837K
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 23%Medicare 19%Other / private 58%

This home reported $837K 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

$462per resident / day
operating cost
$14,037per month
≈ monthly operating cost
$458per 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 055512. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-22, 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.

What to do next